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Pediatric OCD. Joe Edwards, Psy.D. Stephanie Eken, M.D. David Causey, Ph.D. Prevalence of OCD in children. OCD is considerably more common than once thought 1 in 200 are thought to suffer from OCD 3 or 4 in each elementary school have it - PowerPoint PPT Presentation
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Pediatric OCD
Joe Edwards, Psy.D.Stephanie Eken, M.D.David Causey, Ph.D.
Prevalence of OCD in children
OCD is considerably more common than once thought 1 in 200 are thought to suffer from OCD 3 or 4 in each elementary school have
it Up to 20 adolescents in an averaged-
sized high school have OCD 7 ½ million in the US will suffer OCD
during their lifetime (15 million OCD spectrum disorders)
Prevalence of OCD cont.
Unfortunately, only 4 of 18 children found to have OCD were under professional mental health care (Flament et al., 1988), of those 18 had been identified as having OCD
OCD has been called the “hidden epidemic” (Jenike, 1989)
Factors contributing to underdiagnosis of OCD
Factors in OCD: secretiveness & lack of insight
Fear of being seen as CrazyFactors with healthcare providers:
incorrect dx.’s, lack of familiarity with (or unwillingness to use) proven treatments, differentiating variants of OCD symptoms
Access to good treatment
DSM-IV criteria for OCD
OCD is characterized by recurrent obsessions and/or compulsions that cause marked distress and interference with social or role functioning
Children may present with either obsessions or compulsions (most have both)
In youth, the types of symptoms, can change rapidly
DSM-IV criteria for OCD
OCD behaviors can occur in a child without meeting criteria for OCD
DSM-IV specified OCD symptoms must cause distress, being time-consuming (> than 1 hr/day) , or must significantly interfere with school, social activities, or important relationships
DSM-IV criteria for OCD
Obsessions are more than simply excessive worries about real life problems
Obsessions originate from within the mind
At some point in the illness, the person recognizes that the O/C are excessive and unreasonable
DSM-IV criteria for OCD
Specific content obsessions are not related to another Axis I disorder (obsessions about food in an eating disorder or guilty thoughts with ruminations in depression)
Common OCD symptoms in children
Obsessions Contamination
themes Harm to self or others Aggressive themes Sexual themes Scrupulosity/
religiosity Forbidden thoughts Symmetry urges Need to tell, ask,
confess
Compulsions Washing or cleaning Repeating Checking Touching Counting Ordering/arranging Hoarding Praying
Common OCD symptoms in children
OCD symptoms frequently change over time
By the end of their adolescence most all of the classic symptoms have been experienced by the child
Assessment of OCD
*See Merlo et al., 2005
Clinical Interview Be sure to include:
Impact on activities (which ones) Impact on family (and family dynamics) Accomodation behaviors (see scale) Child’s attitude toward symptoms (ego-
dystonic versus ego-syntonic)
Diagnostic Interviews
Anxiety Disorders Interview Schedule (Silverman & Albano, 1996) – not high agreement between child and parent
Schedule for Affective Disorders and Schizophrenia for School-Age Children (Kaufman et al., 1997)
Measures
Children Yale-Brown Obsessive Compulsive Scale (CY-BOCS) (Scahill et al., 1997) Clinician Rated (past week) Assess severity of symptoms, control
Some evidence that clinician-rated is superior to subject-rated (Stewart et al., 2005)
Measures
Leyton Obsessional Inventory-Child Version (Berg et al., 1988) Includes a short form
Children’s Obsessional Compulsive Inventory (Shafran et al., 2003)
Children’s Yale-Brown Obsessive-Compulsive Scale-Child Report and Parent Report (Storch et al., 2004)
Measures
CBCL Obsessive-Compulsive Scale(Storch et al., 2005)
6 items; adequate psychometrics
Child Obsessive Compulsive Impact Scale (Piacentini & Jaffer, 1999)* School activities, home/family activities, social
activities
Family Accomodation Scale (Calvacoressi et al., 1995)* Correlation with severity and family dysfunction
What is not OCD
Developmental Factors Most children exhibit normal age-
dependent obsessive-compulsive behaviors (Liking things done “just so” or insist on elaborate bedtime rituals (Gessell, Ames, & Ilg, 1974)
By middle childhood, these behaviors are replaced by collecting, hobbies and focused interests
What OCD is not
Individuals who display excessive worry that does not cause severe discomfort or disrupt daily life
O-C PD—obsessive people who are punctual and/orderly (but perfectionism, stinginess, or aloofness can interfere with their life or the quality of relationships)
Compulsive eaters, Pathological Gambling, Promiscuous sex, or Drug abuse (these people derive pleasure from the compulsive activity)
Comorbidity with OCD
More than one disorder is often present (the Dx. of OCD is not exclusionary)
Many children become so distressed and overwhelmed by OCD symptoms that they develop MDD
Comorbidity with OCD
Tic disorders, anxiety disorders, LD, & disruptive behavior disorders are not uncommon
OCD is a spectrum disorderDisorders on the OCD spectrum
include: trichotillomania body dsymorphic disorder Tourette Syndrome/tic disorders
Only a small number exhibit signs of OC personality disorder
What does not cause OCD
Overly strict toilet training
Watching a parent or sibling carry out OCD rituals (those without a genetic predisposition)
Factors that may be related to OCD
Early life experiences (Rachman & Hodgson, 1980) found that excessively harsh punishment for making mistakes may predispose individuals to develop obsessive doubts and checking rituals
Life stress (psychosocial distress) (Findley et al., 2003) – stress differentiate clinical OCD from nonclinical group
OCD is a neuropsychiatric disorderNeuropsychology has identified the following
symptoms:
Non-verbal skills < Verbal Reasoning skills(which place kids at risk for dysgraphia, dyscalculia, poor
written language skills, & reduced processing speed & efficiency)
Association with Asperger Syndrome
Also included on “list” of symptoms found in “Childhood Bipolar Disorder”
OCD is a neuropsychiatric disorderSuccessful treatment utilizes
serotonin reuptake inhibitors (SSRIs) The “serotonin hypothesis” (OCD) “Grooming behavior gone awry”
Neuroimaging studies implicate abnormalities in circuits linking the basal ganglia to the cortex--these circuits have responded to both BT and SSRIs.
OCD and medical conditions (PANDAS, SC) Pediatric Autoimmune
Neuropsychiatric Disorder Associated with Strep (PANDAS) In a subgroup of children, OCD
symptoms may develop or be exacerbated by strep throat
With Sydenham’s chorea (a variant of rheumatic fever--RF) OC behaviors are common, OCD is more
common in RF patients when chorea is present
OCD associated with PANDAS or RF/Sydenham chorea
Group A antigens may cross react with basal
ganglia neural tissue resulting in OCD or tic symptoms
If there has been a rapid onset of OCD or Tic symptoms, or a dramatic exacerbation of these symptoms, following PANDA or RF, the patient should be worked up for Group A strep infection, since antibiotic therapies may benefit select patients
History of Behavior TX with OCD
Traditional behavior therapy involving Systematic Desensitization did not produce good results with OCD patients
In 1966, Dr. Victor Meyer (a British psychiatrist) instructed nurses working on a Psych. Ward to actively prevent patients from carrying out their rituals—14/15 patients shows rapid improvement
The active ingredients for Behavior Tx—E/RP
Exposure (E)—confronting a situation you fear
Response Prevention (RP)—keeping yourself from acting on the compulsions afterwards
Principles for E/RP
1. Confront the things you fear as often as possible
2. If you feel like you need to avoid something don’t
3. If you feel like you have to perform a ritual to feel better, don’t
4. Continue steps 1, 2, & 3 for as long as possible
Habituation
Habituation comes from the Latin word habitus, for habit (to make familiar by frequent use or practice)
After long familiarity with a situation that at first produces a strong emotional reaction, our bodies learn to get used to or ignore that situation
Setting Goals recommendations by Lee Baer, Ph.D.
1. Work on one major goal at a time2. Carefully choose the 1st symptom to work
on—what symptom do you have the best chance with success with?
3. Convert symptoms to goals4. Set realistic goals5. Rank your Goals6. Be aware of “Flat Earth Syndrome”7. Set long-term goals—by the end of
treatment, “I want to be able to________”
Setting Practice Goals
1. I will expose myself to X, without doing Y2. Put practice goals in writing3. Ask the 80% question—”If I practiced this
goal 10 times, would I likely be successful 8?
4. Use Subjective Units of Distress (SUD) ratings to guide practice goals
5. Strive to achieve but be forgiving6. Notice small gains7. Set practice goals each session
Techniques to assist E/RP by Lee Baer, Ph.D.
1. Practice with your helpera) discuss your goals openly with helperb) accept encouragement for even partial accomplishmentsc) ask any reasonable question (not for
reassurance, and trust their opinion) d) do not argue or get angry with your helper
Techniques to assist E/RP
2. You will feel anxiety if you are doing the exposures and response prevention correctly (but it will be less than feared)
3. Keep reminders hand (index cards)4. Reward yourself for success5. Visualize your long-term goals6. Let obsessions pass through your mind
(do not try and block them—due to rebound)
Techniques to assist E/RP
7. Maintain standards in E/PR (avoid keeping fingers crossed, saying a prayer or smoking a cigarette to reduce anxiety during an exposure)
8. Hints for RP—break down goals into small steps
9. Use Audiotapes (for idiosyncratic ones) and Videotapes to intensify exposures
10.Set aside “worry time” for obsessions11. In working with kids, parents must be
involved—a reward system can be helpful
Treatment of OCD in children
Assessment of OCD:Individualized diagnostic assessment: review of OCD symptoms r/o co-morbid disorders (depressive or
disruptive disorders, other spectrum dx.’s)
review of psychosocial factors
Treatment of OCD in childrenTreatment of choice for OCD in
children: is a combined treatment (CT) approach-- CBT & SSRI’s
Expert consensus treatment guidelines for 1st line treatments Prepubescent children: CBT (mild or
severe OCD)
Adolescents: CBT for milder OCD;
CBT & SRI (or SRI alone) for severe OCD
Treatment of OCD in children
CBT alone CBT is a remarkably
effective & durable TX for OCD (Dar & Greist, 1992)
While “booster” sessions may be necessary, those who are successfully treated with CBT alone tend to stay well
Medication alone Relapse is more
common following the discontinuance of medications
March (1994) found that improvement persisted in 6 of 9 CT responders following withdrawal from medication (CBT helps inhibit relapse)
Treatment of OCD in children
Clinical Interview (including a review of developmental level, temperament, level of adaptive functioning--current and pre-morbid)
Screening Measures (CBCL & TRF & CDI)
Assessment of OCD symptoms If possible should be administered to both
primary caregiver and child (independently) Should be done initially and be periodically
re-administered to measure progress
Treatment of OCD in childrenGoals of the 1st evaluative session
Review of symptoms Obtain history (standard) Assessment Diagnosis Recommendations might include:
1) additional assessment (psychological or medical)2) CBT3) medication4) academic and/or other behavioral interventions
CBT with children
Step I: Psychoeducation The family and patient need to have an
understanding of OCD within a neurobehavioral model
A review of the risks and benefit of CBT Begin to externalize OCD as the
“enemy” and treatment involves “bossing back” OCD
CBT with childrenStep 2: Cognitive Training (a
training in cognitive tactics for resisting OCD) Goals of CT include: increasing self-
efficacy, predictability, controllability, and self-attributed likelihood of a positive outcome with Exposure & Response Prevention
Targets for CT include: reinforcing accurate information about OCD & TX., cognitive resistance “bossing back OCD,” and self-administered positive reinforcement & encouragement.
CBT with childrenStep 3: Mapping OCD
OCDChild
After Treatment
OCDChild
Before Treatment
Transition Zone
Transition Zone
CBT with children
Step 3: Mapping continued
10 - No Way!
8 - Really Hard
6- I’m not sure
4 - Hard
2- I’m unease
0 - No problem
Fear Thermometer
CBT with children
May also use analogies that child relates to directly due to interests in daily life:
Cartoons, sports, hobbies, etc.Example:
Spongebob - easier Squigwart – medium Mr. Crabs - hard
CBT with children
Trigger Obsession Compulsion Temp 1-10
Symptom List (Stimulus Hierarchy)
CBT with children
Step 4: Graded Exposure & Response Prevention (E/RP)
“Exposure” occurs when children expose themselves to the feared object, action, or thought
“Response Prevention” is the process of blocking rituals and/or minimizing avoidance behaviors
CBT with children
Tips in executing E/PR OCD is the enemy and all parties
work against it Only the child can battle against
OCD, however, he can use his allies (therapist, parents or friends) and newly learned strategies (CT and E/RP) to combat OCD
CBT with children
What is the role of parents? Parents are an important part of the
CBT treatment process While they can’t combat OCD for their child,
they can encourage the child to “boss back” OCD and not engage in behavior that helps reinforce OCD symptoms.
Parents should have adequate psychoeducation about OCD and should be involved in the child’s treatment
Questions about the Tx of OCD
1. How long will CBT take? Weekly, then bimonthly, and eventually monthly over 6 months (Dr. Hurley at MGH)
If they are very determined and motivated to work hard
If less motivated patient’s stay in treatment longer
Most important how willing is the patient to work on Exposure and Response Prevention?
Questions about the Tx of OCD
2. Will CBT eliminate all OCD symptoms? No3. Is BT is affective for children as for adults?
Yes4. Are all types of OCD are as easy to treat
as another type? No—cleaning or contamination types are the most straight forward to apply E/RP
5. What are the most difficult types of OCD to treat? Compulsive slowness and mental rituals
Other approaches
Metacognitive therapy: initial results appear to be positive
(Simons et al., 2006)
“Family-based CBT”: positive results reported
(Storch et al., 2007)
Family Involvement
Family education (noted above)
Family accomodation behaviors
Impact of family – parent distress
Family dynamics
Helpful Tips
What’s “GOOD” and what’s “BAD” about the OCD behaviors? (Compare lists)
Externalize the problem, give it a name E.g., Mr. Worry, OC Flea, etc.
Use analogies to describe what the OCD does E.g., redial button (hang up)
Helpful Tips
Work with parents on what they do that is: “helpful” and “not helpful”? (Moritz)
Helpful: positive self-talk, avoid over-involvement, look for positives, etc.
Not Helpful: punishment, criticism, blaming and shame, accommodating, etc.
A Contrast in Cases (1):
Age/Gender: 7 year old boySymptom onset: evident since age 2Characterized by: moderate and chronic;
obsessions – symmetry, exactness, order, moral
Attitude toward OCD: ego-syntonic – patient angry about therapy; tantrum at 1st appt.
Family: chronic / consistent accomodation; occasionally refused to do as he requested, parents each with OC tendencies
Other issues: strong willed, controlling child
A Contrast in Cases (2):
Age/Gender: 10 year old boy Symptoms onset: typical, gradual onset, “last 6
months” Characterized by: mild-moderate; obsessions – worry
thoughts / compulsions - checking and counting Attitude toward OCD: ego-dystonic – wanted to
exclude parents and resolve with therapist Family: typical responses - some accomodation, some
frustration, some refusal to support, etc. Dynamic with older sister Frequent inconvenience to family
Other issues: consider issue of excluding parents in tx.
A Contrast in Cases (3):
Age/Gender: 13 year old girl Symptom onset: OC tendencies for years, dramatic
onset for about 1 month near beginning of 7th grade Characterized by: severe disruption; obsessions –
moral, exactness, order, contamination / compulsions – cleaning, rituals, counting, confession, reassurance seeking, checking
Attitude toward OCD: ego-dystonic – patient initially worried about being “crazy”, embarrassed
Family: healthy, typical mixed response, strong and positive investment by mother and others in tx.
Other issues: patient later showed trichotillomania
Treatment Approach: Case 1
List symptoms Patient willing to rate how upset he feels if he can’t do
them: 0 – 3 rating scale Started dialogue re: distress/anger Focused on parents:
Minimizing accommodation behaviors with a focus on issues child rated as 1-2 on scale
Discussed ways to provide alternatives to child to reduce tantrums, but then instructed parents to expect tantrums
Also suggested we closely monitor overall level of distress as we do this (some children develop heightened stress with no reduction in symptoms over time)
Developed a plan for differential reinforcement Outcome: parents reporting progress with limited distress
Treatment Approach: Case 2
List obsessions and compulsions Developed rating symptom: 0-10 related worry/distress Educated child and family about OCD; some normalizing Externalize the problem: Mr. Worry Developed E/RP plan; separate sheet for each specific
problem; some conducted in office (e.g., faucet) Assisted parents with family dynamics, their own coping
behaviors, consequences for “being late” Progress monitored by parent observation (and report)
and child self-report Outcome: significant reduction in checking behaviors;
some issues resolved without specific intervention
Treatment Approach: Case 3
List obsessions and compulsions Education and normalizing: “you’re not crazy” Developed rating symptom: 0-10 related to worry/distress Educated child and family about OCD; OCD book Strategies: E/RP; worry plan, “worry time”, relaxation, differential
reinforcement (planned ignoring), E/RP in office (e.g., bubble sheets, writing)
Due to severity, distress and impact on school – med. referral Progress monitored by parent observation (and report) and child
self-report Outcome: significant reduction in OCD; still a bit embarrassed but
developed sense of humor; some mild evidence of symptoms; no obvious impact on daily life at this time; still some trichotillomania, “amnesia” about some of past OC behaviors
Discussed and developed relapse prevention plan