Obsessive Compulsive Disorder (OCD) CLINICAL PEARLS • Pediatric OCD has a prevalence rate of about 1–2%, but it often goes undiagnosed due to secretive nature of symptoms. A substantial number of pediatric-onset OCD cases will become sub-clinical over time. About one third of adult OCD cases have childhood onset.1 • OCD is strongly familial. Non-genetic factors have also been studied, including immune response to Group A beta-hemolytic strep infection (i.e. PANDAS).2 • Children and adolescents have higher rates of aggressive/harm obsessions (fear of catastrophic events, such as death or illness of a loved one or themselves). • Among compulsions, hoarding is seen more often in children and adolescents than adults. As with adults, children and adolescents typically have multiple obsessions and compulsions. • Children may present primarily with compulsive behaviors, with poor insight into obsessions or limited ability to communicate them due to developmental stage.1 • Medication alone leads to 30-40% reduction in OCD symptoms, leaving clinically significant symptom burden in moderate-to-severe cases. For this reason, combination treatment with cognitive behavior therapy (CBT) and medication is strongly recommended.3 Alone or in combination with medication, patients treated with CBT show higher probability of improvement and remission.4 • OCD is frequently comorbid with other psychiatric disorders. RATING SCALE • Children’s Yale-Brown Obsessive Compulsive Scale (CY-BOCS) https://iocdf.org/wp-content/uploads/2016/04/05-CYBOCS-complete.pdf TREATMENT APPROACH Stage 1: Diagnostic assessment including clinical interview based on DSM-5 criteria and CY-BOCS administered by a clinician. Assessment for comorbid psychiatric disorders should be included.2 Stage 2: Cognitive behavior therapy with elements of exposure and response prevention is first line treatment for OCD and can be used as monotherapy in mild-to-moderate cases.2 Stage 3: For moderate-to-severe OCD (CY-BOCS score >23) or failure to respond to CBT alone, combination treatment with CBT and medication is indicated. • Start an SSRI (sertraline, fluoxetine, fluvoxamine) with titration to the maximum effective dose over first four weeks of treatment.5
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