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adolescents. It is common for those affected to go to great lengths to
hide their symptoms from parents, peers and professionals because of
their concern that their symptoms will seem peculiar or ‘mad’ to others.
This is probably one reason why mental health services see children
and adolescents with OCD less often than would be expected from the
disorder’s prevalence in the community.
Associated features
Comorbid anxiety and depressive disorders are common and may be
secondary to the OCD. Sometimes it is the anxiety or depression that
leads to psychiatric referral and the child or adolescent may not disclose
the ‘shameful’ obsessive-compulsive symptoms unless specific inquiry is
made. Parents and siblings may be drawn into rituals and demands for
reassurance. About 10% have premorbid obsessive personality. There is
no premorbid excess of bedtime rituals, and children and adolescents with
OCD can generally distinguish clearly between their obsessive-compulsive
symptoms and their ordinary rituals and superstitions.
Differential diagnosis
1 Normal development. Bedtime rituals often peak at 2–3 years and rarely
persist much beyond 8 years. Rule-bound play increases from 5 years.
Collecting often begins around 7. Adolescent ‘obsessions’ such as with
a particular sport or pop idol are culturally sanctioned and aid peer
integration. OCD has some resemblance to normal rituals, with a
bedtime peak and some common themes, for example, counting and
putting things in order. OCD also differs from normal rituals: there is
no age trend in OCD rituals, and symptoms interfere with, rather than
enhance, socialisation and the growth of independence.
2 Primary depressive disorderscan result in secondary obsessive-compulsive
symptoms. It is important to take a careful history to determine whether
depressive symptoms started first.
3 Undifferentiated emotional disorders. Children and adolescents (like adults)
may present with relatively undifferentiated emotional disorders in
which mild obsessive-compulsive symptoms are mixed with fears, wor-
ries and misery, with no one element predominating.
4 Autistic spectrum disorders. The ritualistic and repetitive behaviours char-
acteristic of autistic spectrum disorders differ in several respects from
those seen in OCD:
(a)They are accompanied by other autistic impairments in communi-
cation and social interaction.
(b) They are often simpler than OCD rituals.
(c) They are not seen as unwelcome, distressing or alien (ego-dystonic).