1. Joe Edwards, Psy.D. Stephanie Eken, M.D. David Causey, Ph.D.
Pediatric OCD
Joe Edwards, Psy.D.
Stephanie Eken, M.D.
David Causey, Ph.D.

2. 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)

3. 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)

4. Factors contributing to underdiagnosis of OCD
Factors in OCD: secretiveness & lack of insight
Fear of being seen as Crazy
Factors 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

5. 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

6. 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

7. 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

8. 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)

9. 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

10. 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

11. 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)

12. 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)

13. 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)

14. 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)

15. 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

16. 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

17. 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)

18. 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

19. Comorbidity with OCD
Tic disorders, anxiety disorders, LD, & disruptive behavior disorders are not uncommon
OCD is a spectrum disorder
Disorders on the OCD spectrum include:
trichotillomania
body dsymorphic disorder
Tourette Syndrome/tic disorders
Only a small number exhibit signs of OC personality disorder

20. What does not cause OCD Overly strict toilet training
Watching a parent or sibling carry out OCD rituals (those without a genetic predisposition)

21. 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

22. OCD is a neuropsychiatric disorder
Neuropsychology 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”

23. OCD is a neuropsychiatric disorder
Successful 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.

24. 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

25. 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

26. 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

27. 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

28. Principles for E/RP Confront the things you fear as often as possible
If you feel like you need to avoid something don’t
If you feel like you have to perform a ritual to feel better, don’t
Continue steps 1, 2, & 3 for as long as possible

29. 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

30. Setting Goals recommendations by Lee Baer, Ph.D.
Work on one major goal at a time
Carefully choose the 1st symptom to work on—what symptom do you have the best chance with success with?
Convert symptoms to goals
Set realistic goals
Rank your Goals
Be aware of “Flat Earth Syndrome”
Set long-term goals—by the end of treatment, “I want to be able to________”

31. Setting Practice Goals
I will expose myself to X, without doing Y
Put practice goals in writing
Ask the 80% question—”If I practiced this goal 10 times, would I likely be successful 8?
Use Subjective Units of Distress (SUD) ratings to guide practice goals
Strive to achieve but be forgiving
Notice small gains
Set practice goals each session

32. Techniques to assist E/RP by Lee Baer, Ph.D.
Practice with your helper
a) discuss your goals openly with helper
b) accept encouragement for even partial
accomplishments
c) ask any reasonable question (not for
reassurance, and trust their opinion)
d) do not argue or get angry with your
helper

33. Techniques to assist E/RP
You will feel anxiety if you are doing the exposures and response prevention correctly (but it will be less than feared)
Keep reminders hand (index cards)
Reward yourself for success
Visualize your long-term goals
Let obsessions pass through your mind (do not try and block them—due to rebound)

34. Techniques to assist E/RP
Maintain standards in E/PR (avoid keeping fingers crossed, saying a prayer or smoking a cigarette to reduce anxiety during an exposure)
Hints for RP—break down goals into small steps
Use Audiotapes (for idiosyncratic ones) and Videotapes to intensify exposures
Set aside “worry time” for obsessions
In working with kids, parents must be involved—a reward system can be helpful

35. 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

36. Treatment of OCD in children
Treatment 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

37. 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)

38. 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

39. Treatment of OCD in children
Goals of the 1st evaluative session
Review of symptoms
Obtain history (standard)
Assessment
Diagnosis
Recommendations might include:
1) additional assessment (psychological or medical)
2) CBT
3) medication
4) academic and/or other behavioral interventions

40. 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

41. CBT with children
Step 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.

42. CBT with children Step 3: Mapping OCD Before Treatment OCD
Transition Zone
Child
After Treatment
Transition Zone
Child
OCD

43. CBT with children Step 3: Mapping continued Fear Thermometer
10 - No Way!
8 - Really Hard
6- I’m not sure
4 - Hard
2- I’m unease
0 - No problem
Fear Thermometer

44. 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

45. CBT with children
Symptom List (Stimulus Hierarchy)

46. 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

47. 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

48. 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

49. Questions about the Tx of OCD
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?

50. Questions about the Tx of OCD
Will CBT eliminate all OCD symptoms? No
Is BT is affective for children as for adults? Yes
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
What are the most difficult types of OCD to treat? Compulsive slowness and mental rituals

51. Other approaches
Metacognitive therapy: initial results appear to be positive
(Simons et al., 2006)
“Family-based CBT”: positive results reported
(Storch et al., 2007)

52. Family Involvement Family education (noted above)
Family accomodation behaviors
Impact of family – parent distress
Family dynamics

53. 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)

54. 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.

55. A Contrast in Cases (1): Age/Gender: 7 year old boy
Symptom onset: evident since age 2
Characterized 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

56. 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.

57. 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

58. 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

59. 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

60. 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