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Obsessive Compulsive Disorder (OCD) in Children/Youth: Information for Primary Care

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Sommaire : Presence of obsessions and/or compulsions
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Dave is a 15-yo teenager who has always been somewhat anxious. Since the start of Gr. 11 however, he has been washing his hands numerous times a day, to the point that his hands are raw and sore from all the washing. He gets extremely upset if others touch him because he thinks he will be contaminated with disease causing germs. Stressors include parental separation and being bullied at school.


What are you going to do to help Dave? 


Point prevalence 0.2% (Waddell et al, 2002).


Lifetime prevalence of 1.9% to 3.0% and is significantly associated with both tics and ADHD.


Excessive cleaning (eg: handwashing, toothbrushing, showering)


Repeating rituals (eg: going in and out of doors, restarting phrases, rereading)


Checking rituals (checking the doors are locked, the appliances are tuned off, that the homework is perfect).

Hx/Interviewing Questions

For the patient:

  • Obsessions: “Do you have any disturbing thoughts, images or urges that keep coming back to you, and that are hard to get out of your head? E.g. feeling contaminated or that terrible things are going to happen?”
  • Compulsions: “Do you have any habits or rituals that absolutely have to do, other wise you feel upset? E.g. washing or cleaning over and over again, or counting things over and over again…

For caregivers, parents, family members:

  • Obsessions: “Any thoughts that s/he gets over and over again?”
  • Compulsions: “Any habits or rituals that s/he absolutely has to do, over and over again?”

Screening / Diagnostic Tools

Physical Exam (Px)


  • Fear of contamination may lead to avoidance of shaking hands with the health care professional; avoidance of touching things such as doorknobs in the office; keeping on jackets and coats
  • Need for symmetry may manifest in touching or doing things in a symmetrical fashion


  • Hands may appear red and chapped chapping from repetitive washing

DSM Criteria

DSM-5, compared to DSM-IV

Obsessive-compulsive and related disorders include:

  • ​OCD
  • Body dysmorphic disorder
  • Trichotillomania (hair pulling disorder)
  • Hoarding disorder
  • Excoriation (skin-picking)

DSM-IV Diagnosis

A.  Either obsessions or compulsions with obsessions as defined by (1), (2), (3) and (4)

  1. Recurrent and persistent thoughts, impulses or images that are experienced at some time during the disturbance, as intrusive an inappropriate and that cause marked anxiety or distress.
  2. The thoughts, impulses or images are not simply excessive worries about real life problems.
  3. The person attempts to ignore or suppress such thoughts, impulses or images or to neutralize them with some other thought or action.
  4. The person recognizes that the obsessional thoughts, impulses or images are a product of his/her own mind (not imposed from without as in thought insertion).

Compulsions as defined by (1) and (2)

  1. Repetitive behaviors (e.g. hand washing, ordering, checking) or mental acts (e.g. praying, counting, repeating words silently) that the person feels driven to perform in response to an obsession, or according to rules that must be applied rigidity.
  2. The behaviors or mental acts are aimed at preventing or reducing distress or preventing some dreaded event or situation, however, these behaviors or mental acts either are not connected in a realistic way with what they are designed to neutralize or prevent or are clearly excessive.

Differential Diagnosis

Medical conditions that can cause or contribute to anxiety symptoms in general include:

  • Gastric ulcer
  • Asthma
  • Thyroid problems
  • Overuse of stimulant medications (e.g. ADHD medications, caffeine, diet pills, decongestants)

Medications that can mimic OCD include:

  • Paediatric Autoimmune and Neurologic Diseases Associated with Streptococcal Infection (PANDAS)


There are no unique laboratory measures for diagnosing OCD.


However, if the onset of obsessions or compulsions is believed to be associated with a PANDA or a recent infection, consider testing for

  • Streptococal infection, e.g. throat swab
  • Antistreptolysin O Titre (ASOT)

Management / Treatment

If OCD due to PANDAS is suspected

  • Treat any active streptococcal infection
  • Consider referral to Neurology and Psychiatry

Psychological Treatment


Mild to moderate OCD

  • Cognitive behavioural therapy (CBT) with Cognitive restructuring and Exposure with response prevention (E/RP)

Medication Treatment

Medications may be indicated if OCD symptoms have not responded to non-medication treatment (such as CBT), or for moderate to severe OCD, or if CBT not available.


Therapeutic Dose Range


First Line


SSRIs are first line as they are reasonably well tolerated

Side effects typically insomnia, nausea, agitation, tremor, fatigue


6-12 years: 25-200 mg/day;

13-17 years: 50-200 mg/day

FDA Approved for OCD treatment in adults and children 6-17 years.


6-12 years: 20-30 mg/day;

13-17 years: 20-60 mg/day

FDA Approved for OCD treatment in adults and children 7-17 years.


6-12 years: 50-200 mg/day;

13-17 years: 50-300 mg/day

FDA Approved for OCD treatment in adults and children 7-17 years.

Second Line




Up to 3 mg/kg/day or 200 mg/day (whichever is less)

Clomipramine is felt to be effective, but is not first-line due to increased side effects compared to SSRIs

FDA Approved for OCD treatment in adults and children 10-17 years.

Venlafaxine XR

6-12 years: Start at 37.5 mg, increase to 75 mg initial target; max 150 mg daily

13-17 years: Start at 37.5-75 mg daily, increase to 150 mg daily initial target; maximum 225-300 mg daily  

Approved in adults for MDD, GAD and social anxiety

Not FDA nor Health Canada approved for any indications in children/youth; nonetheless, has been used clinically for depression, anxiety and ADHD


6-12 years: Start at 5-10 mg daily; initial target 10 mg daily; maximum 20 mg daily

13-17 years; start at 10 mg daily; increase up to 20 mg daily initial target; maximum 40 mg daily

Off-label for OCD

Watch for increased QT prolongation risk, which is why it is recommended to not exceed 40 mg daily


6-12 years: Safety not established

13-17 years: Start at 15 mg qhs, increase to 30 mg initial target (dosage information from Haapasalo-Pesu, 2004)

Adults: Approved by FDA/Health Canada for depression

Children/youth: No approved indications by FDA / Health Canada

Clinically used mood/anxiety and increasing appetite  

Adjunctive Risperidone

Start at 0.25 mg daily (if <20 kg) or 0.5 mg daily (if > 20 kg)

Increase to 0.5 mg daily (if <20 kg) or 1 mg daily (if >20 kg)

Maximum 0.5-3 mg daily

Adults: FDA approved for schizophrenia.

Children/youth: FDA approved for “irritability associated with autistic disorder”.

Use in OCD is off-label.



  • Augmentation strategies with atypical antipsychotics
    • Adding Risperidone to SRI
  • Adjunctive:
    • Mirtazapine, olanzapine, quetiapine, haloperidol, gabapentin, topiramate, tramadol, riluzole, St John’s wort, pindolol
  • IV clomipramine, escitalopram, phenelzine, tranylcypromine

Reference: Vitiello B, Psych Annals 2010; drug dosages from various sources.

Patient Handout




Clinical Practice Guidelines

  • Ajouter au Panier Info
    Obsessive compulsive disorder (OCD) and body dysmorphic disorder (BDD)
    Publiée 2005
    Produit par National Institute for Health and Clinical Excellence (NICE)
    Âges servis Tous âges
    Site web
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    Practice Parameter for the Assessment and Treatment of Children and Adolescents With Obsessive-Compulsive Disorder (OCD)
    Publiée 2012
    Produit par American Academy of Child and Adolescent Psychiatry (AACAP)
    Âges servis Jusqu'à 18 ans
    Site web

Case, Part 2 

Given that Dave's symptoms of OCD are mild, and there do not feel he has any other significant diagnoses, you decide to provide education and recommend that the family see a therapist skilled in OCD. Fortunately, he forms a good connection with the therapist, and within a few visits, he is reporting significantly reduced distress from the OCD. 

Self-Help Books

Foa EB, Wilson R. Stop obsessing: how to overcome your obsessions and compulsions. Revised. New York (NY): Bantam Books; 2001.


Grayson J. Freedom from obsessive-compulsive disorder: a personalized recovery program for living with uncertainty. New York (NY): Berkeley Publishing Group; 2004.


Hyman BM, Pedrick C. The OCD workbook: your guide to breaking free from obsessive-compulsive disorder. 2nd ed. Oakland (CA): New Harbinger Publications; 2005.


Purdon C, Clark DA. Overcoming obsessive thoughts: how to gain control of your OCD. Oakland (CA): New Harbinger Publications; 2005.


Alario, A & Birnkrant, J (2008), Practical Guide to the Care of the Pediatric Patient, 2nd edition. Elsevier.


Clinical Practice Guideline, Management of Anxiety Disorders, Chtp 6, Obsessive Compulsive Disorder, Canadian Psychiatric Association


Geller et al.: Which SSRI? A Meta-Analysis of Pharmacotherapy Trials in Pediatric Obsessive-Compulsive Disorder, Am J Psychiatry 160:1919-1928, November 2003


Haapasalo-Pesu K et al.: Mirtazapine in the treatment of adolescents with major depression: an open-label, multicenter pilot study. J Child Adolesc Psychopharmacol. 2004 Summer;14(2):175-84.


Kaplan & Sadock's synopsis of psychiatry : behavioral sciences/clinical psychiatry / Benjamin J. Sadock; 10th ed., Wolter Kluwer/Lippincott Williams & Wilkins, 2007.


Waddell, C; Offord, D; Shepherd, C; Hua, J; McEwan, K (2002), Child Psychiatric Epidemiology and Canadian Public Policy-Making: The State of the Science and the Art of the Possible, Can J Psychiatry, 47:825-832.

About this Document

Written by members of the team which includes members of the Department of Psychiatry and Family Medicine at the University of Ottawa. Reviewed by members of the Family Medicine Program at the University of Ottawa, including Dr's Farad Motamedi; Mireille St-Jean; Eric Wooltorton.


Information in this pamphlet is offered ‘as is' and is meant only to provide general information that supplements, but does not replace the information from a health professional. Always contact a qualified health professional for further information in your specific situation or circumstance.

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Affichée le : Sep 11, 2012
Date de la dernière modification : Jul 26, 2017

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