Juvenile obsessive-compulsive disorder (OCD) often starts at the mean age of 10.3 years. However, OCD manifests at even younger age in some patients. An earlier age of onset and a longer duration of illness have been associated with increased persistence of OCD.
Objective
To understand the clinical presentation, diagnosis and possible treatment of OCD in very young children.
Case Series
Five cases of OCD in children (aged 4-5 years) were followed-up for 6 months. At presentation, children were severely impaired by their OCD. Table 1 describes the cases.
Table 1 Five cases of early childhood OCD
| Name | Age | Sex | CY-BOCS first session | CGI-S first session | Clinical presentation of compulsions | Comorbidities | Family History |
|---|---|---|---|---|---|---|---|
| Patient 1 | 4 | f | 15 | 3 | Repetitive behaviour, symmetry, hoarding, tydying | Separation anxiety | Mother social anxious child |
| Patient 2 | 4 | m | 15 | 3 | Counting steps, pronouncing certain phrases, fare-well ritual, repeating or winding back of situations | Lisping | Parents report no psychopathology |
| Patient 3 | 4 | m | 15 | 3 | Repeating or winding back of situations, winding back time | Stuttering | Mother anxious, grandmother f.s. severe OCD |
| Patient 4 | 5 | f | 15 | 3 | Just-Right-compulsions with clothings and shoes, excessive cleaning and drying rituals after urinating, tydying, symmetry | Separation anxiety | Parents report no psychopathology, grandmother m.s. light OCD |
| Patient 5 | 4 | f | 20 | 3 | Just-Right-compulsions with clothings and shoes, excessive cleaning and drying rituals after urinating, tydying, symmetry | Separation anxiety, Astrocytoma | Mother social anxious child |
| CGI-S Clinical Global Impression Severity Scale, CY-BOCS Children’s Yale-Brown Obsessive Compulsive Scale, f.s. father’s side, m.s. mother’s side *Adapted from source |
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Intervention
- Medication was not indicated due to young age of patients & parents denied in-patient treatment.
- Therefore, parent-oriented CBT intervention was provided to reduce family accommodation for OCD & facilitate developmental tasks (4-10 sessions).
- Parents were guided to enhance praise and reward for adequate behaviors of the child.
Treatment outcomes
- A significant decline in OCD-severity after 3 months which sustained till 6 months was observed (table 2).
- All the children progressed to attending the kindergarten daily & we admitted to next level.
Table 2 CGI-S and CY-BOCS scores at intake, 3 months and 6 months follow-up
| Name | Age | Sex | CGI-S first session | CY-BOCS first session | CY-BOCS 3 months | CY-BOCS 6 months | CGI-S 6 months |
|---|---|---|---|---|---|---|---|
| Patient 1 | 4 | f | 3 | 15 | 0 | 0 | 0 |
| Patient 2 | 4 | m | 3 | 15 | 5 | 7 | 1 |
| Patient 3 | 4 | m | 3 | 15 | 9 | 7 | 1 |
| Patient 4 | 5 | f | 3 | 15 | x | 4 | 1 |
| Patient 5 | 4 | f | 3 | 20 | 13 | 4 | 1 |
| CGI-S Clinical Global Impression Severity Scale, CY-BOCS Children’s Yale-Brown Obsessive Compulsive Scale × Because of serious illness of the grandfather in the meantime, it was not possible to administer the CY-BOCS at 3 months follow-up. However, the interview at 6 months follow-up revealed that OCD symptom reduction had been progressive and comparable to that of the other children, also with regard to regular attendance of Kindergarten *Adapted from source |
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Initiation of treatment is an important aspect of the overall burden of OCD. With CBT-based parent-oriented intervention:
- The reduction on CY-BOCS scores was reached without medication.
- Children could continue their developmental milestones without disruptions, like staying at home for a long period or an inpatient treatment.
- Results were achieved without high expenses and separation problems at the young age due to in-patient treatment.
Limitations
- No intelligence testing was performed.
- Comorbidities were assessed according to clinical impression and parents’ reports.
- Parent-oriented CBT did not have a fixed protocol and was adjusted individually to meet the needs of every family.
- Lack of control group.
Conclusion
- Clinicians should consider a diagnosis of OCD in young children with OCD symptoms.
- CY-BOCS, a validated tool, must be included in the diagnosis of OCD in children.
- A parent-based treatment targeting family accommodation should be offered.
- Early assessment and treatment shorten the long delay between first symptoms of OCD and disease-specific treatment, while preventing chronicity of the condition.