poc very child

Children with very early onset obsessive-compulsive disorder: clinical features and

treatment outcome

Eriko Nakatani,1 Georgina Krebs,2 Nadia Micali,1 Cynthia Turner,1,2

Isobel Heyman,1,2 and David Mataix-Cols1,21King’s College London, Institute of Psychiatry; 2OCD and Related Disorders Clinic for Young People, South London

and Maudsley NHS Foundation Trust, London, UK

Background: There is emerging evidence that early onset obsessive-compulsive disorder (OCD) may bea phenomenologically distinct subtype of the disorder. Previous research has shown that individualswho report an early onset display greater severity and persistence of symptoms, and they may be lessresponsive to treatment. To date, this question has been investigated solely in adult samples. Thepresent study represents the first investigation into the effect of age at onset of OCD on clinical char-acteristics and response to treatment in a paediatric sample. Methods: A total of 365 young peoplereferred to a specialist OCD clinic were included in the study. Clinical records were used to examinepotential differences in key clinical characteristics between those who had a very early onset of thedisorder (before 10 years) and those who had a late onset (10 years or later). Group differences intreatment responsiveness were also examined within a subgroup that received cognitive behaviourtherapy (CBT) alone or CBT plus medication (n = 109). Results: The very early onset group werecharacterised by a longer duration of illness, higher rates of comorbid tics, more frequent ordering andrepeating compulsions and greater parent-reported psychosocial difficulties. There were no differencesin treatment response between the groups, and when age at onset was examined as a continuousvariable, it did not correlate with treatment response. Conclusions: Very early onset OCD may beassociated with different symptoms and comorbidities compared with late onset OCD. However, thesedifferences do not appear to impact on responsiveness to developmentally tailored CBT alone or incombination with medication. These findings further indicate the value in early detection and treatmentof OCD in childhood. Keywords: Obsessive-compulsive disorder, paediatric, age at onset, early onset,cognitive behaviour therapy.

IntroductionObsessive-compulsive disorder (OCD) is a chronicand debilitating condition with a lifetime prevalenceof approximately 2% in general population (Ruscio,Stein, Chiu, & Kessler, 2010). The disorder oftenemerges in childhood or adolescence, with approxi-mately a third to a half of adult patients reporting achildhood onset (Rasmussen & Eisen, 1990). Paedi-atric OCD is increasingly recognised as a putativedevelopmental subtype of the disorder, which ischaracterised by a higher preponderance of boys(Tukel et al., 2005), an increasing familial load forOCD (Nestadt et al., 2000; Rosario-Campos et al.,2005) and higher comorbidity with tic disorders(Diniz et al., 2004; Millet et al., 2004; Rosario-Cam-pos et al., 2001).

Investigations into early onset OCD to date havebeen complicated by methodological inconsistenciesin the literature. First, definitions of age at onsethave varied, with some studies reporting the age atwhich the patient and/or family members first

noticed the presence of obsessive-compulsivesymptoms (Diniz et al., 2004; de Mathis et al., 2008;Rosario-Campos et al., 2001), and others reportingthe age at which the patient first fulfilled strictdiagnostic criteria for OCD (Sobin, Blundell, &Karayiorgou, 2000).

Second, it remains unclear how early onset shouldbe defined and whether particular age cut-offsshould be employed. Previous studies using adultand/or paediatric samples have used variousthresholds to select their early onset samples. Forexample, early onset has been defined as before 15(Millet et al., 2004), 17 (Fontenelle, Mendlowicz,Marques, & Versiani, 2003; Tukel et al., 2005), andeven 18 years (Sobin et al., 2000). In another study,thresholds of 10 and 17 years were used to catego-rise early and late onset, respectively (Rosario-Campos et al., 2001). Recently, a large-scale study(n = 330) attempted to establish the most appropri-ate cut-off points to differentiate early and late onsetOCD (de Mathis et al., 2008). The authors suggestedthat ages of 10 and 17 years might be reasonablethresholds, although concluded that age at onsetmay be best measured as a continuous variable.The lack of consensus in this area was further

Eriko Nakatani and Georgina Krebs are joint first authors.

Conflict of interest statement: No conflicts declared.

Journal of Child Psychology and Psychiatry **:* (2011), pp **–** doi:10.1111/j.1469-7610.2011.02434.x

� 2011 The Authors. Journal of Child Psychology and Psychiatry � 2011 Association for Child and Adolescent Mental Health.Published by Blackwell Publishing, 9600 Garsington Road, Oxford OX4 2DQ, UK and 350 Main St, Malden, MA 02148, USA

highlighted in a recent worldwide survey among OCDexperts, who failed to agree on the appropriate cut-off for early onset OCD (Mataix-Cols, Pertusa, &Leckman, 2007).

The clinical utility of differentiating early and lateonset OCD is uncertain. Some studies have reportedthat early onset is associated with poorer prognosisand more severe symptoms after treatment(Ackerman, Greenland, Bystritsky, Morgenstern, &Katz, 1994; Fontenelle et al., 2003; Ravizza, Barze-ga, Bellino, Bogetto, & Maina, 1995; Rosario-Cam-pos et al., 2001), while others have found nosignificant relationship between age at onset andtreatment response (Ackerman, Greenland, & Bys-tritsky, 1998; Alonso et al., 2001; Shavitt et al.,2006; Uguz, Askin, Cilli, & Besiroglu, 2006). How-ever, most of these studies examined this question inrelation to medication response, rather than cogni-tive behaviour therapy (CBT), which is the first-linetreatment for the disorder in young people (e.g. Na-tional Institute for Health and Clinical Excellence,2005).

To date, only three studies have examined therelationship between age at onset of OCD and CBTresponse. In a survey of 617 adults with OCD, self-report data were collected on age at onset andtreatment history (Millet et al., 2004). No differenceswere found in response to selective serotonin reup-take inhibitor (SSRI) medication or behaviour ther-apy between individuals who reported early onset(before 15 years) and late onset (after 15 years). Animportant limitation of this study was the reliance onretrospective self-report of treatment response. Inanother study, case records of 254 adult inpatientswho had received CBT for OCD were reviewed(Langner et al., 2009). No significant differenceswere found between the early onset (before 12 years)and late onset (15 years or later) groups in terms oftreatment outcome, although there were group dif-ferences in terms of the variables that predictedtreatment responsiveness. Lomax, Oldfield, andSalkovskis (2009) compared CBT response ratesbetween early onset (12 years or younger; n = 22)and a late onset (16 years or older; n = 23) OCD.They found that the two groups were equallyresponsive to CBT, although the early onset grouphad more severe symptoms both before and aftertreatment; the authors suggested that such individ-uals may require an extended course of CBT.

Arguably, the main limitation of research in thisarea is the fact that most studies have ascertainedage at onset retrospectively in adult samples of OCDpatients. This limitation can be partially overcome bystudying the correlates of age at onset in paediatricsamples because children seek help much earlierthan adults with OCD and recall bias is thereforeless likely. For example in a recent UK study, youngpeople were first seen at a specialist OCD clinic onaverage 3 years after the onset of the disorder(Nakatani, Mataix-Cols, Micali, Turner, & Heyman,

2009). This compares with a reported average delayof 8 years until diagnosis in adult populations (Sto-bie, Taylor, Quigley, Ewing, & Salkovskis, 2007). Todate, no study has examined the relationship be-tween age at onset and CBT response in a paediatricsample.

In this study, we report on a large sample of pa-tients referred to a national specialist clinic for chil-dren and adolescents with OCD. The first aim was tocompare the demographic characteristics, clinicalfeatures, and severity of symptoms of patients withvery early (i.e. before 10 years) onset OCD and thosewith a late onset (i.e. between 10 and 18 years) OCD.The second aim was to determine whether there wasa differential effect of age at onset on response toCBT (delivered as a monotherapy or in combinationwith SSRI medication). It was predicted that patientswith very early age at onset would be more likely tobe male, have comorbid tic disorders and presentwith more severe symptoms, but that they would bejust as likely to benefit from specialist CBT tailoredto the young person’s developmental level.

MethodsParticipants

All children and adolescents consecutively referred forassessment and/or treatment to a national specialistpaediatric OCD clinic at the Maudsley Hospital, Lon-don, between the years 1996 and 2007 were included inthe study. Young people are referred to the clinic fromacross the United Kingdom and tend to be a relativelysevere or treatment-refractory group, or have complex-ities regarding diagnosis. All participants met Interna-tional Classification of Diseases (ICD)-10 (World HealthOrganisation, 1996) diagnostic criteria for OCD, asconfirmed by the specialist multidisciplinary team.Detailed sociodemographic and clinical information,including age at onset, was gathered from the patientsand their parents at the initial assessment, which las-ted approximately 3 hr. In addition to assessing OCDsymptoms, clinical assessment included a careful clin-ical screen for current/ever tics based on ICD-10 cri-teria, as well as direct observation and probe forfamily history of tic disorders. All data were collected aspart of routine clinical practice at the clinic, and advicefrom local ethics committee recommended this projectbe classed as audit.

After exclusion of four patients whose age at onset wasmissing, a total of 365 patients were included in thestudy. Of these, a subgroup of 109 individuals receivedCBT. The decision to offer CBTwas largely determined byclinical appropriateness and geographical location (i.e.feasibility of travelling to the clinic for weekly sessions).

Age at onset was defined as the age at which patientsfirst displayed significant distress or impairment asso-ciated with obsessive-compulsive symptoms. Thisinformation was obtained on the day of the initialassessment and based primarily on parental report andsupplemented with the young person’s report. In thetotal sample, the mean age at onset of OCD was 10.2

2 Eriko Nakatani et al.

� 2011 The Authors. Journal of Child Psychology and Psychiatry � 2011 Association for Child and Adolescent Mental Health.

(SD = 2.9; range = 3–17) and the median was 10 years(Figure 1). A median split was used to define the two ageat onset groups: ‘very early onset’ included children whoreported onset at 9 years or younger and the ‘late’ onsetgroup constituted children who reported an onset at10 years or older. While relatively arbitrary, thisapproach ensured similar sized groups and sufficientstatistical power for analysis. In any case, analyses wererepeated using various ages as the defined cut-off pointwith no difference on the results obtained (data availableupon request). Furthermore, the role of age at onset wasalso examined as a continuous variable.

Measures

The Children’s Yale-Brown Obsessive-Compulsive Scale(CY-BOCS; Scahill et al., 1997) is a widely used clini-cian-administered measure of OCD symptom severity.It includes a symptom checklist and severity scale.Severity scores range from 0 to 40. It has establishedpsychometric properties (Scahill et al., 1997) and issensitive to treatment effects (Storch, Lewin, De Nadai,& Murphy, 2010).

The Children’s Obsessive-Compulsive Inventory(ChOCI; Shafran et al., 2003) is a self-report instru-ment developed to assess obsessive-compulsive symp-toms in children and adolescents. It has a patient and aparent version, both of which consist of the followingfour subscales: obsessions, impairment associated withobsessions, compulsions and impairment associatedwith compulsions. The total score, ranging from 0 to 48,is constructed by summing the impairment items. Ithas been shown to have good internal consistency andcriterion validity and to be significantly correlated withthe CY-BOCS (Uher, Heyman, Turner, & Shafran,2008).

The Beck Depression Inventory for Youth (BDI-Y;Beck, Beck, & Jolly, 2001) is a 20-item, self-reportmeasure of depressive symptoms, which includesquestions about negative thoughts, feelings of sadnessand physiological indications of depression. Total rawscores range from 0 to 60, and can be translated into a T

score based on the age and gender of the young person.The BDI-Y displays good internal consistency and test-criterion validity, and correlates highly with otherestablished measures of depression (Beck et al., 2001).The BDI-Y was administered to a subset of the currentsample (n = 95).

The Global Assessment of Psychosocial Disability(GAPD; World Health Organisation, 1996) constitutesAxis VI of the ICD-10, and is a measure of psychologi-cal, social and educational/occupational disability thathas arisen as a consequence of psychiatric or develop-mental disorders coded on Axes I, II and III. Cliniciansassign a score, ranging from 0 (superior/good socialfunctioning) to 8 (profound and pervasive social dis-ability). The scale has been shown to have good inter-rater reliability and comparable properties with theChildren’s Global Assessment Scale, a widely usedmeasure of global functioning (Dyborg et al., 2000).

The Strengths and Difficulties Questionnaire (SDQ;Goodman, 1997) is a self-report measure that assessespsychological adjustment in children and adolescents.It has self, parent and teacher versions and includes 25items divided among five subscales that relate to dif-ferent areas of difficulty. The total difficulties score wasused in the present study, and is constructed by sum-ming the symptom subscales. The measure has goodinternal consistency, cross-informant correlation andretest stability after 4–6 months, and an elevated scoreis predictive of psychiatric diagnosis (Goodman, 2001).

Treatment

CBT was protocol-driven, and broadly based on apublished treatment manual (March & Mulle, 1998). Itinvolved the following key components: psychoeduca-tion about OCD and anxiety, and development of ahierarchy of compulsions (Sessions 1 and 2); gradedexposure with response prevention (ERP; Session 3onwards); and relapse prevention (final session). Thetreatment was carefully tailored to the developmentallevel of the young person, for example, by modifying thelanguage and worksheets used. The extent of parental

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Figure 1 Distribution of age at onset in the sample

Children with very early onset OCD 3


involvement varied depending both on the develop-mental level of the young person and the extent towhich parents were involved in, or accommodating,compulsive behaviours and avoidance. Sessions usu-ally lasted 1 hr, and were conducted on a weekly basiswhenever possible. In most cases, 8–12 sessions wereoffered. For most patients, CBT was delivered in anindividual, face-to-face format, although some receivedgroup CBT (n = 4) or telephone-based CBT (n = 2). Aproportion of young people (n = 77) also received SSRImedication in combination with CBT; in most cases,medication was started and had reached a stable dosebefore CBT commenced.

Statistical analyses

Datawas analysedusingSPSS version18 (IBM,Chicago,Illinois). software. Chi-squared tests were used forbetween-group comparisons of categorical variables andindependent sample t-tests for continuous variables. Amixed model ANOVA was used to test for a differentialeffect of age at onset on responsiveness to CBT. Theassociations between age at onset (as a continuousvariable) and other clinical variables of interest wereexamined with Pearson correlations. Finally, a multipleregression analysis was conducted to investigate the ex-tent towhichageatonsetpredictsOCDsymptomseverityfollowing CBT, controlling for other variables of interest.The significance level was set at p < .05 (two-tailed).

ResultsSample characteristics

The sample consisted predominantly of boys(58.6%), with a mean age of 13.8 years (SD = 2.5,

range = 6–18 years) at assessment, and duration ofillness of 3.6 years (SD = 2.8, range = 0–13). Themean total CY-BOCS score was 22.3 (SD = 7.9),indicating moderately severe OCD. The most fre-quently assigned grade on the GAPD was 3, corre-sponding to moderate psychosocial disability(M = 3.2, SD = 1.5).

Comparison of very early and later onset groups

Demographic and clinical characteristics of the twogroups are shown in Table 1. The very early onsetgroup was younger at assessment and had a longerhistory of OCD than the late onset group. The twogroups were comparable in terms of genderdistribution, family history of OCD, symptom sever-ity (CY-BOCS and ChOCI), depression (BDI) andpsychosocial disability (GAPD). Comorbid chronic ticdisorders were more frequent in the very early onsetgroup, although the proportion of patients withcomorbid Tourette syndrome was comparable. Onthe parent-rated SDQ, patients with very early onsetOCD had significantly greater scores on the totaldifficulties. There were no between-group differenceson the self or teacher versions of the SDQ. Repeatingand ordering compulsions were significantly morefrequent in the very early onset group (Table 2).

Effectiveness of CBT

Of the total sample, 109 (40 very early onset, 69 lateronset) were treated with CBT at the clinic and hadavailable CY-BOCS scores before and after the treat-

Table 1: Comparison of demographic and clinical characteristics of patients in very early and later onset group

Very earlyonset (n=151)

Later onset(n=214)

Chi square/t-test

p

Age (years) at assessment, mean (SD) 12.5 (2.9) 14.7 (1.7) )8.45 <0.0001**Boys, n (%) 89 (58.9) 125 (58.4) 0.01 0.91Duration of OCD (years), mean (SD) 5.1 (3.4) 2.6 (1.7) 8.48 <0.0001**Age at onset (years), mean (SD) 7.4 (1.7) 12.5 (2.9) )9.18 <0.0001**Tic disordersChronic Tics, n (%) 25 (16.6) 18 (8.4) 5.65 0.02*Tourette syndrome, n (%) 24 (15.9) 23 (10.7) 2.09 0.14Any Tic disorder, n (%) 49 (32.5) 41 (19.2) 8.42 0.004**

Family history of OCD, n (%) 17 (11.5) 16 (7.7) 1.52 0.22CY-BOCS scores (n=329)Total, mean (SD) 22.2 (7.7) 22.4 (8.0) )0.26 0.78Obsessions score, mean (SD) 10.1 (4.6) 10.7 (4.7) )1.07 0.28Compulsions score, mean (SD) 12.0 (3.8) 11.7 (4.3) 0.54 0.58

ChOCI scoresSelf total (n=251), mean (SD) 29.5 (8.7) 28.1 (9.8) 1.16 0.24Parent total (n=228), mean (SD) 32.4 (8.5) 32.6 (8.6) )0.18 0.85

SDQ scoresSelf total (n=218), mean (SD) 17.7 (6.9) 17.5 (6.4) 0.31 0.75Parent total (n=328), mean (SD) 19.2 (7.2) 17.4 (6.8) 2.34 0.03*Teacher total (n=209), mean (SD) 14.4 (7.6) 14.3 (7.4) 0.11 0.90

GAPD score (n=365), mean (SD) 3.0 (1.4) 3.3 (1.5) )1.81 0.07BDI-Y score (n=95), mean (SD) 23.3 (11.3) 21.7 (12.0) 0.68 0.49

OCD, obsessive-compulsive disorder; CY-BOCS, Children’s Yale-Brown Obsessive-Compulsive Scale; ChOCI, Children’s Obsessive-Compulsive Inventory; SDQ, Strengths and Difficulties Questionnaire; GAPD, Global Assessment of Psychosocial Disability;BDI-Y,Beck Depression Inventory for Youth. * = significant at .05 level;** = significant at .01 level.



ment. Analysis of this subgroup with respect todemographic and clinical characteristics yieldedsimilar findings to the total sample. Patients in thevery early onset were significantly younger (M = 12.7vs. M = 14.8 years, p < .001) and had a longer dura-tion of illness (M = 5.3 vs. M = 2.4 years, p < .001).There were no significant differences in terms ofgender distribution in the very early and later onsetgroups (boys: 60.5% and 55.1%; v2 = .251, df = 1,p = .69). Of the 109 treated patients, 75 received CBTconcomitant with SSRI medication. The proportionof patients receiving combined treatment was equiv-alent in the very early and later onset groups (77.5%vs. 63.8%; v2 = 2.22, df = 1, p = .20).

Mean CY-BOCS scores pre- and post-treatment areshown in Table 3. The mean percentage reduction intotal CY-BOCS score from the baseline to post-treat-ment was 58.4% for very early onset group and 51.5%for the later onset group. A mixed-model ANOVA with

the within-subjects factor of time (pre- vs. post-treat-ment) and the between-subjects factor of onset group(very early vs. later onset) was conducted and revealedamain effect of time [F(1, 108) = 332.46, p < .001], asindicatedbya significant reduction inCY-BOCSscoreover the course of the treatment [M = 23.40,SD = 5.60 vs. M = 10.76, SD = 6.92; t(108) = 18.51,p < .001]. There was no main effect of onset group[F(1, 108) = 0.319, p = .57], and no significantTime · Onset Group interaction [F(1, 108) = 1.64,p = .208], indicating that the two onset groups re-sponded equally well to treatment.

Participants were classified into the followingseverity groups based on their total CY-BOCS score:subclinical (0–10); mild (11–19); moderate (20–29);and severe (>30). Of the 109 treated patients, 24(60.0%) in very early onset group and 38 (55.1%) inthe later onset group were classified as having sub-clinical OCD symptoms following treatment(v2 = .251, df = 1, p = .69; Figure 2).

Age at onset as a continuous variable

Planned correlational analyses were conducted tofurther investigate the relationship between age atonset and other clinical characteristics. On theparent-rated SDQ, there was a negative correlationbetween age at onset and the total difficulties score(r = )0.14, p < .05). There were no other statisticallysignificant associations between age at onset andclinical measurements (CY-BOCS, ChOCI, BDI, SDQand GAPD). Among the 109 treated patients, therewas no statistically significant correlation betweenage at onset and the outcome variables includingpost-treatment CY-BOCS score and percentagereduction on the CY-BOCS (all p > .05).

An additional exploratory multiple regressionanalysis was conducted with the post-treatmentCY-BOCS score as the dependent variable and thefollowing variables as regressors: pretreatmentCY-BOCS score; age at onset; presence of tic disorder;chronicity of OCD; medication status; and gender.This analysis revealed that pretreatment severitypredicted post-treatment severity (b = .367, t = 4.09,p < .001). Concomitant use of SSRIs (b = .230,t = 2.60, p = .011) was also a significant predictor;combined treatment was associated withmore severesymptoms after CBT, controlling for pretreatmentseverity. No other variables were significant predic-tors of post-treatment symptom severity.

DiscussionThis study examined the influence of age at onset ofOCD on clinical characteristics and responsivenessto CBT in a large paediatric sample. As predicted, wefound a number of differences in the demographicand clinical characteristics of the very early onsetgroup compared with the late onset group. Individ-uals who developed OCD before 10 years were found

Table 2: Frequency of obsessions and compulsions in youngpeople with very early and late onset OCD according to theCY-BOCS symptom checklist.

Very earlyonset

(n=124)Later onset(n=177)

Chisquare p

Obsessions (%)Contamination 85 (68.5) 123 (69.5) 0.03 0.86Aggressive 89 (71.8) 124 (70.1) 0.04 0.75Sexual 23 (18.5) 41 (23.2) 0.92 0.34Hoarding 39 (31.5) 43 (24.3) 1.88 0.17Magical 42 (33.9) 59 (33.3) 0.009 0.92Somatic 42 (33.9) 66 (33.7) 0.37 0.54Religious 37 (29.8) 67 (37.9) 0.20 0.15

Compulsions (%)Cleaning 91 (71.7) 122 (68.9) 0.26 0.61Checking 91 (71.7) 117 (66.1) 1.05 0.30Repeating 91 (71.7) 102 (57.6) 6.22 0.01*Counting 59 (46.5) 73 (41.2) 1.05 0.37Ordering 74 (58.3) 77 (43.5) 6.44 0.01*Hoarding 41 (32.3) 60 (33.9) 0.08 0.77Superstitious games 49 (38.6) 68 (38.4) 0.001 0.98Rituals involvingothers

72 (56.7) 108 (61.0) 0.57 0.45

* = significant at .05 level.

Table 3 Mean (standard deviation) Children’s Yale-BrownObsessive-Compulsive Scale (CY-BOCS) scores pre- and post-treatment for the very early and late onset groups

Treatmenttime point

Very earlyonset

(n = 40)

Lateonset

(n = 69) t p

CY-BOCS totalPre 23.6 (5.6) 23.3 (5.6) 0.277 .782Post 9.8 (5.8) 11.3 (7.5) )1.076 .284

CY-BOCS obsessionsPre 10.9 (3.5) 11.1 (4.0) )0.251 .802Post 4.3 (3.1) 5.4 (4.3) )1.318 .190

CY-BOCS compulsionsPre 12.7 (2.9) 12.2 (3.2) 0.807 .421Post 5.7 (3.4) 6.0 (4.2) )0.369 .297



to have had a longer duration of illness, despitebeing younger at assessment, compared with the lateonset group. This may partly be because of obses-sive-compulsive symptoms being mistaken as anormal developmental phase in very young children,and partly because of poorer insight in this popula-tion which in turn means they are less likely to seekhelp. The very early onset group also had higherrates of comorbid tic disorders, and their OCDsymptoms more frequently involved repeating andordering/arranging. These findings are consistentwith previous studies which have demonstrated arelationship between early onset OCD and tic disor-ders (Diniz et al., 2004; Millet et al., 2004; Rosario-Campos et al., 2001), and also elevated levels ofrepeating and ordering compulsions among OCDpatients with tic disorders (Scahill et al., 2003).

No relationship was found between age at onsetand OCD symptom severity, an association that hasbeen demonstrated in previous studies conductedamong adults with OCD (e.g. Jansch et al., 2007;Lomax et al., 2009). However, parents of the veryearly onset group reported a higher level of psycho-social difficulties, possibly indicating greaterimpairment associated with OCD symptoms, whichcould well be a consequence of greater duration ofillness. Both the very early and later onset groupswere characterised by a male preponderance, whichis a well-replicated finding among paediatric OCDstudies (e.g. Geller et al., 2001; Last & Strauss,1989; Swedo, Rapoport, Leonard, Lenane, & Che-slow, 1989). Somewhat surprisingly, no group dif-ferences were observed in the gender distribution,unlike previous studies conducted among adultswhich have demonstrated a greater ratio of boysamong early onset patients (Tukel et al., 2005). Thisinconsistency may be explained by the varying age

thresholds used across studies, and the fact that thesex ratio in OCD may switch from predominantlymen to predominantly women during teenage years(Castle, Deale, & Marks, 1995; Geller et al., 2001).

Crucially, both the very early onset and late onsetgroups demonstrated significant reductions in OCDsymptoms over the course of CBT, and the extent ofsymptom reduction and the proportion of patientsachieving remission was found to be equivalent forthe two groups. When age at onset was examined asa continuous variable, again no relationship wasfound between this factor and CBT response. Thisfinding is in line with previous studies in adultpopulations (Langner et al., 2009; Lomax et al.,2009; Millet et al., 2004), and suggests that devel-opmentally appropriate CBT for OCD, delivered as amonotherapy or in combination with SSRI medica-tion, is robust to age at onset and duration of illnessin young people. This was further supported by amultiple regression analysis, which found that age atonset did not predict OCD symptom severity aftertreatment. More severe pretreatment symptoms andconcomitant medication were both independentpredictors of more severe symptoms at post-treat-ment. With respect to medication, this finding mayreflect a tendency to prescribe medication for caseswith greater complexities in their clinical presenta-tion (e.g. significant comorbidities), which mightcreate barriers in CBT.

This study has a number of limitations. First, age atonset was determined by retrospective recall by theyoung person and parents. However, compared withprevious studies that have been conducted in adultpopulations and relied solely on the patient’s report,this study has the advantage of establishing onsettimings closer to the actual onset date, as well asutilising multiple informant accounts. Second, this

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Figure 2 Obsessive-compulsive disorder symptom severity (total Children’s Yale-Brown Obsessive-Compulsive Scale scores) reported bythe very early and later onset groups before and after cognitive behaviour therapy



study was conducted in a specialist clinic that tendsto receive referrals for complicated or severe OCD,and hence the patients may not have been a repre-sentative sample. However, as discussed before, anumber of similarities were noted between the sam-ple characteristics reported here and previous stud-ies. Third, no structured diagnostic interviews wereused to assign diagnoses and therefore it was notpossible to examine the influence of age at onset oncomorbidity, other than tic disorders which wereroutinely assessed. Fourth, some of the young peoplewho received CBT were also on SSRI medication,although in most cases medication was started andhad reached a stable dose before CBT commenced.Furthermore, the proportion of patients on medica-tion in the very early and late onset groups wascomparable.

In summary, this study represents the firstinvestigation into the potential influence of age atonset of OCD on responsiveness to treatment inyoung people. The current findings suggest thatalthough very early onset OCD could be phenome-nologically distinct from late onset OCD, the age atwhich the disorder emerges is not a prognostic factorfor treatment. Individuals who have a very earlyonset respond equally well to CBT that is tailored totheir developmental level, compared with young

people with a late onset. This finding is encouragingand indicates the value of early detection and treat-ment of the disorder. At present, OCD in youth oftengoes undetected for many years, thus delayingaccess to evidence-based treatment. A longer dura-tion of illness has been shown to predict persistenceof OCD symptoms (e.g. Micali et al., 2010), whichcan in turn lead to substantial disability thatexpands into adulthood. Further investigation intothe phenotype of OCD in childhood has the potentialto assist clinicians in the detection and diagnosis ofthe disorder, thereby facilitating early interventionand improving clinical outcomes.

AcknowledgementsThis study was partially funded by a grant from theSouth London and Maudsley NHS FoundationTrust.

Correspondence toDavid Mataix-Cols, King’s College London, Institute ofPsychiatry, PO Box 69, De Crespigny Park, London SE58AF, UK; Tel: +44 2078480543; Email: [email protected]

Key points

• The current study represents the first investigation into the potential association between age at onset of OCDand responsiveness to treatment in young people.

• Young people who developed OCD before 10 years of age were more likely to present with comorbid tics,ordering and repeating compulsions, and their parents reported greater psychosocial difficulties, comparedwith those who developed OCD at 10 years or later.

• Importantly, the very early onset and late onset groups were equally responsive to CBT, delivered alone or incombination with medication.

• CBT tailored to the developmental age of the child is a powerful treatment either as monotherapy or incombination with SSRI medication.

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