**3.8. Primary vs. secondary depression**

Depression is often comorbid with OCD and may be treated differently whether it is secondary and occurring in response to the stress caused by OCD or it is a primary condition that is separate from the OCD. Comorbid depression is associated with increased OCD symptom severity and increased functional impairment [14, 33]. Screening for depression is important to ensure treatment is effective and taking into account a person's overall well-being. Notably, several studies have revealed that treating OCD through exposure and response prevention can lead to a decrease in comorbid depression and that treatment outcomes are not worsened by the presence of depression [15, 34, 35]. Distinguishing whether depression is primary or secondary to OCD can guide treatment decisions whether to begin with exposure and response prevention or to begin with CBT targeting depression. Assessing the content of depressive cognitions can provide information on whether depressive thoughts center on impairment or quality of life issues related to OCD. Additionally, obtaining a timeline of symptoms (such as whether depression preceded OCD or began afterward) can assist with identifying if depression is reactionary to OCD or a distinct condition.

with OCD are likely to have other first-degree relatives that also have OCD as well as anxiety, mood, ADHD, and tic disorders [9]. Numerous studies have demonstrated elevated rates of OCD in parents of children with early onset of the disorder, including a study that found a quarter of fathers and almost 10% of mothers meeting criteria for OCD [41]. For a subset of individuals, the pathogenesis of OCD is related to an autoimmune infectious disease known as autoimmune neuropsychiatric disorders associated with Streptococcus (PANDAS), which is also implicated in Tourette's disorder. It has been suggested this year that PANDAS be

Manifestation and Treatment of OCD and Spectrum Disorders within a Pediatric Population

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With regard to environmental factors, family environment has been identified as a likely contributor to OCD development in children [42]. Social learning is theorized to play an important role in the development of childhood anxiety disorders. Children learn from seeing how their parents function in the world and how their parents cope with their own anxiety and emotional distress. Additionally, parent communication style and relationship quality impacts child development of psychopathology. Authoritarian parenting style (low warmth, high behavioral control) has been linked to higher incidences of obsessive compulsive symptoms and obsessive compulsive beliefs (such as regarding the importance of thoughts and personal responsibility) [43]. This finding is consistent with other studies that have demonstrated an association between parental control and higher rates of child anxiety [44]. Family factors are therefore important to address in the treatment of

Children's OCD symptoms affect and are affected by family dynamics and the family environment. As children are heavily reliant on their parents for activities of daily living and general well-being, parents often bear the brunt of their child's OCD severity and impairment. Extensive research demonstrates the importance of accounting for family factors in the treatment of pediatric OCD [45–48]. In fact, family-based therapy has demonstrated effectiveness

A parent of a child with OCD is faced with many challenges on a daily basis. Children may delay family activities due to involvement in rituals or may refuse to partake in activities or gatherings altogether due to their OCD symptoms. When children become distressed by their obsessions and compulsions, it is typically family members who deal with the resulting temper tantrums, crying, reassurance seeking, or avoidance of situations and activities. Children may request or demand their parents adjust their behavior to assist with rituals or prevent feared negative consequences related to obsessional fears (e.g., expecting a parent to hand-wash excessively after a parent touches something the child considers dirty). Parents are faced with difficult questions such as how to cope effectively with their children's emotional distress, whether to assist in rituals or provide reassurance, and how to respond when children avoid or refuse to participate in activities. In addition, parents often have to deal with

and is highly encouraged, especially in the case of younger children [45, 49].

the poor interpersonal relations these children exhibit [50].

renamed to encephalitis autoimmune disorder poststreptococci.

pediatric OCD.

**6. Parent-child interactions**
