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God, Sex, & Germs: Obsessive Compulsive Disorder in Children January 23, 2010 Penn State Cooperative Extension Early Childhood Education & Care Professionals.

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Presentation on theme: "God, Sex, & Germs: Obsessive Compulsive Disorder in Children January 23, 2010 Penn State Cooperative Extension Early Childhood Education & Care Professionals."— Presentation transcript:

1 God, Sex, & Germs: Obsessive Compulsive Disorder in Children January 23, 2010 Penn State Cooperative Extension Early Childhood Education & Care Professionals Conference, State College, PA Marolyn Morford, PhD Center for Child and Adult Development State College, PA

2 Clinical examples

3 How childhood OCD might first appear Eczema (from handwashing) Skin lesions (skin picking) Bathroom problems (from fear of contamination) Ordering others, including adults Teacher complaints about not completing work, time out of classroom, excessive erasing Child complains that s/he cant stop doing something Child asks the same or similar question over (and over)

4 OCD is an Anxiety Disorder Anxiety disorders are the most common mental health problems affecting both children and adults. An estimated 19 million adult Americans and children suffer from anxiety disorders

5 Types of anxiety disorders found in children Separation anxiety disorder Post traumatic stress disorder Phobias Panic disorder Social anxiety disorder Generalized anxiety disorder Obsessive-compulsive disorder

6 Catastrophic Thinking Danger = Fight or flight response

7 What is OCD? Thoughts, images (obsessions) + Actions (compulsions) + Impairment

8 What is Obsessive-Compulsive Disorder? Thoughts that trigger high anxiety (fear, disgust, doubt, feeling something incomplete) Obsessions: recurrent, persistent thoughts, impulses, images, considered intrusive, inappropriate, cause anxiety and distress; not simply excessive worries about real life problems; person tries to suppress them with some other thought or action, recognizes that they are a product of own mind

9 Obsessive-Compulsive Disorder, definition, cont. Behaviors or mental actions (covert) done to get rid of 'bad thought', reduce the anxiety Compulsions: repetitive behaviors (hand- washing, ordering, checking), mental acts (praying, counting, repeating words) that person is driven to perform in response to an obsession, or according to rules that must be applied; behaviors/acts are aimed at preventing or reducing distress or a dreaded event, but are not realistically connected

10 All repeating behavior is not OCD Differs from normal temporary worries or needs for sameness that some children have (bedtime rituals, lining up toys) To differentiate, identify Developmental stage of child The relationship between the thought and the behavior The content of the thought or image (seems bizarre) The severity and breadth of impairment

11 Obsessive-Compulsive Disorder, definition, cont. Person recognizes that obsessions and compulsions are not reasonable (does not apply to children) Obsessions/compulsions cause distress, are time consuming (>1 hour/day), or significantly interfere with normal routine, job, school, social activities, relationships

12 Functional impairment Time lost to obsessions and compulsions Cause distress (for children or perhaps only to family) Avoidance of situations likely to prompt obsessions Diminished concentration Withdrawal from social contact, interfere with school, social activities, or important relationships Criteria of insight is waived for children

13 Contamination Compulsions: Washers/cleaners Situations that cause distress: anything that might be contaminated (toilets, garbage, bodily fluids, school desk seat, shoes, paper on a floor, a doorknob, markers, public salt/pepper shakers) Thoughts/Images: NO! I am contaminated/dirty, I havent gotten it all off, I/someone else will become contaminated (or die) if I am not clean, I cant stand this, Ill go crazy

14 Checkers Situations that cause distress: making a mistake (writing the wrong word or number, writing something incriminating), leaving home, eating food (without checking it), putting homework in backpack, identifying correct assignment Thoughts/Images: Did I do the right assignment? Did I accidentally leave water running? Did I take the right book? Did I put the right name on the paper? Is there glass in this food? Did I put it there? Do I have my phone?

15 Repeaters Situations that cause distress: Not doing something the right number of times, leaving/entering a room, doing things the wrong way Thoughts/Images: My father will have an accident/parents will die, I am a bad person I must do this the right way, The teacher wants it a certain way (and not able to identify clearly)

16 Orderers Situations that cause distress: Objects not placed in exact order/sequence (pillows, clothing, pencils, collections), asymmetry Thoughts/Images: Things are out of place Things are touching each other the wrong way This is not right I will go crazy if this is not fixed

17 Hoarders Situations that cause distress: throwing things away, change to ones collection, removal of a part of something, leaving something somewhere Thoughts/Images: What if I need this and I dont have it, what will I do then? What if I cant find it? I will go crazy if I cannot keep this I have to have this

18 Pure Obsessionals (Worriers, Thinking Ritualizers) Situations that cause distress: Any situation in which harm could come to someone, a situation in which the child could make a bad mistake or decision, any other place or event that, for the child, produces distressing thoughts Thoughts/Images: Self-criticism and criticism from others, Ive made mistake/I did that all wrong Something terrible will happen Something I do/dont do will harm someone The world is dangerous I will never get better I had sex with my cousin when I was 5 What if Im gay? Im going to kiss her/shes going to touch me

19 Childhood OCD Prevalence is estimated at 1-3% of population, or 1-3 in 100 children and adolescents 6-8 in an avg elementary school; ~40 in a high school Ratio of males to females higher in preteens then equalizes Early identification and intervention may prevent behavioral restrictions and impairments that affect later development

20 Childhood OCD, cont. Boys more likely To have prepubertal onset To have a family member with OCD or Tourettes syndrome To show tic-like symptoms Girls more likely To have onset during adolescence To have more phobic symptoms

21 Childhood OCD, cont. Frequently unidentified or untreated, called the hidden epidemic (Jenike, 1989) Child secretiveness and lack of insight Community lack of familiarity with diagnosis Clinician lack of familiarity or unwillingness to use proven treatments Lack of access to treatment resources Behaviors & thoughts are often ego syntonic

22 Childhood OCD characteristics Obsessions and/or compulsions Obsessions are distressing, intrusive, often more to family than to the child Content can be very unusual and frightening to both the child and the adult who hears about it, therefore often misdiagnosed or overlooked Insight about the problem can range from very good to poor or absent

23 Related Problems Depression (26%) Social anxiety disorder Generalized anxiety disorder Disruptive behavior disorders (ADHD/ODD)

24 Other Related Problems Habit disorders: Trichotillomania (hair pulling), skin picking, nail biting Body dysmorphic disorder, Eating disorders Tic disorders (30%) Learning disorders: At risk for dysgraphia, dyscalculia, poor expressive written language, reduced processing speed, inefficiency

25 OCD is a brain disorder: How do we know this ? Rapid response to SRI (serotonin reuptake inhibitor) medication Serotonergic, possibly dopaminergic transmission abnormalities Neuroimaging studies implicate abnormal basal ganglia*/frontostriatal pathways, that show response to treatment; amygdala implicated *caudate nucleus, putamen, substantia nigra, globus pallidus – organize muscle driven motor movements of body


27 Nature of many of the compulsions (licking, picking, washing, evening up), joined with trichotillomania (hair pulling) led to hypothesis of OCD as grooming behavior gone awry Family genetic studies show OCD and TS may represent alternate expressions of same gene

28 PANDAS: Pediatric Autoimmune Neuropsychiatric Disorders Associated with Strep Sudden or dramatic OCD symptom and/or tic disorder onset Illness diagnosed or suspected strep throat infection (Group A beta hemolytic streptococcal infection – GABHS) Sydenhams chorea (neurological variant of rheumatic fever) – symptoms are tic-like writhing in extremities Not characteristic of most childhood OCD

29 Developmental Course Symptoms can change over time Can have more than one symptom at a time Approximately 50% of adult OCD sufferers experienced childhood onset Complete remission rate in 10-50% of children by late adolescence (varies by study) Unknown : the course or exact experience of OCD in childhood

30 6 most common obsessions in childhood OCD Concern with dirt, germs, or toxins Concern that something terrible will happen such as fire, illness, death, murder Symmetry order, or exactness Scrupulosity (religious obsessions) Sexual themes Concern about bodily waste, secretions

31 6 most common compulsions in childhood OCD Excessive or ritualized handwashing, showering, toothbrushing, other grooming Repeating by going in & out of door or up & down from chair, erasing, rereading Checking doors, locks, stove, homework Rituals to remove contact w/contaminants (eating, sitting, touching) Ritual touching or pattern of tapping Reassurance seeking (repetitive questioning)

32 Some observations from my office Distress of involved parent Of 95 children (under 18) with an anxiety disorder of some type seen over 3.5 years, 23 (24%) were diagnosed with OCD Of those 23, 18 (78%) were first seen before 13 years of age in my office. 11 (61%) of these 18 were male

33 What I see regarding young childrens obsessions or rituals : Ordering/Need for order of sequence of events of day/Need to order others behavior Self contamination worries and avoidances: eating, sitting, touching Repeating behaviors: mostly verbal repetition, typically questions Confessing behaviors have to do with offending God, sexual thoughts, or thoughts of having harmed someone Sexual thoughts described by children 10 and up; sexual-like behaviors in two 8 y.o. females Preoccupation w/danger & doubt

34 Other problems Eating behaviors or conditions for eating Tactile hypersensitivities: avoidance of restrictions on body Most have indications of hyperarousal (anxiety) Most have tantrums Most have sleep onset or maintenance problems

35 Family involvement & symptoms History of parental compensation Frog in the pot Parent distress Examples: buying & preparing safe foods, buying acceptable socks, allowing more time in bathroom (for rituals), responding to questions, ritual demands, requests for reassurance

36 How can I tell it's OCD? Never begin an evaluation looking for one category or diagnosis, use general assessment diagnostic tools Clinical interview Instruments

37 Clinical Interview Distress of parent Im walking on eggshells I dont have a life anymore I cant stand my child much of the time S/hes always trying to control me S/he tantrums about everything I havent slept solidly for years S/he just wont stop Child concerns My parents are always mad at me I cant stop I dont have any control over this Listen, ask child & parents to describe minutely each of their experience (mapping OCD)

38 Diagnostic Procedure *NIMH/Childrens Yale Brown OCS Therapeutic nature of this interview *Achenbach Child Behavior Checklist (CBCL), Parent & teacher Conners Rating Scales: Parent & Teacher *Childrens Depression Inventory Anxiety Disorders Interview Schedule for Children Multidimensional Anxiety Scale for Children

39 Treatment Psychoeducation (P&C) + CBT (P&C) + Medication Psychoeducation Basic information about the disorder for child & family and educating them about OCD Discuss adaptability of anxiety as a survival response; Normalize the experience Discuss activities and course of treatment

40 Treatment Success rate of CBT therapy 40-85% CBT > Medication for long term success CBT + Medication important for some cases

41 Treatment: Pharmacotherapy SRIs – Tricyclic antidepressant clomipramine SSRIs – fluoexetine, fluvoxamine, paroxetine, sertraline Studies ongoing for their use in children Need for 8-10 weeks of treatment 1/3 or more of patients will not respond to one medication

42 OCD & Cognitive Therapy Thoughts – feelings (anxiety & depression) – and behavior are tightly related Thoughts (Obsessions) Feelings Behaviors (Distress)(Compulsions)

43 Relationship between anxiety and ritual/compulsion

44 Treatment: Cognitive-Behavioral Therapy Relaxation, stress reduction, incl. real life changes Behavior: Ritual prevention (like response prevention) Cognitive: Reframing and accepting thoughts Treating Family: Reframe childs behavior Incorporating family: Stop participation, encourage child

45 Cognitive Behavioral Therapy Preventing the response (ritual): Wait longer Walk away, go somewhere else Limit where, when, and how long you do it Change the ritual (invite the worry thought in) Do the opposite of what you're being told to do Do something else you like to do Make it funny, ridiculous

46 Cognitive Behavioral Therapy Talking back to OCD Name it, separate it from the rest of you Label it (bossy) Call it out: That's my OCD! Practice having the thought on purpose, to get away from the fear from thought-action fusion

47 Behavioral Therapy Trigger the child's obsessions and fears, encourage them NOT to do the compulsion Exposure and Ritual Prevention (E/RP) – …blah, blah, the thing youre afraid of… [or, NOT do it] – …blah, blah, blah..the more you do it the easier it gets. Gwen Franklin, Age 6

48 Conceptualization behind E/RP An association has been made between the ritual and the obsession. The conclusion is that the ritual will take away the anxiety associated with the obsession and prevent the catastrophe that is often assumed will happen. In the absence of contradictory experience, this link is reinforced and strengthened every time the pairing occurs.

49 Relationship between anxiety and ritual/compulsion

50 Prevention of Ritual (Habituation Process)

51 Anxiety Hierarchies and SUDS List stressful situations Develop awareness of triggers *Self-monitoring of thoughts/behaviors Competing responses: what else can you do besides the compulsion?

52 Identify Subjective Units of Distress How to do this with children – develop a vocabulary Arrange stressful events/situations by hierarchy level: difficult with young children, consult with parents Relaxation training

53 Imaginal (pretend) exposure/Response delay In vivo (real) exposure/Response delay Overpracticing/Changing the response Competing responses: what else can you do?

54 CBT & the family Help child to talk back to OCD Positive self statements Theres my OCD again; Im not going to let it ruin this day I will control my OCD, it wont control me If I cant remember it, it didnt happen Accepting the obsession: Reducing the desire to avoid or run away from the obsession – Practicing this with the child Paradoxical effect: The more you fight it, the more frequent and intense it can become

55 CBT & the family Helping child to consider that other behaviors can reduce distress – teach flexibility Help child to examine thoughts: What is the probability that I had sex with my dog and no one saw me? Has anyone else ever touched that door handle without getting sick? How will my worry keep my parents safe? What can I do if my mother never comes home?

56 CBT & the family and other important adults ***Unhook from the rituals and compulsions (gently refuse to participate) Address parents catastrophic thoughts Reframe their lack of response as helpful Encourage cheerleading – lots of positive acknowledgement for achievements Rewards for related behaviors

57 CBT & the family & others Instruct parents to talk to the child with the confidence that they know child can triumph over their OCD (but acknowledge the challenge) Model this for parents Keep an eye out for activities that allow happiness (flow) and permit little time for rumination or rituals What makes them happy? Make sure more of that can happen.

58 Conclusions OCD is frequently missed or misdiagnosed in young children: Dont ask & I wont tell and the Fear Factor OCD is a chronic vulnerability that can be managed (consider a diabetes model) Anxiety is the primary dysfunction We are poorly informed about the nature and course of OCD in children Special problems with diagnosing & treating OCD in very young children

59 Unanswered questions: OCD thought content & developmental course Is the thought content appreciably different from adult thought content? What exactly is the variation of representation of thought content? Can the presence of unusual thought content, say, an 8 year old with disturbing sexual thoughts, be significant for an OCD diagnosis? Is there a gender difference in content or preferred compulsion? How long is a period of remission, is it related to age? To type of obsession or compulsion?

60 References Christophersen, E.R. & Mortweet, S. (2002). Treatments that Work with Children: Empirically Supported Strategies of Managing Childhood Problems. Wash. D.C.: APA. Foa, E. & Wilson, R. (2001). Stop Obsessing! How to overcome your obsessions & compulsions. NY: Bantam. Franklin, M. et al. (2003). Treatment of obsessive-compulsive disorder. In Reinecke et al. Cognitive Therapy with Children & Adolescents. NY: Guilford. March, J. & Mulle, K. (1998). OCD in Children & Adolescents: A cognitive-behavioral treatment manual. NY: Guilford. Morris, T. & March, J. (2004). Anxiety Disorders in Children & Adolescents, 2 nd Ed. NY: Guilford Press. Swinson, R. P. et al. (1998). Obsessive Compulsive Disorder: Theory, Research, and Treatment. NY: Guilford Press.

61 Anxiety Disorders Association of America ADAA Obsessive Compulsive Foundation (search for CY-BOCS)

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