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OCD in children
1) OCD affects approximately 1% of children, with rituals persisting into adulthood if left untreated. Common symptoms include contamination fears, checking behaviors, and reassurance seeking. 2) Treatment involves psychoeducation, cognitive techniques, exposure therapy to confront fears, and prevention of compulsive rituals. The gold standard is combined cognitive behavioral therapy and selective serotonin reuptake inhibitors. 3) For severe pediatric OCD, treatment guidelines recommend starting with CBT for milder cases and adding an SSRI or using an SSRI alone for more severe presentations in adolescents. Exposure therapy involves gradually confronting feared stimuli while resisting compulsions to reduce anxiety.
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Introduction to OCD significance in children, affecting 1 in 200, treatment requires family context.
OCD prevalence in children, early diagnosis impacts adult cases, and normal rituals versus OCD rituals.
Definition of obsessions and compulsions, common symptoms in children, detailing typical OCD behaviors.
Effects of OCD at home and school, including distress caused by rituals and impact on academic performance.
Identification of OCD signs, such as contamination behaviors, compulsive checking, and reassurance seeking.
OCD as a neuropsychiatric disorder, treatment implications, and the role of PANDAS and rheumatic fever.
Exploration of dysfunctional cognitions associated with OCD, including black and white thinking and risk overestimation.
Importance of education about OCD and the combined treatment approach of CBT and SSRIs as the first line.
Step-wise CBT approach including psychoeducation, symptom hierarchy development, exposure, and response prevention.
Utilization of SSRIs in treatment, potential for augmentation, and caution in combining medications.
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OCD in children
- 1. OCD in Children Dr.Shewikar El Bakry
- 2. Overview 2 • Family dysfunctiondoes not cause OCD, however family members affect and are affected by a child with OCD • OCD disrupts the psychosocial and academic performance of roughly 1 in 200 children/adolescents (Academy of Child and Adolescent Psychiatry) • Treatment tailored to a child’s developmental needs and family context may reduce chronic nature of OCD
- 3. Children at Risk OCDaffects as many as 1% of children (as common as childhood asthma) 50% of adult cases of OCD are diagnosed before age 15 2% of children are diagnosed between ages of 7- 12 OCD is more prevalent in boys (2:1 ratio) 20% of children with OCD have a family member with OCD 3
- 4. Children and Rituals 4 •Some compulsive and ritualistic behaviors in childhood are part of normal development – most common between the ages of 4-8; an attempt to master fears and anxieties • Many children collect objects, engage in ritualized play, avoid imaginary contaminants
- 5. Children and Rituals 5 •Many childhood rituals advance development, enhance socialization, assist with separation anxiety, and help define their environment • Childhood rituals disappear on their own – rituals of a child with OCD persist well into adulthood
- 6. Obsessive Compulsive Disorder (OCD) •Obsessions: ▫Recurrent or persistent thoughts, impulses, or images seen as intrusive or inappropriate that cause marked anxiety/distress ▫ Not simply excessive worries ▫ Attempts are made to suppress or neutralize obsessions American Psychiatric Association. (2000).
- 7. Obsessive Compulsive Disorder(OCD) • Compulsions: ▫ Repetitive behaviors or mental acts driven to perform in response to obsession, or according to rules rigidly applied ▫ Behaviors or mental acts are aimed at preventing or reducing distress or preventing dreaded event or situation American Psychiatric Association. (2000).
- 8. Obsessions Compulsions Fear/Anxiety Reduction in Distress The Obsessive-CompulsiveCycle Negative Reinforcement (Piacentini et al, 2006) 8
- 9. Common OCD symptomsin children Obsessions • Contamination themes • Harm to self or others • Aggressive themes • Sexual themes • Scrupulosity/religiosit y • Forbidden thoughts • Symmetry urges • Need to tell, ask, confess Compulsions • Washing or cleaning • Repeating • Checking • Touching • Counting • Ordering/arranging • Hoarding • Praying
- 10. Symptoms at Home 10 •May be worse at home than at school • Repeated thoughts they find unpleasant – not realistic • Repeated actions to prevent a feared consequence • Consuming obsessions and compulsions • Distress if ritual is interrupted • Difficulty explaining unusual behavior • Attempts to hide obsessions or compulsions
- 11. Symptoms at Home 11 •Resistance to stopping the obsessions of compulsions • Concern that they are “crazy” because of their thoughts
- 12. Symptoms at School 12 Familiesoften seek treatment once symptoms affect school performance Difficulty concentrating – problem finishing or initiating school work Social Isolation Low self-esteem
- 13. Symptoms at School 13 •Other conditions – ADHD • Learning disorders/cognitive problems which are often overlooked • Daydreaming – the child may be obsessing • Repetitive need for reassurance
- 14. Symptoms at School 14 •Rereading and re-writing, repetitively erasing – look for neatness, holes in paper • Repetitive behaviors – touching, checking, tracing letters • Fear of doing wrong or having done wrong
- 15. Symptoms at School 15 •Avoid touching certain “unclean” things • Withdrawal from activities or friends
- 16. Signs of OCDin Children • Contamination Behaviors ▫ Frequent cleaning/hand washing (red, chapped hands) ▫ Long frequent trips to the bathroom. ▫ Avoidance of the playground, art supplies, sticky substances. ▫ Untied shoe laces (may be contaminated) • Checking and redoing activities/behaviors ▫ Compulsively going over letters and numbers with pencil. ▫ Taking excessive time to perform tasks. ▫ Rereading and rewriting, and frequent erasing.
- 17. Signs of OCDin Children (Cont.) • Reassurance Seeking ▫ Am I okay, is this right? ▫ Asking frequent questions when the answer is already evident. • Anxiety and Avoidance ▫ Withdrawal from usual activities or friends. ▫ Excessive fear of bad things happening to self or others. ▫ Excessive fears of making mistakes. ▫ Persistent lateness. • Counting and Organizing
- 18. OCD is aneuropsychiatric disorder • Successful treatment utilizes serotonin reuptake inhibitors (SSRIs) ▫ The “serotonin hypothesis” (OCD) ▫ • Neuroimaging studies implicate abnormalities in circuits linking the basal ganglia to the cortex--these circuits have responded to both BT and SSRIs.
- 19. OCD and medicalconditions (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
- 20. Treatment 20 “There is nothing thatis wrong with me that what's right with me can’t fix”
- 21. Dysfunctional cognitions • Blackand white/all or nothing thinking ▫ “If it is not perfect, then it’s garbage.” • Magical thinking ▫ “If I think a bad thought, then something bad will happen.” • Overestimation of risk ▫ “If I even take the slightest chance, something bad will happen.” • Hypermoraity ▫ “Ill go to hell if . . .”
- 22. Dysfunctional cognitions • Thought/actionfusion (similar to magical thinking) ▫ “If I have the bad thought, it will happen.” • Overimportance of thought ▫ “I cannot have bad thoughts—I must have a pure mind.” • “What if” thinking ▫ “In the future, what if I . . . Make a mistake? Get AIDS? Hurt someone? • Intolerance of uncertainty ▫ “I cannot relax unless I am 100% certain that I will be okay, safe, certain. • The martyr complex ▫ “I choose to . . . To prevent . . . “
- 23. Psychoeducation • Provide informationon OCD to children and caregivers ▫ Prevalence ▫ Course of the disorder ▫ Impact on families ▫ Nature of symptoms • Describe CBT ▫ Treatment components ▫ Efficacy of the treatment, especially for OCD ▫ Typical number of sessions, length of sessions
- 24. Treatment of OCDin 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
- 25. CBT for pediatricOCD • Step 1: Psychoeducation for child and family • Begin to externalize OCD as the “enemy” and treatment involves “bossing back” OCD • Step 2: Cognitive Training (a training in cognitive tactics for resisting OCD) goals and targets and reinforcements • Step 3: Mapping OCD
- 26. Development of a SymptomsHierarchy • Day 1 or 2 (the easiest part of treatment) • Work with child to develop a list of feared stimuli or situations • Write down everything and ask clarifying questions • Rank order items on a scale (1 – 10; 1 – 100) • “Everything is a 10!” • “Nothing scares me” • Use of anchor points and contrasts
- 27. 27 OCD Hierarchy SUDS Level 99 Touchingan unknown sticky substance, without washing 95 Holding loose hair 90 Touching known sticky substances (e.g. egg), without washing 85 Touching unknown trash articles 60 Using a public restroom 60 Witnessing a political argument 60 Witnessing other sensitive-subject arguments (i.e. religion) 60 Seeing parents spend a lot of money at one time 60 Touching loose hair with finger 55 Touching known sticky substance (e.g. syrup),without washing 50 Touching a known sticky substance (e.g. soda), without washing 30 Touching a dirty railing 30 Walking into a public bathroom
- 28. 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
- 29. CBT with children TriggerObsession Compulsion Temp 1-10 Symptom List (Stimulus Hierarchy)
- 30. • 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
- 31. Pharmacotherapy • SSRI • Augementingclomipramine and SSRI Fluvoxamine is the SSRI with the most synergistic effect when added to clomipramine. Even low-dose augmentation (25–75 mg/day) may be useful, but care must be taken when combining clomipramine with fluvoxamine and with CYP-450 2D6 inhibitors such as fluoxetine or paroxetine owing to potentially toxic increases in serum clomipramine levels, which must be monitored in addition to EKG indices. • Treatment resistance in pediatric OCD no controlled data exist risperidone and haloperidol and aripiprazole