obsessive - compulsive disorder ( ocd ) is a disabling and distressing disorder , beginning in late second decade or early third decade of life .
however , symptoms can appear in first decade sometimes as early as 2 years . estimated prevalence of ocd in very young children ( 5 - 7 years of age ) is 0.01% which is much lower than in general pediatric patients ( 0.5 - 4.0% ) .
pre - pubertal onset is more common in boys than girls , in the ratio of 2 - 3:1 .
a case of ocd in a 4-year - old child is reported here and related diagnostic and therapeutic dilemmas are discussed .
the present case report is about a 4-year - old female child with normal physical and psychological development until date and no family history of significant physical or psychiatric illness was brought for psychiatric consultation , for excessive anger in the child when her mother did not comply with her wishes of performing or not performing certain acts , since last 2 months .
child insisted on being bathed by mother repeatedly , up to 5 - 6 times successively .
she insisted on dressing herself and denied any assistance / advises in dressing up ( even though she had not yet learnt to dress herself properly ) .
she insisted on climbing or walking in a particular way ; climbing each step with one foot not missing any step .
she refused to be helped to climb taller steps or to cross hurdles while walking .
while returning from school she had to enter the house first , followed by mother .
child restrained all family members , from speaking to her unless she speaks to them .
she restrained mother from speaking to anyone else apart from her , not even over telephone .
child did not wish her behavior to be reported to others and sought repeated reassurance from mother about it .
mother had to describe the child 's behavior to the doctor secretly to avoid child 's anger .
any noncompliance would result in instantaneous anger which was acted upon by crying , yelling , beating - up mother , scratching mother or herself , pulling her hair and throwing things accessible at the moment like cell - phone , remote - control of television .
nail - biting was also observed during such situations , which she did not have earlier .
mother had no option than following the child 's wishes , to escape from her anger .
mother was unable to adhere to all the child 's orders and felt very sad and frustrated .
there was no history of fever prior to onset of symptoms or repeated involuntary movements of face / vocal utterances .
it took three - four visits to out - patient department to establish rapport with the child . during the interview
, child expressed that her mother makes mistakes in bathing her / dressing her and hence it should be redone correctly . her book should not be touched as some papers may fall - off from the book .
she should climb steps or walk in a particular manner in order to avoid slipping into the dirt or else she has to clean herself .
morbid - preoccupation with contamination ( bathing ) , symmetry ( dressing ) and pathological - doubt ( reassurance - seeking ) were predominant in her behavior .
aslo titer was 5.93 iu / ml ( normal levels up to 100 iu / ml ) .
as child was unable to answer the questionnaires , mother was administered parent - versions of children yale - brown obsessive - compulsive scale ( cybocs ) , child oc - impact scale - revised parent - version ( cois - rp ) and problem - behavior checklist ( pbcl ) .
on most of the items rating was  severe  to  extreme .  on cois - rp score was 55 and on pbcl was107 , which was in moderate problem - behavior range .
diagnosis of ocd was made using diagnostic and statistical manual of mental disorders , 4 edition criteria .
child was started on tablet escitalopram 1.25 mg / day and dose was escalated to 2.5 mg over a period of 2 weeks .
 on cois - rp score was 10 and on pbcl child scored 90 which is in low problem - behavior .
repetitive behaviors and magical thinking which can be part of normal child development occur between age 3 and 6 years .
they are self - limiting and rarely time - consuming or distressing . in this child
the behaviors were time - consuming , interfered with her daily activities and caused distress to child and mother .
distress in ocd could be due to characteristics of the symptom such as irrationality , content , ego - alieness , social acceptability , efforts to resist and associated disability or secondary to being prevented from carrying out compulsive acts .
a child 's appreciation of these features is inadequate , they may not evoke the same degree of distress as in adults . even if appreciated , their objective elicitation is difficult .
this raises the question , whether it is tenable to diagnose ocd in the absence of above features . but
diagnosis of ocd can be reliably made from the age of 4 - 5 years .
this child repeatedly asked the mother  my acts are not wrong , is it ?  child also repeatedly sought reassurance about non - divulgence of her behavior and got angry whenever it was discussed with others .
extensive literature review did not yield any reports of ocd in very young children , though children as young as four can develop full - blown ocd .
children having ocd rely on their caregivers for symptom execution as they are dependent on them for physical and emotional needs .
coercive / disruptive behaviors refer to imposing rules and prohibitions on family members by the patient , due to the disorder .
coercion includes forced participation in compulsive rituals , demands to perform actions instead of the child or to refrain from certain behaviors , to avoid distress to the child and compulsive behaviors on the part of the child that negatively impact on others .
accommodation refers to family members actions to facilitate rituals , acquiesce to the child 's demands , provide reassurance , decrease child 's responsibility , assist with or complete tasks for the child .
parents are willing to sacrifice in order to avoid children 's anger , distress or to restore the peace to the home .
distress is correlated with the degree to which family members are involved in the patient 's symptoms .
mother of this child was forcibly and extensively involved in doing the compulsive activities for the child .
any noncompliance by mother was met with verbal and physical abuse , who felt depressed .
father of this child was not targeted as he stayed away most of the time .
cognitive - behavior therapy ( cbt ) is the first - line treatment for ocd in children .
normal children aged 5 - 11 year can engage in tasks required for cognitive therapy .
the abstract concepts of cbt are difficult to communicate to a child , but children with early - onset ocd having good insight benefit from cbt .
any effort to discuss psychopathology was met with resistance in the form of deviating from the topic of discussion . though selective serotonin reuptake inhibitors such as fluvoxamine , sertraline and fluoxetine have been successfully used in childhood - onset ocd ,
this child was started on tablet escitalopram in very low dose which was titrated gradually .
choice of drug was based on the author 's experience with the drug as antidepressant .
it is intended to follow - up this child to observe the long - term course and outcome .
ocd in very young children though rare and fraught with diagnostic and therapeutic dilemmas , can be reliably diagnosed . though cbt is proposed as the first - line treatment , there are practical difficulties in administering it .
pharmacotherapy in very young children is beset with lack of literature regarding type and dose of medication .
caregivers of childhood - ocd undergo significant psychological distress due to coercion by the child and the need to accommodate for the child 's obsessive - compulsive behavior .
though this child remitted well in short - term , only continued follow - up will reveal long - term course and outcome of her illness .
 obsessive - compulsive disorder ( ocd ) is a very distressing disorder for both patient and caregiver . 
 usual onset of the disorder is in late second or early third decade of life . 
 it is diagnosed in children but rarely before 5 years . a case of ocd in a 4-year - old girl is reported here . 
 diagnostic and therapeutic dilemmas in such a situation are discussed . 
INTRODUCTION
CASE REPORT
DISCUSSION
CONCLUSION