1、Pediatric OCDJoe Edwards,Psy.D.Stephanie Eken,M.D.David Causey,Ph.D.Prevalence of OCD in childrenzOCD is considerably more common than once thoughty 1 in 200 are thought to suffer from OCDy 3 or 4 in each elementary school have ity Up to 20 adolescents in an averaged-sized high school have OCDy 7 mi
2、llion in the US will suffer OCD during their lifetime(15 million OCD spectrum disorders)Prevalence of OCD cont.zUnfortunately,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 OCDzOCD has been called the“
3、hidden epidemic”(Jenike,1989)Factors contributing to underdiagnosis of OCDzFactors in OCD:secretiveness&lack of insightzFear of being seen as CrazyzFactors with healthcare providers:incorrect dx.s,lack of familiarity with(or unwillingness to use)proven treatments,differentiating variants of OCD symp
4、tomszAccess to good treatment DSM-IV criteria for OCDzOCD is characterized by recurrent obsessions and/or compulsions that cause marked distress and interference with social or role functioningzChildren may present with either obsessions or compulsions(most have both)zIn youth,the types of symptoms,
5、can change rapidly DSM-IV criteria for OCD z OCD behaviors can occur in a child without meeting criteria for OCDz 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 relationshipsDSM-IV crite
6、ria for OCDz Obsessions are more than simply excessive worries about real life problemsz Obsessions originate from within the mindz At some point in the illness,the person recognizes that the O/C are excessive and unreasonableDSM-IV criteria for OCDz Specific content obsessions are not related to an
7、other Axis I disorder(obsessions about food in an eating disorder or guilty thoughts with ruminations in depression)Common OCD symptoms in childrenObsessionsz Contamination themesz Harm to self or othersz Aggressive themesz Sexual themesz Scrupulosity/religiosityz Forbidden thoughtsz Symmetry urgesz
8、 Need to tell,ask,confessCompulsionsz Washing or cleaningz Repeatingz Checkingz Touching z Countingz Ordering/arrangingz Hoardingz PrayingCommon OCD symptoms in childrenz OCD symptoms frequently change over timez By the end of their adolescence most all of the classic symptoms have been experienced
9、by the childAssessment of OCDz*See Merlo et al.,2005z Clinical Interviewz Be sure to include:yImpact on activities(which ones)yImpact on family(and family dynamics)yAccomodation behaviors(see scale)yChilds attitude toward symptoms(ego-dystonic versus ego-syntonic)Diagnostic InterviewszAnxiety Disord
10、ers Interview Schedule(Silverman&Albano,1996)not high agreement between child and parentzSchedule for Affective Disorders and Schizophrenia for School-Age Children(Kaufman et al.,1997)Measuresz Children Yale-Brown Obsessive Compulsive Scale(CY-BOCS)(Scahill et al.,1997)yClinician Rated(past week)yAs
11、sess severity of symptoms,controlzSome evidence that clinician-rated is superior to subject-rated(Stewart et al.,2005)MeasureszLeyton Obsessional Inventory-Child Version(Berg et al.,1988)yIncludes a short formzChildrens Obsessional Compulsive Inventory(Shafran et al.,2003)zChildrens Yale-Brown Obses
12、sive-Compulsive Scale-Child Report and Parent Report(Storch et al.,2004)Measuresz CBCL Obsessive-Compulsive Scale(Storch et al.,2005)y6 items;adequate psychometricsz Child Obsessive Compulsive Impact Scale(Piacentini&Jaffer,1999)*ySchool activities,home/family activities,social activitiesz Family Ac
13、comodation Scale(Calvacoressi et al.,1995)*yCorrelation with severity and family dysfunctionWhat is not OCDzDevelopmental Factorsy Most children exhibit normal age-dependent obsessive-compulsive behaviors(Liking things done“just so”or insist on elaborate bedtime rituals(Gessell,Ames,&Ilg,1974)y By m
14、iddle childhood,these behaviors are replaced by collecting,hobbies and focused interestsWhat OCD is not z Individuals who display excessive worry that does not cause severe discomfort or disrupt daily lifez O-C PDobsessive people who are punctual and/orderly(but perfectionism,stinginess,or aloofness
15、 can interfere with their life or the quality of relationships)zCompulsive eaters,Pathological Gambling,Promiscuous sex,or Drug abuse(these people derive pleasure from the compulsive activity)Comorbidity with OCD zMore than one disorder is often present(the Dx.of OCD is not exclusionary)zMany childr
16、en become so distressed and overwhelmed by OCD symptoms that they develop MDDComorbidity with OCDzTic disorders,anxiety disorders,LD,&disruptive behavior disorders are not uncommon zOCD is a spectrum disorderzDisorders on the OCD spectrum include:y trichotillomaniay body dsymorphic disordery Tourett
17、e Syndrome/tic disorders zOnly a small number exhibit signs of OC personality disorderWhat does not cause OCDz Overly strict toilet training z Watching a parent or sibling carry out OCD rituals(those without a genetic predisposition)Factors that may be related to OCD z Early life experiences(Rachman
18、&Hodgson,1980)found that excessively harsh punishment for making mistakes may predispose individuals to develop obsessive doubts and checking ritualszLife stress(psychosocial distress)(Findley et al.,2003)stress differentiate clinical OCD from nonclinical groupOCD is a neuropsychiatric disorderNeuro
19、psychology has identified the following symptoms:y Non-verbal skills Verbal Reasoning skills(which place kids at risk for dysgraphia,dyscalculia,poor written language skills,&reduced processing speed&efficiency)y Association with Asperger Syndrome yAlso included on“list”of symptoms found in“Childhoo
20、d Bipolar Disorder”OCD is a neuropsychiatric disorderzSuccessful treatment utilizes serotonin reuptake inhibitors(SSRIs)y The“serotonin hypothesis”(OCD)y“Grooming behavior gone awry”zNeuroimaging studies implicate abnormalities in circuits linking the basal ganglia to the cortex-these circuits have
21、responded to both BT and SSRIs.OCD and medical conditions(PANDAS,SC)zPediatric Autoimmune Neuropsychiatric Disorder Associated with Strep(PANDAS)y In a subgroup of children,OCD symptoms may develop or be exacerbated by strep throat zWith Sydenhams chorea(a variant of rheumatic fever-RF)y OC behavior
22、s are common,OCD is more common in RF patients when chorea is present OCD associated with PANDAS or RF/Sydenham choreaGroup A antigens may cross react with basalganglia neural tissue resulting in OCD or tic symptoms zIf there has been a rapid onset of OCD or Tic symptoms,or a dramatic exacerbation o
23、f these symptoms,following PANDA or RF,the patient should be worked up for Group A strep infection,since antibiotic therapies may benefit select patientsHistory of Behavior TX with OCDzTraditional behavior therapy involving Systematic Desensitization did not produce good results with OCD patientszIn
24、 1966,Dr.Victor Meyer(a British psychiatrist)instructed nurses working on a Psych.Ward to actively prevent patients from carrying out their rituals14/15 patients shows rapid improvement The active ingredients for Behavior TxE/RPzExposure(E)confronting a situation you fearzResponse Prevention(RP)keep
25、ing yourself from acting on the compulsions afterwardsPrinciples for E/RP1.Confront the things you fear as often as possible2.If you feel like you need to avoid something dont3.If you feel like you have to perform a ritual to feel better,dont4.Continue steps 1,2,&3 for as long as possibleHabituation
26、 zHabituation comes from the Latin word habitus,for habit(to make familiar by frequent use or practice)zAfter long familiarity with a situation that at first produces a strong emotional reaction,our bodies learn to get used to or ignore that situationSetting Goals recommendations by Lee Baer,Ph.D.1.
27、Work on one major goal at a time2.Carefully choose the 1st symptom to work onwhat 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 goalsby the end of treatment,“I want to be able t
28、o_”Setting Practice Goals1.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 goals5.Strive to achieve but be forgiving6.Notice
29、 small gains7.Set practice goals each sessionTechniques 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
30、 get angry with your helperTechniques to assist E/RP2.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 yo
31、ur mind(do not try and block themdue to rebound)Techniques to assist E/RP7.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 RPbreak down goals into small steps9.Use Audiotapes(for idiosyncratic ones)and V
32、ideotapes to intensify exposures10.Set aside“worry time”for obsessions11.In working with kids,parents must be involveda reward system can be helpful Treatment of OCD in childrenAssessment of OCD:Individualized diagnostic assessment:yreview of OCD symptoms yr/o co-morbid disorders(depressive or disru
33、ptive disorders,other spectrum dx.s)yreview of psychosocial factorsTreatment of OCD in childrenTreatment of choice for OCD in children:is a combined treatment(CT)approach-CBT&SSRIs Expert consensus treatment guidelines for 1st line treatmentsy Prepubescent children:CBT(mild or severe OCD)y Adolescen
34、ts:CBT for milder OCD;CBT&SRI(or SRI alone)for severe OCDTreatment of OCD in childrenCBT alonez CBT is a remarkably effective&durable TX for OCD(Dar&Greist,1992)z While“booster”sessions may be necessary,those who are successfully treated with CBT alone tend to stay wellMedication alonez Relapse is m
35、ore common following the discontinuance of medicationsz March(1994)found that improvement persisted in 6 of 9 CT responders following withdrawal from medication(CBT helps inhibit relapse)Treatment of OCD in childrenzClinical Interview(including a review of developmental level,temperament,level of ad
36、aptive functioning-current and pre-morbid)zScreening Measures(CBCL&TRF&CDI)zAssessment of OCD symptomsyIf possible should be administered to both primary caregiver and child(independently)yShould be done initially and be periodically re-administered to measure progress Treatment of OCD in childrenzG
37、oals of the 1st evaluative sessionyReview of symptomsyObtain history(standard)yAssessment yDiagnosis yRecommendations might include:1)additional assessment(psychological or medical)2)CBT3)medication4)academic and/or other behavioral interventionsCBT with childrenzStep I:PsychoeducationyThe family an
38、d patient need to have an understanding of OCD within a neurobehavioral model yA review of the risks and benefit of CBTyBegin to externalize OCD as the“enemy”and treatment involves“bossing back”OCDCBT with childrenzStep 2:Cognitive Training(a training in cognitive tactics for resisting OCD)yGoals of
39、 CT include:increasing self-efficacy,predictability,controllability,and self-attributed likelihood of a positive outcome with Exposure&Response Prevention yTargets for CT include:reinforcing accurate information about OCD&TX.,cognitive resistance“bossing back OCD,”and self-administered positive rein
40、forcement&encouragement.CBT with childrenzStep 3:Mapping OCDOCDChildAfter TreatmentOCDChildBefore TreatmentTransition ZoneTransition ZoneCBT with childrenzStep 3:Mapping continued10-No Way!8-Really Hard6-Im not sure4-Hard2-Im unease0-No problemFear ThermometerCBT with childrenzMay also use analogies
41、 that child relates to directly due to interests in daily life:zCartoons,sports,hobbies,etc.zExample:ySpongebob-easierySquigwart mediumyMr.Crabs-hardCBT with childrenTriggerObsessionCompulsionTemp 1-10Symptom List(Stimulus Hierarchy)CBT with childrenzStep 4:Graded Exposure&Response Prevention(E/RP)z
42、“Exposure”occurs when children expose themselves to the feared object,action,or thoughtz“Response Prevention”is the process of blocking rituals and/or minimizing avoidance behaviors CBT with childrenzTips in executing E/PR yOCD is the enemy and all parties work against it yOnly the child can battle
43、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 childrenzWhat is the role of parents?yParents are an important part of the CBT treatment processyWhile they cant combat OCD for their child,they can encourage the ch
44、ild to“boss back”OCD and not engage in behavior that helps reinforce OCD symptoms.yParents should have adequate psychoeducation about OCD and should be involved in the childs treatment Questions about the Tx of OCD1.How long will CBT take?Weekly,then bimonthly,and eventually monthly over 6 months(Dr
45、.Hurley at MGH)x If they are very determined and motivated to work hardx If less motivated patients stay in treatment longerx Most important how willing is the patient to work on Exposure and Response Prevention?Questions about the Tx of OCD2.Will CBT eliminate all OCD symptoms?No3.Is BT is affectiv
46、e for children as for adults?Yes4.Are all types of OCD are as easy to treat as another type?Nocleaning 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 ritualsOther approacheszMetacognitive therapy:i
47、nitial results appear to be positive (Simons et al.,2006)z“Family-based CBT”:positive results reported (Storch et al.,2007)Family InvolvementzFamily education(noted above)zFamily accomodation behaviorszImpact of family parent distresszFamily dynamicsHelpful TipszWhats“GOOD”and whats“BAD”about the OC
48、D behaviors?(Compare lists)zExternalize the problem,give it a nameyE.g.,Mr.Worry,OC Flea,etc.zUse analogies to describe what the OCD doesyE.g.,redial button(hang up)Helpful TipszWork with parents on what they do that is:“helpful”and“not helpful”?(Moritz)zHelpful:positive self-talk,avoid over-involve
49、ment,look for positives,etc.zNot Helpful:punishment,criticism,blaming and shame,accommodating,etc.A Contrast in Cases(1):zAge/Gender:7 year old boyzSymptom onset:evident since age 2zCharacterized by:moderate and chronic;obsessions symmetry,exactness,order,moralzAttitude toward OCD:ego-syntonic patie
50、nt angry about therapy;tantrum at 1st appt.zFamily:chronic/consistent accomodation;occasionally refused to do as he requested,parents each with OC tendencieszOther issues:strong willed,controlling childA Contrast in Cases(2):z Age/Gender:10 year old boyz Symptoms onset:typical,gradual onset,“last 6
