9 Child and adolescent psychiatry9.7 Disorders in childhood and adolescence
9.7.5 Anxiety disorders including OCD in children
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Written by Resident Doctor Committee · Published
When fear becomes a disorder
Anxiety is a disorder when fear is excessive for the child's developmental stage and circumstances, persistent and impairing. No particular age marks the point at which separation distress becomes pathological.
ICD-11 places separation anxiety disorder and selective mutism in the anxiety or fear-related group, without restricting them to childhood.
Obsessive-compulsive disorder (OCD) has its own related-disorders grouping in ICD-11.
Epidemiology
Anxiety disorders are the most prevalent group of psychiatric disorders in children and adolescents in community surveys.
Separation anxiety disorder affects about 3.5 to 4% of children (about 1 in 25), a higher rate than in adolescents.
Generalised anxiety disorder (GAD) is less common in very young children, and panic disorder is less common before puberty.
OCD has a bimodal age at onset, with an early peak at a mean of about 10 years and a second peak in the early twenties.
OCD in young people occurs at a similar rate in both sexes.
Childhood anxiety raises the later risk of anxiety and depression.
Presentation by age
Age | Usual presentation |
|---|---|
Preschool | Tearfulness and clinging |
Middle childhood (about 5 to 12 years) | Bodily complaints, health worries and aggression |
Adolescence | Worry is described more clearly, but avoidance is hidden through seating choices, toilet breaks or reassurance seeking |
Irritability when a child faces a feared task can look like oppositional behaviour.
Family accommodation is reassuring, joining rituals or changing routines to spare the child distress; the immediate relief reinforces both the child's avoidance and the adult's accommodation.
The anxiety disorders
Disorder | Core feature | What tells it apart |
|---|---|---|
Separation anxiety disorder | Fear of harm to an attachment figure during separation | Appears at every separation, not only at school; the child is well when the parent is present |
GAD | Diffuse, hard-to-control worry about many everyday matters most days, moving between unrelated topics | Reassurance seeking, headaches, worry about performance, sensitivity to criticism |
Social anxiety disorder | Fear of being watched and judged by peers, with autonomic symptoms and avoidance | Situation-bound; the child is at ease with family and trusted people |
Selective mutism | Consistent failure to speak in particular settings, such as school beyond the first month | Normal speech elsewhere |
Specific phobia | Persistent, disproportionate fear and avoidance | Ordinary fears of animals, darkness or heights are not enough |
Post-traumatic stress disorder (PTSD) | Re-experiencing, avoidance and hyperarousal after a threatening event | Re-experiencing shows as repetitive play re-enacting the event and distressing dreams |
Panic disorder | Recurrent unexpected attacks with continuing concern or changed behaviour | One isolated attack is not a disorder |
Separation anxiety disorder usually reaches care through repeated anticipatory physical complaints (headaches, abdominal pain, nausea) when separation is expected.
Morning worsening (diurnal variation) points to depression, not GAD.
School refusal
School refusal describes difficulty attending, not a diagnosis, so assess separation and social anxiety, depression, autism, bullying, learning problems and physical illness.
Feature | School refusal | Truancy |
|---|---|---|
Absence | Open | Concealed |
Emotion | Anxiety, distress and somatic symptoms | No fear or distress about school |
Whereabouts | At home | Away from home |
Parents | Aware | Often unaware |
Associations | Anxiety and depression | Conduct or substance problems |
School refusal peaks at 11 to 13 years and typically begins at a school transition, most often the move from primary to secondary school.
Boys and girls are affected about equally.
Waiting for the anxiety to settle reinforces avoidance, so clinicians plan a supported, phased return.
OCD in children
Childhood OCD is ego-dystonic: feared intrusive obsessions are paired with rule-bound compulsions performed to neutralise them, and they cause impairment.
Children may have limited insight or struggle to describe obsessions, so compulsions and family rituals are often the first visible signs.
Poor insight alone does not establish psychosis.
Behaviour | What drives it | How the child experiences it |
|---|---|---|
Compulsion | An obsession or feared outcome; the act is goal-directed to neutralise it | Feels driven; resisting raises distress |
Autistic routine | Predictability, interest or sensory regulation | Comforting; interruption may distress |
Tic | A premonitory sensory urge; the act has no purpose | Brief relief after the movement or sound |
GAD differs from OCD because its worry is diffuse and is not tied to rituals.
Compulsions and tics are both partly suppressible, worsen with stress and stop in sleep, so the goal-directed purpose of a compulsion is what separates them.
Autistic children can also have OCD, and children with OCD may not name a feared consequence.
PANDAS
PANDAS (paediatric autoimmune neuropsychiatric disorders associated with streptococcal infections) is a proposed post-streptococcal autoimmune syndrome in which OCD symptoms, with or without tics, begin or worsen abruptly in a prepubertal child after group A streptococcal infection.
The proposed mechanism is cross-reacting antibodies.
PANS (paediatric acute-onset neuropsychiatric syndrome) is broader, covering abrupt OCD or severely restricted eating with other acute symptoms.
There is no diagnostic biomarker, raised antistreptococcal titres do not prove causation, and antibiotics or immunomodulation are not routine OCD treatments.
Treating anxiety disorders
Condition | First-line treatment |
|---|---|
Specific phobia | Exposure-based cognitive behavioural therapy (CBT), including a brief one-session format |
Social anxiety disorder | CBT focused on social anxiety, individual or group, typically 8 to 12 sessions; no routine medication |
PTSD | Individual trauma-focused CBT; no medication under 18 |
Anxiety-based school refusal | Individualised exposure-based CBT with family work embedded |
Body dysmorphic disorder | Fluoxetine is the antidepressant of choice when medication is added |
These are the recommendations of the National Institute for Health and Care Excellence (NICE).
Benzodiazepines are not recommended for anxiety disorders in children and adolescents, because they lack trial evidence of benefit and risk disinhibition.
The parent-only SPACE programme, which targets family accommodation, was non-inferior to child CBT in a trial of 124 children aged 7 to 14.
Treating OCD
NICE stepped care
Presentation | Step |
|---|---|
Mild impairment | Guided self-help with information for the family |
Moderate or severe impairment, mild learning disability, or mild impairment after self-help failed | CBT including exposure and response prevention, with the family involved |
Psychological treatment declined or not possible | Consider a selective serotonin reuptake inhibitor (SSRI) with careful monitoring |
No response after 12 weeks of full CBT | Multidisciplinary review; consider adding an SSRI at 8 to 11 years, offer one at 12 to 18 |
Two SSRIs failed, each at full dose for an adequate period alongside CBT | Multidisciplinary review, then consider clomipramine with a baseline electrocardiogram (ECG) |
Severe, no outpatient response, self-neglect or suicide risk | Assess for intensive or inpatient care |
CBT comes before any SSRI in children even when impairment is severe, unlike the adult rule of combined treatment for severe impairment.
Exposure and response prevention is a graded plan of approaching feared situations while rituals, reassurance and family participation are cut back in agreed steps.
Pediatric OCD Treatment Study (POTS)
Over 12 weeks, remission was 53.6% with combined CBT and sertraline, 39.3% with CBT, 21.4% with sertraline and 3.6% with placebo.
Combined treatment beat either alone and both beat placebo, so the authors advised starting with the combination or with CBT alone.
Medication
Drug | Position in paediatric OCD |
|---|---|
Sertraline | Licensed in the UK from age 6; the usual first drug, with the strongest evidence because POTS used it |
Fluvoxamine | Licensed from age 8 |
Fluoxetine | Preferred when significant depression coexists; first-line SSRI for depression (Treatment for Adolescents with Depression Study) |
Paroxetine | Unsuitable under 18 |
Other tricyclics, monoamine oxidase inhibitors, serotonin-noradrenaline reuptake inhibitors | Not used |
A licence for OCD in adults only, or a paediatric licence for depression, confers nothing for paediatric OCD.
Clomipramine needs careful thought about toxicity in overdose.
Clinicians start low, sometimes at a quarter or half the usual starting dose for the first week, and benefit may take up to 12 weeks.
All antidepressants need monitoring for suicidal thoughts, self-harm, hostility and activation, especially early and after dose changes.
Continue an effective SSRI for at least 6 months after remission, meaning no clinically significant symptoms and full functioning for 12 weeks, then taper gradually.
Antipsychotics are not used alone; augmentation is reserved for resistant cases under specialist care.
Outcome
Residual symptoms and relapse are common after CBT, and OCD can persist hidden.
For continuing symptoms, arrange an adult service and a named clinician before transition.