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

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Presentation on theme: "Pediatric OCD Joe Edwards, Psy.D. Stephanie Eken, M.D. David Causey, Ph.D."— Presentation transcript:

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

2 Prevalence of OCD in children zOCD is considerably more common than once thought y 1 in 200 are thought to suffer from OCD y 3 or 4 in each elementary school have it y Up to 20 adolescents in an averaged- sized high school have OCD y 7 ½ million in the US will suffer OCD during their lifetime (15 million OCD spectrum disorders)

3 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 OCD zOCD has been called the hidden epidemic (Jenike, 1989)

4 Factors contributing to underdiagnosis of OCD zFactors in OCD: secretiveness & lack of insight zFear of being seen as Crazy zFactors with healthcare providers: incorrect dx.s, lack of familiarity with (or unwillingness to use) proven treatments, differentiating variants of OCD symptoms zAccess to good treatment

5 DSM-IV criteria for OCD zOCD is characterized by recurrent obsessions and/or compulsions that cause marked distress and interference with social or role functioning z Children may present with either obsessions or compulsions (most have both) z In youth, the types of symptoms, can change rapidly

6 DSM-IV criteria for OCD z OCD behaviors can occur in a child without meeting criteria for OCD z 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 z Obsessions are more than simply excessive worries about real life problems z Obsessions originate from within the mind z At some point in the illness, the person recognizes that the O/C are excessive and unreasonable

8 DSM-IV criteria for OCD z 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 zContamination themes zHarm to self or others zAggressive themes zSexual themes zScrupulosity/religiosity zForbidden thoughts zSymmetry urges zNeed to tell, ask, confess Compulsions z Washing or cleaning z Repeating z Checking z Touching z Counting z Ordering/arranging z Hoarding z Praying

10 Common OCD symptoms in children z OCD symptoms frequently change over time z By the end of their adolescence most all of the classic symptoms have been experienced by the child

11 Assessment of OCD z*See Merlo et al., 2005 z Clinical Interview z 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)

12 Diagnostic Interviews zAnxiety Disorders Interview Schedule (Silverman & Albano, 1996) – not high agreement between child and parent zSchedule for Affective Disorders and Schizophrenia for School-Age Children (Kaufman et al., 1997)

13 Measures zChildren Yale-Brown Obsessive Compulsive Scale (CY-BOCS) (Scahill et al., 1997) yClinician Rated (past week) yAssess severity of symptoms, control zSome evidence that clinician-rated is superior to subject-rated (Stewart et al., 2005)

14 Measures zLeyton Obsessional Inventory-Child Version (Berg et al., 1988) yIncludes a short form zChildrens Obsessional Compulsive Inventory (Shafran et al., 2003) zChildrens Yale-Brown Obsessive- Compulsive Scale-Child Report and Parent Report (Storch et al., 2004)

15 Measures zCBCL Obsessive-Compulsive Scale (Storch et al., 2005) y6 items; adequate psychometrics zChild Obsessive Compulsive Impact Scale (Piacentini & Jaffer, 1999)* ySchool activities, home/family activities, social activities zFamily Accomodation Scale (Calvacoressi et al., 1995)* yCorrelation with severity and family dysfunction

16 What is not OCD zDevelopmental Factors y 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 middle childhood, these behaviors are replaced by collecting, hobbies and focused interests

17 What OCD is not z Individuals who display excessive worry that does not cause severe discomfort or disrupt daily life z O-C PDobsessive people who are punctual and/orderly (but perfectionism, stinginess, or aloofness 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)

18 Comorbidity with OCD zMore than one disorder is often present (the Dx. of OCD is not exclusionary) zMany children become so distressed and overwhelmed by OCD symptoms that they develop MDD

19 Comorbidity with OCD zTic disorders, anxiety disorders, LD, & disruptive behavior disorders are not uncommon zOCD is a spectrum disorder zDisorders on the OCD spectrum include: ytrichotillomania ybody dsymorphic disorder yTourette Syndrome/tic disorders zOnly a small number exhibit signs of OC personality disorder

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

21 Factors that may be related to OCD z Early life experiences (Rachman & Hodgson, 1980) found that excessively harsh punishment for making mistakes may predispose individuals to develop obsessive doubts and checking rituals zLife 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: 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 Childhood Bipolar Disorder

23 OCD is a neuropsychiatric disorder zSuccessful 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 responded to both BT and SSRIs.

24 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 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 zIf 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 zTraditional behavior therapy involving Systematic Desensitization did not produce good results with OCD patients zIn 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

27 The active ingredients for Behavior TxE/RP zExposure (E)confronting a situation you fear zResponse Prevention (RP)keeping yourself from acting on the compulsions afterwards

28 Principles for E/RP 1.Confront the things you fear as often as possible 2.If you feel like you need to avoid something dont 3.If you feel like you have to perform a ritual to feel better, dont 4.Continue steps 1, 2, & 3 for as long as possible

29 Habituation 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 situation

30 Setting Goals recommendations by Lee Baer, Ph.D. 1.Work on one major goal at a time 2.Carefully choose the 1 st symptom to work onwhat symptom do you have the best chance with success with? 3.Convert symptoms to goals 4.Set realistic goals 5.Rank your Goals 6.Be aware of Flat Earth Syndrome 7.Set long-term goalsby the end of treatment, I want to be able to________

31 Setting Practice Goals 1.I will expose myself to X, without doing Y 2.Put practice goals in writing 3.Ask the 80% questionIf 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 forgiving 6.Notice small gains 7.Set practice goals each session

32 Techniques to assist E/RP by Lee Baer, Ph.D. 1.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 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 success 5.Visualize your long-term goals 6.Let obsessions pass through your mind (do not try and block themdue to rebound)

34 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 RPbreak down goals into small steps 9.Use Audiotapes (for idiosyncratic ones) and Videotapes to intensify exposures 10.Set aside worry time for obsessions 11.In working with kids, parents must be involveda reward system can be helpful

35 Treatment of OCD in children Assessment of OCD: Individualized diagnostic assessment: yreview of OCD symptoms yr/o co-morbid disorders (depressive or disruptive disorders, other spectrum dx.s) yreview of psychosocial factors

36 Treatment of OCD in children Treatment of choice for OCD in children: is a combined treatment (CT) approach- -CBT & SSRIs Expert consensus treatment guidelines for 1st line treatments y Prepubescent children: CBT (mild or severe OCD) y Adolescents: CBT for milder OCD; CBT & SRI (or SRI alone) for severe OCD

37 Treatment of OCD in children CBT alone zCBT is a remarkably effective & durable TX for OCD (Dar & Greist, 1992) zWhile booster sessions may be necessary, those who are successfully treated with CBT alone tend to stay well Medication alone z Relapse is more common following the discontinuance of medications z 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 zClinical Interview (including a review of developmental level, temperament, level of adaptive functioning--current and pre-morbid) zScreening Measures (CBCL & TRF & CDI) zAssessment of OCD symptoms yIf possible should be administered to both primary caregiver and child (independently) yShould be done initially and be periodically re- administered to measure progress

39 Treatment of OCD in children zGoals of the 1st evaluative session yReview of symptoms yObtain history (standard) yAssessment yDiagnosis yRecommendations might include: 1) additional assessment (psychological or medical) 2) CBT 3) medication 4) academic and/or other behavioral interventions

40 CBT with children zStep I: Psychoeducation yThe family and patient need to have an understanding of OCD within a neurobehavioral model yA review of the risks and benefit of CBT yBegin to externalize OCD as the enemy and treatment involves bossing back OCD

41 CBT with children zStep 2: Cognitive Training (a training in cognitive tactics for resisting OCD) yGoals of 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 reinforcement & encouragement.

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

43 CBT with children zStep 3: Mapping continued 10 - No Way! 8 - Really Hard 6- Im not sure 4 - Hard 2- Im unease 0 - No problem Fear Thermometer

44 CBT with children zMay also use analogies that child relates to directly due to interests in daily life: zCartoons, sports, hobbies, etc. zExample: ySpongebob - easier ySquigwart – medium yMr. Crabs - hard

45 CBT with children Symptom List (Stimulus Hierarchy)

46 CBT with children zStep 4: Graded Exposure & Response Prevention (E/RP) zExposure occurs when children expose themselves to the feared object, action, or thought zResponse Prevention is the process of blocking rituals and/or minimizing avoidance behaviors

47 CBT with children zTips in executing E/PR yOCD is the enemy and all parties work against it yOnly 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 zWhat is the role of parents? yParents are an important part of the CBT treatment process yWhile they cant combat OCD for their child, they can encourage the child 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

49 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) xIf they are very determined and motivated to work hard xIf less motivated patients stay in treatment longer xMost important how willing is the patient to work on Exposure and Response Prevention?

50 Questions about the Tx of OCD 2.Will CBT eliminate all OCD symptoms? No 3.Is BT is affective for children as for adults? Yes 4.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 rituals

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

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

53 Helpful Tips zWhats GOOD and whats BAD about the OCD behaviors? (Compare lists) zExternalize the problem, give it a name yE.g., Mr. Worry, OC Flea, etc. zUse analogies to describe what the OCD does yE.g., redial button (hang up)

54 Helpful Tips zWork with parents on what they do that is: helpful and not helpful? (Moritz) zHelpful: positive self-talk, avoid over- involvement, look for positives, etc. zNot Helpful: punishment, criticism, blaming and shame, accommodating, etc.

55 A Contrast in Cases (1): zAge/Gender: 7 year old boy zSymptom onset: evident since age 2 zCharacterized by: moderate and chronic; obsessions – symmetry, exactness, order, moral zAttitude toward OCD: ego-syntonic – patient angry about therapy; tantrum at 1 st appt. zFamily: chronic / consistent accomodation; occasionally refused to do as he requested, parents each with OC tendencies zOther issues: strong willed, controlling child

56 A Contrast in Cases (2): zAge/Gender: 10 year old boy zSymptoms onset: typical, gradual onset, last 6 months zCharacterized by: mild-moderate; obsessions – worry thoughts / compulsions - checking and counting zAttitude toward OCD: ego-dystonic – wanted to exclude parents and resolve with therapist zFamily: typical responses - some accomodation, some frustration, some refusal to support, etc. yDynamic with older sister yFrequent inconvenience to family zOther issues: consider issue of excluding parents in tx.

57 A Contrast in Cases (3): zAge/Gender: 13 year old girl zSymptom onset: OC tendencies for years, dramatic onset for about 1 month near beginning of 7 th grade zCharacterized by: severe disruption; obsessions – moral, exactness, order, contamination / compulsions – cleaning, rituals, counting, confession, reassurance seeking, checking zAttitude toward OCD: ego-dystonic – patient initially worried about being crazy, embarrassed zFamily: healthy, typical mixed response, strong and positive investment by mother and others in tx. zOther issues: patient later showed trichotillomania

58 Treatment Approach: Case 1 zList symptoms zPatient willing to rate how upset he feels if he cant do them: 0 – 3 rating scale zStarted dialogue re: distress/anger zFocused on parents: yMinimizing accommodation behaviors with a focus on issues child rated as 1-2 on scale yDiscussed ways to provide alternatives to child to reduce tantrums, but then instructed parents to expect tantrums yAlso suggested we closely monitor overall level of distress as we do this (some children develop heightened stress with no reduction in symptoms over time) yDeveloped a plan for differential reinforcement zOutcome: parents reporting progress with limited distress

59 Treatment Approach: Case 2 zList obsessions and compulsions zDeveloped rating symptom: 0-10 related worry/distress zEducated child and family about OCD; some normalizing zExternalize the problem: Mr. Worry zDeveloped E/RP plan; separate sheet for each specific problem; some conducted in office (e.g., faucet) zAssisted parents with family dynamics, their own coping behaviors, consequences for being late zProgress monitored by parent observation (and report) and child self-report zOutcome: significant reduction in checking behaviors; some issues resolved without specific intervention

60 Treatment Approach: Case 3 zList obsessions and compulsions zEducation and normalizing: youre not crazy zDeveloped rating symptom: 0-10 related to worry/distress zEducated child and family about OCD; OCD book zStrategies: E/RP; worry plan, worry time, relaxation, differential reinforcement (planned ignoring), E/RP in office (e.g., bubble sheets, writing) zDue to severity, distress and impact on school – med. referral zProgress monitored by parent observation (and report) and child self-report zOutcome: 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 zDiscussed and developed relapse prevention plan

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