Childhood-onset OCD: A Case Report on the Role of Early Intervention in Symptom Management

Introduction

Pediatric obsessive-compulsive disorder (OCD) is a chronic psychiatric condition that significantly impairs social, familial, and academic functioning. Epidemiological studies indicate that the prevalence of OCD in childhood and adolescence ranges from 0.5% to 4%. ¹ Early onset of OCD is associated with increased severity and poorer outcomes. Notably, there are two peaks of incidence, one in pre-adolescence and another in early adulthood. ² Despite the prevalence of early-onset OCD, specific diagnostic or management guidelines for this age group are limited, and the long-term course and outcomes remain under-researched. ² We present a case of a 6-year-old girl with childhood-onset OCD who demonstrated a positive initial response to the interventions employed.

Case Description

A 6-year-old girl was brought to the psychiatry department due to frequent temper tantrums and irritable behavior, primarily occurring when family members refused to comply with her demands for specific repetitive actions. The mother reported noticing changes in the child’s behavior around the age of 4, following her recovery from a febrile illness. The fever had been low-grade and intermittent, without any associated rash, cold, cough, or changes in cognitive status. She was treated on an outpatient basis without any specific investigations. Medication details were not available. During this time, the child would persistently organize her toys on a shelf and would become upset if anyone disrupted the arrangement. She would become irritable over trivial issues and would throw temper tantrums if her demands were not fulfilled. However, these behaviors initially went unnoticed as they were attributed to normal childhood tendencies.

Over time, these behaviors intensified, particularly after she started school. She insisted on arranging her study table symmetrically and became agitated if anyone touched her belongings. She frequently screamed and hit her younger brother when he attempted to interfere with her items. Additionally, she developed a habit of washing her hands excessively, initially 5–10 times a day, which escalated to 30–50 times daily, spending 5–10 min each time. She believed her hands were dirty, especially after using the restroom or coming home. Efforts by her mother to interrupt these behaviors led to extreme reactions, including crying, screaming, and physical aggression.

These behaviors affected her daily routine significantly. She often arrived late to school or missed it altogether because of the time spent on her compulsive routines. At school, she avoided sitting near classmates and refrained from eating lunch out of fear of contamination. As a result of all of these, her academic performance began to decline. There was a period of school refusal, secondary to obsessive-compulsive symptoms and associated distress. Emotional distress was mainly related to obsessive-compulsive symptoms, without an identifiable other comorbid anxiety disorder.

The child’s symptoms were indicative of obsessive behaviors, including a preoccupation with symmetry and contamination. These obsessive thoughts and compulsive behaviors were experienced as distressing and unwanted, with observable resistance, suggesting ego-dystonic features appropriate to the child’s developmental level. These symptoms were continuous and worsening progressively over time.

There were no associated involuntary repetitive movements, hyperactivity, or neurological abnormalities. The child was born of a non-consanguineous marriage and was delivered at term via normal vaginal delivery in a hospital setting. Both the mother and the child had no antenatal, perinatal, or postnatal complications. Immunizations were completed as per age, and developmental milestones were age-appropriate.

A formal assessment of stable temperament was not feasible due to the child’s age and the presence of active psychopathology. Parental reports suggested that prior to the onset of illness, the child had a moderate activity level and regular biological rhythms. She was somewhat slow to warm up in unfamiliar situations but settled with reassurance. During the course of illness, biological rhythms were disrupted due to compulsive routines. The child showed low adaptability, becoming distressed when routines were changed. Emotional reactions were intense, especially when rituals were interrupted. Affect was predominantly anxious, with brief periods of playfulness. Persistence was high for OCD-related tasks but variable otherwise. Attention was somewhat focused on compulsive behaviors during the illness phase.

There were no obsessive-compulsive related disorders, vocal tics, or other psychiatric comorbidities. There was no reported history of behaviors indicative of neurotic tendencies, including nail-biting, head banging, thumb-sucking, or enuresis. There was no history suggestive of autism spectrum disorder, as developmental history prior to illness onset revealed intact reciprocal social interaction, age-appropriate social communication, and adequate peer engagement. No history of restricted or repetitive interests typical of autism spectrum disorder. Developmental history suggested age-appropriate physical and psychological growth, and there was no history of any significant familial or interpersonal conflicts influencing her behavior. There was a family history of obsessive-compulsive traits in her mother.

On examination, the child was well oriented, and higher mental functions were age-appropriate. Her vitals were within normal limits, and height and weight were age-appropriate. Neurological and systemic examination showed no abnormalities. Children’s Yale-Brown Obsessive-compulsive Scale (CY-BOCS) parent version and Children’s Global Assessment Scale (CGAS) were administered. On initial assessment, the scores were 28 (Obsessions: 14, Compulsions: 14) and 45, respectively, indicating severe symptomatology. Formal intellectual assessment using the Wechsler Preschool and Primary Scale of Intelligence 4th Edition (WPPSI-IV) revealed a Full-Scale IQ (FSIQ) score of 134, indicating above-average intellectual functioning. Laboratory investigations, including complete blood count, thyroid function test, blood glucose levels, kidney and liver function tests, were normal. Hemoglobin level (12.5 g/dL), total leukocyte count (8800 mm ³ ), differential leukocyte count (P65 L28 M4 E2), all within normal reference ranges. C-reactive protein (CRP) was 1.2 mg/L, within normal limits, and the anti-streptolysin O (ASO) titer was negative.

In accordance with DSM-5 criteria, a diagnosis of OCD with good or fair insight was confirmed, and the parents were psychoeducated about the disorder, its course, prognosis, and available treatment options. The child was managed on an outpatient basis. Treatment began with fluoxetine, a selective serotonin reuptake inhibitor (SSRI), starting with 5 mg daily and slowly increased to 10 mg daily over 4 weeks. This pharmacological intervention resulted in a reduction in the severity of symptoms, as reflected by a decrease in the CY-BOCS score from 28 (Obsessions: 14, Compulsions: 14) to 19 (Obsessions: 11, Compulsions: 8).

Once the child showed a positive initial response to medication, exposure and response prevention (ERP) therapy was initiated. ERP therapy was started thrice weekly, 45 min each, with concurrent parent management training. The mother participated as a co-therapist in most sessions. All ERP sessions were delivered by a clinical psychologist trained in cognitive-behavioral therapy (CBT) and supervised weekly by a psychiatrist. An age-appropriate exposure hierarchy was collaboratively developed with parental input appropriate for the child’s developmental level and distress tolerance. The hierarchy was graded from low-anxiety tasks like tolerating slight disorganization on her study table to progressively more challenging exposures such as delaying handwashing rituals. Techniques were generalized through structured homework assignments implemented at home under parental supervision. Parents were trained to consistently apply response prevention strategies and resist reinforcing the compulsive behaviors, such as avoiding cleaning items unnecessarily or yielding to her demands for reassurance. Coordination with school teachers was undertaken to minimize accommodation of compulsive behaviors and to encourage graded exposure within the classroom setting such, as sitting near peers, and handling shared materials. This ensured continuity of intervention across clinic, home, and school environments. Positive reinforcement in the form of praise, star charts, additional playtime, and access to preferred activities contingent upon successful completion of exposure tasks and resisting compulsions.

Family accommodation was initially high, with parents providing reassurance and assisting in rituals. This was systematically reduced through psychoeducation and parent management training. Parents were guided to gradually reduce reassurance, avoid participating in rituals, and set consistent limits while maintaining a supportive approach. A progressive reduction in accommodation behaviors was observed over the course of therapy.

After 8 weeks, the combination of fluoxetine and 12 sessions of parent-assisted ERP therapy led to significant improvement. The child’s CY-BOCS score decreased further to 13 (Obsessions: 8, Compulsions: 5), indicating mild symptom severity. Her CGAS score improved to 69, reflecting better overall functioning, with only minor difficulties in specific areas. The child continues regular follow-up in the psychiatry OPD. Following symptomatic improvement, the frequency of ERP sessions was gradually tapered from thrice weekly to once weekly, and subsequently to once fortnightly as maintenance sessions. This was aimed at reinforcing therapeutic gains and preventing relapse. Her CY-BOCS score has further reduced to 9 (Obsessions: 5, Compulsions: 4). Parents report marked improvement in her behavioral symptoms, and she has resumed regular school attendance.

This case highlights the importance of an integrated treatment approach, which involved a multidisciplinary team. The consultant psychiatrist was responsible for diagnostic assessment, pharmacological management, and supervision of the ERP protocol. The clinical psychologist conducted structured ERP sessions and provided parent guidance. The psychiatric social worker offered family support and coordinated with the school to facilitate implementation of therapeutic strategies across settings. It also emphasizes the role of parents in supporting therapy for young children with OCD. Their active participation was instrumental in achieving these positive outcomes.

Discussion

Diagnosing OCD in children presents various challenges, as the clinical presentation in children may differ from that of adults. Magical thinking, repetitive behaviors and actions, and rituals are often present as part of normal development in children, particularly in early and middle childhood. These behaviors, however, are typically transient and generally do not cause significant distress, rarely interfere with day-to-day functioning. In contrast, the repetitive behaviors and intrusive thoughts in OCD are distressing, time-consuming, and significantly impair functioning, as seen in this case.

Children with OCD may or may not have insight into the irrationality of their obsessions and compulsions; this can differ depending on developmental stage. According to the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), children are not required to recognize the irrationality of their obsessions for a diagnosis of OCD, unlike adults. ³ In this case, while the child did not fully comprehend the irrationality of her behaviors, she had mild awareness of their uncommon nature and wanted to address them. This aligns with previous findings that insight in pediatric OCD is often less pronounced than in adults, but can still support the diagnosis. ⁴

Misdiagnosis of OCD in children is common due to its variable presentation. Mohapatra and Rath ⁵ reported a case where OCD was initially misdiagnosed as a psychotic disorder due to the atypical presentation of symptoms, emphasizing the importance of a thorough assessment. ⁵ In this case, careful evaluation excluded other potential differential diagnoses, including pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections (PANDAS), based on the absence of choreiform movements, tics, and its usual relapsing-remitting course, and a negative anti-streptolysin O (ASO) titer. ⁶

Treatment guidelines for pediatric OCD, as outlined by the American Academy of Child and Adolescent Psychiatry (AACAP), recommend cognitive-behavioral therapy (CBT) as the first-line treatment, either alone or in combination with selective serotonin reuptake inhibitors (SSRIs) for moderate to severe cases. ⁷ In this case, as the child had been symptomatic since the age of 4, and given the severity, fluoxetine was initiated before CBT to enhance cooperation. This highlights the importance of early intervention and the efficacy of combining CBT at the right time with pharmacotherapy in managing childhood OCD. ⁸

Implementing psychological intervention in a child this young posed several real-world challenges. These included the child’s limited attention span, difficulty in verbalizing distress, and initial resistance to breaking compulsive routines. The treating team overcame these by adopting a parent-assisted model of exposure and response prevention (ERP), tailored to the developmental level of the child. Therapy incorporated key principles of CBT in childhood OCD, such as gradual exposure to anxiety-provoking stimuli, response prevention, behavioral reinforcement, and psychoeducation. Tasks were introduced in a play-based, non-threatening manner, starting with low-anxiety triggers and progressing gradually. Parental involvement was central; they were trained to avoid reinforcing compulsive behaviors and to provide consistent positive feedback for successful exposure attempts. This collaborative, flexible approach allowed the child to build trust and engage meaningfully in therapy sessions, reflecting the adaptability required in real-world pediatric psychiatric settings. ⁹

Childhood-onset OCD is associated with a chronic course if untreated, often extending into adulthood with significant functional impairment. Early detection and intervention are important in mitigating long-term consequences. ¹⁰ The case also highlights the need for careful monitoring during treatment to address potential side effects, ensure adherence, and modify interventions as needed based on the child’s developmental trajectory.

Despite the positive outcomes observed in this case, certain limitations should be acknowledged. A more detailed autoimmune workup and neuroimaging studies could provide additional insights into potential underlying factors. These investigations were not performed due to the absence of clinical signs suggesting an autoimmune etiology or other organic causes. Neuroimaging, in particular, could be valuable in ruling out neurological conditions that may present with similar psychiatric symptoms in young children. These additional investigations could further refine the diagnostic process, ensuring comprehensive care for children with complex presentations.

This case illustrates the importance of a multidisciplinary approach to diagnosing and managing pediatric OCD, emphasizing early intervention and the need for long-term follow-up to ensure sustained improvements and address any emerging challenges.