What would you tell the parents of a school age child who has been worrying a lot about germs and washing his hands excessively? The behavior seems to have just started and I was wondering what the best way is to intervene and prevent this from becoming a full-blown OCD. He appears to be a very bright, verbal, and anxious child. He apparently also insists on going to the bathroom to urinate several times before leaving the house.

These symptoms certainly suggest a possibly developing OCD.

PANDAS, or Pediatric Autoimmune Neuropsychiatric Disorder Associated with Streptococcal Infections, should be considered. It is fairly new , and is not fully accepted , but it is described as rapid onset of obsessive-compulsive symptoms soon after a strep infection. Tics are also sometimes noted. You would inquire if it ever happened before (as it may be self-limited and recurrent) and look for strep. Do a throat culture and get ASLO titers and if you can get them, AntiDNAse B titers, which are thought to be a bit more specific.

Family history of OCD and of rheumatic fever are increased in this disorder. Of course, family history is more often found in OCD without PANDAS, too. Susan Swedo at NIMH showed that plama exchange successfully treated 5 kids with this disorder.

If you are thinking about PANDAS, you would want to get a careful baseline, do your strep tests, and move fairly quickly to begin antibiotics. I should repeat that although this is very interesting, it is vanishingly rare and quite controversial.

Otherwise, OCD is common and seems to be described with increasing frequency over the past few years. SSRI's are effective and I would not hesitate to try them with the child you describe if your psychiatry consultant agrees, whether or not it started with strep.

Just to remind you - lots of kids have rituals and worries and transient tics and phobic superstitions and for some reason this all peaks around nine, the age of compulsive learning of baseball statistics and card collecting and knowledge about makes of cars... Whether this has to do with endemic strep infection patterns or is somehow neurodevelopmental, I've always wondered, but a certain amount of this kind of symptom, if it doesn't distress the child and take up too much time, and keep him from normal life, shouldn't be overreacted to.

If he's bright and verbal, he might be able to tell you what it's about, if you ask him. Even with all the neurophysiologic explanations, his story might help you.

MD consult has a several articles about PANDAS. There is a good review of the subject of OCD by Paul Arnold and M. Richter in the Canadian Medical Association Journal, vol 165 #10, Nov 13, 2001. There's a good book by Judith L Rapoport, MD called The Boy Who Couldn't Stop Washing from 1990 which I'm sure you would find interesting.

Yours, Harriet McGurk