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• W2034718004 abstract "Research in etiology, neurobiology, genetics, clinical correlates, and evidence-based treatments in children and adolescents with obsessive-compulsive disorder indicate a need for the revision of the Practice Parameters for the Assessment and Treatment of Children and Adolescents with Obsessive-Compulsive Disorder first published a decade ago. The present article highlights the clinical assessment and reviews and summarizes the evidence base for treatment. Based on this evidence, specific recommendations are provided for assessment, cognitive behavioral therapy, pharmacotherapy, combined treatment, and other interventions. Research in etiology, neurobiology, genetics, clinical correlates, and evidence-based treatments in children and adolescents with obsessive-compulsive disorder indicate a need for the revision of the Practice Parameters for the Assessment and Treatment of Children and Adolescents with Obsessive-Compulsive Disorder first published a decade ago. The present article highlights the clinical assessment and reviews and summarizes the evidence base for treatment. Based on this evidence, specific recommendations are provided for assessment, cognitive behavioral therapy, pharmacotherapy, combined treatment, and other interventions. Obsessive-compulsive disorder (OCD) is a common psychiatric disorder affecting children and adolescents and causing significant disability. In the previous decade since the Practice Parameters for the Assessment and Treatment of Children and Adolescents with Obsessive-Compulsive Disorder were published,1American Academy of Child and Adolescent PsychiatryPractice parameter for the assessment and treatment of children and adolescents with obsessive-compulsive disorder.J Am Acad Child Adolesc Psychiatry. 1998; 37: 27S-45SPubMed knowledge of pediatric OCD has increased with large family-genetic studies; the elaboration of phenotypic dimensions; descriptions of comorbid disorders and their moderating effects on treatment response and outcome; research on immune-based neuropsychiatric causes (Pediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcus [PANDAS]); the publication of randomized controlled trials of selective serotonin reuptake inhibitors (SSRIs) and concern and scrutiny on the safety of these SSRIs in children; the first large-scale randomized controlled trials of cognitive-behavioral therapy (CBT); new approaches in behavior therapy including intensive in- and outpatient treatment, family-based treatment, group therapy, and behavioral intervention for very young children with OCD; and emerging data on the moderators and predictors of response to specific treatments. This revision of the Practice Parameters is intended to incorporate recent research and empirical clinical wisdom to guide child and adolescent psychiatrists who treat children with OCD and the other medical and mental health providers involved in their care. Information and recommendations used in this Parameter were obtained from literature searches using the Medline, PubMed, PsycINFO, and Cochrane Library databases and by an iterative bibliographic exploration of articles and reviews, beginning with more inclusive and sensitive searches employing the search term “obsessive-compulsive disorder”, multiple free text and relevant medical subject headings (MeSH terms), and an initial period from 1980 to the present day (749 citations). The search was narrowed using delimiters and filters such as age 0 to 18 years, English language only, human studies, published in the previous 10 years, and using the Boolean operators ‘AND’ clinical trial ‘OR’ meta-analysis, practice guideline, randomized controlled trial, review, classical article to decrease the citations to 322. Using similar strategies, obsessive-compulsive disorder AND randomized controlled trial were searched to yield 353 citations, including 11 reviews. Key quality domains were examined including descriptions of the study population (inclusion and exclusion criteria), randomization, blinding, interventions, outcomes (including “last observation carried forward” data and description of dropouts), sources of sponsorship or funding, and statistical analysis. For this Practice Parameter, 65 publications were selected for careful examination based on their weight in the hierarchy of evidence attending to the quality of individual studies, relevance to clinical practice, and the strength of the entire body of evidence. The high prevalence of OCD in children was not generally recognized until the first epidemiologic study just over 20 years ago.2Flament M. Whitaker A. Rapoport J. et al.Obsessive compulsive disorder in adolescence: An epidemiological study.J Am Acad Child Adolesc Psychiatry. 1988; 27: 764-771Abstract Full Text PDF PubMed Scopus (568) Google Scholar In that study, most subjects identified through screening who were later diagnosed with OCD had been previously undiagnosed, leading to the notion of pediatric OCD as a “hidden epidemic.” The secretive nature of OCD symptoms and the isolated and idiosyncratic functional deficits that may be severe but variable and domain specific contribute to the finding that OCD was under-recognized and underdiagnosed in youth. Early epidemiologic studies were conducted in adolescent populations and most used school surveys for sample ascertainment. The prevalence rates of pediatric OCD are around 1% to 2% in the United States and elsewhere.2Flament M. Whitaker A. Rapoport J. et al.Obsessive compulsive disorder in adolescence: An epidemiological study.J Am Acad Child Adolesc Psychiatry. 1988; 27: 764-771Abstract Full Text PDF PubMed Scopus (568) Google Scholar, 3Apter A. Fallon Jr, T.J. King R.A. et al.Obsessive-compulsive characteristics: from symptoms to syndrome.J Am Acad Child Adolesc Psychiatry. 1996; 35: 907-912Abstract Full Text PDF PubMed Scopus (91) Google Scholar In the more recent British Child Mental Health Survey of more than 10,000 5- to 15-year-olds, the point prevalence was 0.25% and almost 90% of cases identified had been undetected and untreated.4Heyman I. Fombonne E. Simmons H. Ford T. Meltzer H. Goodman R. Prevalence of obsessive-compulsive disorder in the British nationwide survey of child mental health.Int Rev Psychiatry. 2003; 15: 178-184Crossref PubMed Scopus (103) Google Scholar There appears to be two peaks of incidence for OCD across the life span, one occurring in preadolescent children5Geller D. Biederman J. Jones J. et al.Is juvenile obsessive compulsive disorder a developmental subtype of the disorder? A review of the pediatric literature.J Am Acad Child Adolesc Psychiatry. 1998; 37: 420-427Abstract Full Text PDF PubMed Scopus (269) Google Scholar and a later peak in young adult life (mean age, 21 years). If all pediatric cases of OCD persisted in adulthood, one would expect an increasing cumulative prevalence of OCD across the life span as more cases are added to the population. Studies have shown that this anticipated cumulative increase in prevalence is modified by the variable outcome of childhood-onset OCD, with a substantial number becoming subclinical over time.6Stewart S.E. Geller D.A. Jenike M. et al.Long term outcome of pediatric obsessive compulsive disorder: a meta-analysis and qualitative review of the literature.Acta Psychiatr Scand. 2004; 110: 4-13Crossref PubMed Scopus (334) Google Scholar The contribution of genetic factors to the development of OCD has been explored in twin, family-genetic, and segregation analysis studies.7Pauls D. Alsobrook II, J. Goodman W. Rasmussen S. Leckman J. A family study of obsessive-compulsive disorder.Am J Psychiatry. 1995; 152: 76-84PubMed Google Scholar, 8Hanna G. Himle J.A. Curtis G.C. Gillespie B. A family study of obsessive-compulsive disorder with pediatric probands.Am J Med Genet. 2005; 134: 13-19Crossref Scopus (124) Google Scholar, 9Shugart Y.Y. Samuels J. Willour V.L. et al.Genomewide linkage scan for obsessive-compulsive disorder: evidence for susceptibility loci on chromosomes 3q, 7p, 1q, 15q, and 6q.Mol Psychiatry. 2006; 11: 763-770Crossref PubMed Scopus (118) Google Scholar Twin studies have shown that the concordance rates for monozygotic twins are significantly higher than for dizygotic twins. Although family studies also have consistently demonstrated that OCD is familial,7Pauls D. Alsobrook II, J. Goodman W. Rasmussen S. Leckman J. A family study of obsessive-compulsive disorder.Am J Psychiatry. 1995; 152: 76-84PubMed Google Scholar the morbid risk of OCD in first-degree relatives appears to be greater for index cases ascertained in childhood. For example, in their multisite family study of adult OCD probands, Nestadt et al.10Nestadt G. Samuels J. Bienvenu J.O. et al.A family study of obsessive compulsive disorder.Arch Gen Psychiatry. 2000; 57: 358-363Crossref PubMed Scopus (488) Google Scholar found a risk for OCD of almost 12% in first-degree relatives, whereas relatives of pediatric OCD probands showed age-corrected morbid risks from 24% to 26% in more recent studies.11Do Rosario-Campos M.C. Leckman J.F. Curi M. et al.A family study of early-onset obsessive-compulsive disorder.Am J Med Genet B Neuropsychiatr Genet. 2005; 136B (*): 92-97Crossref PubMed Scopus (204) Google Scholar Genetic linkage studies of OCD have found evidence for susceptibility loci on chromosomes 1q, 3q, 6q, 7p, 9p, 10p, and 15q.9Shugart Y.Y. Samuels J. Willour V.L. et al.Genomewide linkage scan for obsessive-compulsive disorder: evidence for susceptibility loci on chromosomes 3q, 7p, 1q, 15q, and 6q.Mol Psychiatry. 2006; 11: 763-770Crossref PubMed Scopus (118) Google Scholar There is increasing evidence that glutamate receptor/modulating genes may be associated with OCD.12Hanna G.L. Veenstra-Vanderweele J. Cox N.J. et al.Evidence for a susceptibility locus on chromosome 10p15 in early-onset obsessive-compulsive disorder.Biol Psychiatry. 2007; 62: 856-862Abstract Full Text Full Text PDF PubMed Scopus (61) Google Scholar Although these studies have emphasized genetic factors, they also have pointed clearly to the major effects of “nongenetic” influences on the expression of OCD. For example, twin studies have shown that, even among monozygotic twins, OCD is not fully concordant. Clearly then, nonheritable etiologic factors are as great or greater than genetic factors for the risk of developing OCD. In fact, many, if not most, cases of OCD arise without a known positive family history of the disorder, the so-called sporadic cases. Information on the environmental triggers of the disorder may be especially relevant for the sporadic form because in such cases the OCD cannot be explained by the presence of an affected relative. To date, studies have focused on the perinatal (intrauterine [including potential teratogens such as alcohol and tobacco], birth, and postnatal) experiences of affected subjects13Geller D. Wieland N. Carey K. et al.Perinatal factors affecting expression of obsessive compulsive disorder in children and adolescents.J Child Adolesc Psychopharmacol. 2008; 18: 373-379Crossref PubMed Scopus (16) Google Scholar and immune-mediated neuropsychiatric models of illness. Perhaps no issue has been as controversial in OCD as that of PANDAS. The central hypothesis of PANDAS derives from the observations of neurobehavioral disturbance accompanying Sydenham chorea, a sequel of rheumatic fever. An immune response to group A β-hemolytic streptococcus (GABHS) infections purportedly leads to cross reactivity with, and inflammation of, basal ganglia, with a distinct neurobehavioral syndrome that includes OCD, tics, and perhaps hyperactivity. The diagnostic criteria were laid out by Swedo et al.,14Swedo S.E. Leonard H.L. Garvey M. et al.Pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections: clinical description of the first 50 cases.Am J Psychiatry. 1998; 155 (*): 264-271PubMed Google Scholar but detractors have argued that GABHS may be but one of many nonspecific physiologic stressors that can trigger an increase in tics or OCD.15Kurlan R. Johnson D. Kaplan E.L. Tourette Syndrome Study GroupStreptococcal infection and exacerbations of childhood tics and obsessive-compulsive symptoms: a prospective blinded cohort study.Pediatrics. 2008; 121: 1188-1197Crossref PubMed Scopus (146) Google Scholar, 16Leckman J.F. King R.A. Gilbert D.L. et al.Streptococcal upper respiratory tract infections and exacerbations of tic and obsessive-compulsive symptoms: a prospective longitudinal study.J Am Acad Child Adolesc Psychiatry. 2011; 50: 108-118Abstract Full Text Full Text PDF PubMed Scopus (114) Google Scholar[ct] At this time, the epidemiologic evidence and expert clinical experience support the belief that a small subset of children with OCD and Tourette's disorder have onsets and clinical exacerbations linked to GABHS.17Swedo S.E. Leonard H.L. Rapoport J.L. The Pediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcal Infection (PANDAS) subgroup: separating fact from fiction.Pediatrics. 2004; 113: 907-911Crossref PubMed Scopus (139) Google Scholar, 18Leslie D.L. Kozma L. Martin A. et al.Neuropsychiatric disorders associated with streptococcal infection: a case-control study among privately insured children.J Am Acad Child Adolesc Psychiatry. 2008; 47: 1166-1172Abstract Full Text Full Text PDF PubMed Scopus (88) Google Scholar Despite continuity in the phenotypic presentation of children and adults, issues such as limited insight and the evolution of symptom profiles that follow developmental themes over time may differentiate children from adults with OCD.19Geller D. Biederman J. Agranat A. et al.Developmental aspects of obsessive compulsive disorder: findings in children, adolescents and adults.J Nerv Ment Dis. 2001; 189: 471-477Crossref PubMed Scopus (239) Google Scholar Symptoms of OCD are frequently hidden or poorly articulated, especially in younger children. In addition, children with OCD may display compulsions without well-defined obsessions and rituals other than the typical washing or checking (e.g., blinking and breathing rituals).20Rettew D.C. Swedo S.E. Leonard H.L. Lenane M.C. Rapoport J.L. Obsessions and compulsions across time in 79 children and adolescents with obsessive-compulsive disorder.J Am Acad Child Adolesc Psychiatry. 1992; 31: 1050-1056Abstract Full Text PDF PubMed Scopus (162) Google Scholar Most children exhibit multiple obsessions and compulsions (mean numbers over the lifetime have been reported as 4.0 and 4.8, respectively).20Rettew D.C. Swedo S.E. Leonard H.L. Lenane M.C. Rapoport J.L. Obsessions and compulsions across time in 79 children and adolescents with obsessive-compulsive disorder.J Am Acad Child Adolesc Psychiatry. 1992; 31: 1050-1056Abstract Full Text PDF PubMed Scopus (162) Google Scholar Neither gender nor age at onset has been reported to determine the type, number, or severity of OCD symptoms. Children's obsessions often center on a fear of a catastrophic family event (e.g., death of a parent). Contamination, sexual, and somatic obsessions, and excessive scruples/guilt are the most commonly reported obsessions, and washing, repeating, checking, and ordering are the most commonly reported compulsions.19Geller D. Biederman J. Agranat A. et al.Developmental aspects of obsessive compulsive disorder: findings in children, adolescents and adults.J Nerv Ment Dis. 2001; 189: 471-477Crossref PubMed Scopus (239) Google Scholar OCD symptoms tend to wax and wane and are persistent in most patients, changing over time so that the presenting symptom constellation is not maintained.20Rettew D.C. Swedo S.E. Leonard H.L. Lenane M.C. Rapoport J.L. Obsessions and compulsions across time in 79 children and adolescents with obsessive-compulsive disorder.J Am Acad Child Adolesc Psychiatry. 1992; 31: 1050-1056Abstract Full Text PDF PubMed Scopus (162) Google Scholar Efforts have been made to parse the heterogeneous symptoms of OCD into a few consistent and temporally stable symptom dimensions using factor or cluster analytic methods. The Dimensional Yale-Brown Obsessive-Compulsive Scale21Rosario-Campos C. Miguel E.C. Quatrano S. et al.The Dimensional Yale-Brown Obsessive-Compulsive Scale (DY-BOCS): an instrument for assessing obsessive-compulsive symptom dimensions.Mol Psychiatry. 2006; 11: 495-504Crossref PubMed Scopus (336) Google Scholar measures the presence and severity of OC symptoms within several distinct dimensions that combine thematically related obsessions and compulsions. Early-onset cases have a high frequency of subjective sensations known as “sensory phenomena” preceding or accompanying their compulsions. Physical sensations include localized tactile and musculoskeletal sensations, and mental sensations include “just-right” perceptions (to tactile, visual, and auditory sensory stimuli) and “incompleteness” (or need for accuracy).22Rosario-Campos M.C. Leckman J.F. Mercadante M.T. et al.Adults with early-onset obsessive-compulsive disorder.Am J Psychiatry. 2001; 158: 1899-1903Crossref PubMed Scopus (303) Google Scholar Pediatric OCD is characterized by a 3:2 male-to-female ratio, with more boys at younger ages. The mean age of onset of pediatric OCD ranges from 7.5 to 12.5 years (mean, 10.3 ± 2.5 years) and the mean age at ascertainment ranges from 12 to 15.2 years (mean, 13.2 years),5Geller D. Biederman J. Jones J. et al.Is juvenile obsessive compulsive disorder a developmental subtype of the disorder? A review of the pediatric literature.J Am Acad Child Adolesc Psychiatry. 1998; 37: 420-427Abstract Full Text PDF PubMed Scopus (269) Google Scholar documenting that, on average, the age at assessment was 2.5 years after the age at onset, a finding of considerable clinical importance. Pediatric-onset OCD is increasingly recognized as a putative developmental subtype of the disorder, based on increased familial aggregation, psychiatric comorbidity, and outcome data.11Do Rosario-Campos M.C. Leckman J.F. Curi M. et al.A family study of early-onset obsessive-compulsive disorder.Am J Med Genet B Neuropsychiatr Genet. 2005; 136B (*): 92-97Crossref PubMed Scopus (204) Google Scholar OCD in youth is usually accompanied by another psychopathology that may complicate the assessment and treatment of affected children. Even cases derived from epidemiologic studies, which avoid the referral bias inherent in many clinical studies, have demonstrated rates of comorbid psychiatric diagnoses in more than 50% of affected children.2Flament M. Whitaker A. Rapoport J. et al.Obsessive compulsive disorder in adolescence: An epidemiological study.J Am Acad Child Adolesc Psychiatry. 1988; 27: 764-771Abstract Full Text PDF PubMed Scopus (568) Google Scholar Irrespective of current age, a younger age at the onset of OCD predicts increased risks for comorbid attention-deficit/hyperactivity disorder (ADHD), separation anxiety disorder, specific phobias, agoraphobia, and multiple anxiety disorders. Mood and psychotic disorders are associated with increasing chronologic age. Tourette's disorder has shown associations with age at onset (tics are more frequent in younger patients), gender (tics are more prevalent in boys), and chronologic age (tics usually improve or remit in the second decade of life).23Geller D. Biederman J. Faraone S.V. Bellorde C.A. Kim G.S. Hagermoser L.M. Disentangling chronological age from age of onset in children and adolescents with obsessive compulsive disorder.Int J Neuropsychopharmacol. 2001; 4: 169-178Crossref PubMed Scopus (70) Google Scholar Although not part of the core diagnostic symptoms, interest in a neuropsychological “endophenotype” in children with OCD has grown during recent years out of clinical and anecdotal experiences that many children have academic difficulties that are not wholly explained by their primary disorder. Given the potential involvement of frontostriatal systems in OCD, several aspects of neuropsychological performance have been especially relevant, including measurements of visuospatial integration, processing speed, short-term memory, attention, and executive function. Although not yet well characterized, deficits in visual spatial performance and processing speed appear common.24Andres S. Boget T. Lazaro L. et al.Neuropsychological performance in children and adolescents with obsessive-compulsive disorder and influence of clinical variables.Biol Psychiatry. 2007; 61: 946-951Abstract Full Text Full Text PDF PubMed Scopus (67) Google Scholar Precipitating psychosocial stressors have been described in several reports indicating that these are occasionally associated with the onset of OCD, sometimes dramatically.25Lafleur D.L. Petty C. Mancuso E. et al.Traumatic events and obsessive compulsive disorder in children and adolescents: is there a link?.J Anxiety Disord. 2011; 25: 513-519Crossref PubMed Scopus (34) Google Scholar However, most pediatric non-PANDAS OCD cases do not provide a history of clear precipitating triggers and has a subclinical onset. The long-term prognosis for pediatric OCD is better than originally conceived. Many children will remit entirely or become clinically subthreshold over time.5Geller D. Biederman J. Jones J. et al.Is juvenile obsessive compulsive disorder a developmental subtype of the disorder? A review of the pediatric literature.J Am Acad Child Adolesc Psychiatry. 1998; 37: 420-427Abstract Full Text PDF PubMed Scopus (269) Google Scholar A younger age of OCD onset, an increased duration of OCD, inpatient treatment, and perhaps specific symptom subtypes, such as sexual, religious, or hoarding obsessions, predict greater persistence. Comorbid psychiatric illness and poor initial treatment response are adverse prognostic factors. In contrast, gender, age at assessment, and length of follow-up are not reported as predictors of remission or persistence. Psychosocial function is frequently compromised. Studies have reported high levels of social/peer problems (55–100%), isolation, unemployment (45%), and difficulties sustaining a job (20%). However, at follow-up in one study, pediatric subjects with OCD showed no difference from controls in educational achievement, with 30% to 70% having attended college.5Geller D. Biederman J. Jones J. et al.Is juvenile obsessive compulsive disorder a developmental subtype of the disorder? A review of the pediatric literature.J Am Acad Child Adolesc Psychiatry. 1998; 37: 420-427Abstract Full Text PDF PubMed Scopus (269) Google Scholar Toddlers and preschoolers frequently engage in ritualistic behavior as a part of normal development. Examples include mealtime or bedtime routines that are insisted on. As a rule, they do not cause impairment in family functioning and an interruption of the rituals does not create severe distress in the child. Perhaps the most difficult differential diagnosis occurs in the context of a more pervasive developmental disorder (PDD or “spectrum” disorder). Core symptoms of these disorders include stereotypic and repetitive behaviors, a restricted and narrow range of interests, and activities that may be confused with OCD, especially in young children. A small number of children with OCD (∼5%) may also meet criteria for Asperger's disorder or PDD.23Geller D. Biederman J. Faraone S.V. Bellorde C.A. Kim G.S. Hagermoser L.M. Disentangling chronological age from age of onset in children and adolescents with obsessive compulsive disorder.Int J Neuropsychopharmacol. 2001; 4: 169-178Crossref PubMed Scopus (70) Google Scholar In addition to the core social and communication deficits that are a diagnostic hallmark of “spectrum” disorders, the most helpful criterion for clinicians to differentiate PDD from OCD is whether symptoms are ego-dystonic and are associated with anxiety-driven obsessional fears. Children with PDD frequently engage in stereotypic behaviors with apparent gratification and will become upset only when their preferred activities are interrupted. Another helpful factor is whether symptoms are typical of OCD (such as washing, cleaning, or checking) from which one can infer some obsessional concern. Another diagnostic dilemma occurs in the context of the poor insight of obsessional thoughts, which merge into overvalued ideas and even delusional thinking suggesting psychosis. In fact, insight in children with OCD is not static but varies with anxiety levels and is best assessed when anxiety is at a minimum. Although OC symptoms may rarely herald a psychotic or schizophreniform disorder in youth, especially in adolescents, other positive or negative symptoms of psychosis will usually be present or emerge to assist in the differential diagnosis, and the nature of obsessional ideation in these patients is often atypical. Although the diagnosis of obsessive-compulsive personality disorder (OCPD) is rarely used with young children, OCPD features (defined as a pervasive pattern of preoccupation with orderliness, perfectionism, and control at the expense of flexibility and efficiency, beginning by early adulthood) are sometimes present and documented on Axis II in adolescent evaluations. Some children also demonstrate a preoccupation with minute details and facts, follow rules and regulations rigidly, adhere strongly to routines and schedules, and are inflexible, even relentless, in their thoughts or in pursuing their wishes. Although these behaviors are typically ego-syntonic and insight is lacking, these children do not meet the diagnostic criteria for Asperger's disorder because they do not have core deficits of empathy and social pragmatic skills. Such children may be critical or judgmental toward others, or angry and even aggressive when events do not conform to expectations or wishes, leading to significant family disruption. Only longitudinal studies can show if these children develop OCPD later. Serotonergic medications are of limited help for such children and treatment is primarily behavioral. In this Parameter, recommendations for best assessment and treatment practices are stated in accordance with the strength of the underlying empirical and/or clinical support, as follows:•Clinical standard [CS] is applied to recommendations that are based on rigorous empirical evidence (e.g., meta-analyses, systematic reviews, individual randomized controlled trials) and/or overwhelming clinical consensus.•Clinical guideline [CG] is applied to recommendations that are based on strong empirical evidence (e.g., nonrandomized controlled trials, cohort studies, case-control studies) and/or strong clinical consensus.•Option [OP] is applied to recommendations that are based on emerging empirical evidence (e.g., uncontrolled trials or case series/reports) or clinical opinion but lack strong empirical evidence and/or strong clinical consensus.•Not endorsed [NE] is applied to practices that are known to be ineffective or contraindicated. The strength of the empirical evidence is rated in descending order, as follows:•Randomized controlled trial (rct) is applied to studies in which subjects are randomly assigned to two or more treatment conditions.•Controlled trial (ct) is applied to studies in which subjects are nonrandomly assigned to two or more treatment conditions.•Uncontrolled trial (ut) is applied to studies in which subjects are assigned to one treatment condition.•Case series/report (cs) is applied to a case series or a case report. The psychiatric assessment of children and adolescents should routinely screen for the presence of obsessions and/or compulsions or repetitive behaviors. [CG] Clinicians should screen for OCD even when it is not part of the presenting complaint. Symptoms may be of mild to moderate severity, wax and wane over time, be prominent in one setting and not another, and be kept secret from others (including family). The simplest probes are those that derive from the diagnostic criteria of the DSM-IV: “Do you ever have repetitive, intrusive or unwanted thoughts, ideas, images or urges that upset you or make you anxious and that you cannot suppress?” For younger children the question might be phrased, “Do you have worries that just won't go away?” It is reasonable to offer some examples at this time such as “worries about things not being clean” or “worrying that something bad might happen to you or someone you love.” For compulsions, a similar probe might be: “Do you ever have to do things over and over, even though you don't want to or you know they don't make sense, because you feel anxious or worried about something?” For younger children, the question might be phrased, “Do you do things over and over or have habits you can't stop?” Examples such as washing, checking, repeating, ordering, counting, and hoarding can be offered easily and quickly. Sometimes adults are left to infer obsessions that are not articulated or even acknowledged by observing behaviors in their children. Examples include avoidance behaviors that imply concerns about some normal and expected activity such as entering a room or handling an object. If screening questions suggest that OC symptoms are present, clinicians should follow with more in-depth assessment. The commonly employed parent-report Child Behavior Checklist26Achenbach T.M. Manual for the Child Behavior Checklist 4–18 and 1991 Profile. University of Vermont Department of Psychiatry, Burlington, VT1991Google Scholar includes 8 items derived from factor analysis shown to have good sensitivity and specificity as a screen for OCD in children,27Nelson E.C. Hanna G.L. Hudziak J.J. Botteron K.N. Heath A.C. Todd R.D. Obsessive-Compulsive Scale of the Child Behavior Checklist: specificity, sensitivity, and predictive power.Pediatrics. 2001; 108: E14Crossref PubMed Scopus (81) Google Scholar although even simple positive item scores using item 9 (“obsessions”), item 66 (“compulsions”), and item 112 (“worries”) appear equally useful. The message for clinicians is that screening for OCD is" @default.
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• W2034718004 title "Practice Parameter for the Assessment and Treatment of Children and Adolescents With Obsessive-Compulsive Disorder" @default.
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