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In many ways the
symptoms and treatments of OCD in both children and
adults follow the same general principles. However,
children differ from adults cognitively, developmentally
and physiologically. Because of this, we modify techniques
based on the particular stage of childhood or adolescence.
Symptoms and Features of
OCD
In order to meet DSM-4 criteria for OCD, the
individual must have either obsessions or compulsions.
In actuality, most children and adolescents have
both.
The Diagnostic and Statistical Manual of the
American Psychiatric Association (DSM-4) defines
obsessions as follows:
1.Recurrent and persistent thoughts, impulses or
images that are experienced, at some time during
the disturbance, as intrusive and inappropriate and
that cause marked anxiety or distress
2.The thoughts, impulses, or images are not simply
excessive worries about real-life problems.
3.The person attempts to ignore or suppress such
thoughts, impulses, or images, or to neutralize them
with some other thought or action.
4.The person recognizes that the obsessional thoughts,
impulses, or images are a product of his or her own
mind (not imposed from without as in thought insertion)
5.The DSM-4 defines compulsions as:
Repetitive behaviors (e.g. hand washing, ordering,
checking) or mental acts (e.g. praying, counting,
repeating words silently) that the person feels driven
to perform in response to an obsession, or according
to rules that must be applied rigidly.
The behaviors or mental acts are aimed at preventing
or reducing distress or preventing some dreaded event
or situation; however, these behaviors or mental
acts either are not connected in a realistic way
with what they are designed to neutralize or prevent
or are clearly excessive.
The DSM-4 also requires:
The obsessions or compulsions cause marked distress,
are time consuming (take more than 1 hour per day),
or significantly interfere with the person's normal
routine, occupational (or academic) functioning,
or usual social activities.
At some point during the course of the disorder,
the person has recognized that the obsessions or
compulsions are excessive or unreasonable. Note:
This does not apply to children
Evaluation
When a clinician is evaluating a child or adolescent
for possible OCD, it is important to do a thorough
work up. The clinician should meet with the child
and ask specific questions about obsessions and
compulsions. He or she should also meet with parents
or other primary caregivers. Information from school
and other outside sources is also useful. If there
are obsessions or rituals that occur only at school,
it is important to know about them, so that they
can be addressed too. The parents and usually the
child may also fill out checklists such as the
YBOCS (Yale-Brown Obsessive Compulsive Scale) These
help to determine the baseline number and severity
of the symptoms. Since OCD can be associated with
other disorders, the clinician should look other
childhood psychiatric disorders.
Most individuals with OCD, even young ones, are at
least intermittently aware that their symptoms do
not make logical sense. However, young children are
less capable of abstract thought, so their degree
of insight may not be as good.
Causes
There have been several theories about the cause
of OCD. These include psychodynamic, learning theories,
and neuro-biological. When we discuss cause, it is
important to make it clear that we are looking at
Obsessive Compulsive Disorder, not an obsessive,
perfectionistic personality style. An obsessive-compulsive
personality disorder is different from true Obsessive-Compulsive
Disorder. There may be some overlap or it may have
a different origin.
Psychodynamic: Freud classified Obsessive Compulsive
Disorder as a psychoneurosis. The roots of the illness
lay in a disturbance in the sexual life or development
of the child. Freud did recognize that one's heredity
and innate constitution contributed to the development
of the disorder. In Freud's theory of infantile sexuality,
the child goes through the stages of oral, anal and
Oedipal sexual interest. If the child does not successfully
progress through each phase, he may develop later
difficulties. During early childhood, sometimes during
or just before the Oedipal phase, there might be
a conflict between the ego (the mediating and observing
entity) and the id (the source of sexual and destructive
energy). The ego solves the conflict by setting up
a way of reducing the effect of the id. In some cases,
the solution is an unstable one. Part of the unstable
compromise might be regression to the earlier anal
level of development. Such an individual might have
a tendency to hoard and a horror of throwing things
away. Other obsessive symptoms such as checking might
be seen as a way of dealing with the unwanted intrusion
of hostile Oedipal wishes. (Such as a boy wishing
his father dead so he could marry his mother.) If
one needed to repeatedly check faucets, it might
be a defense against a childhood wish to flood the
house and thus kill the father. The symptoms may
start to express themselves years later when something
happens to weaken the ego and its shakier defenses.
It is possible that these psychodynamic formulations
are more relevant to individuals with obsessive or
compulsive personality traits rather than to individuals
with true OCD.
Biological: Most recent research studies point toward
a biological basis for OCD. However, there may be
subtypes of OCD. Different subtypes may have distinct
biological mechanisms. As research continues, the
understanding of the neurological and related biochemical
mechanisms will improve. PET Scans (a kind of brain
scan that shows levels of brain activity in specific
areas.) have shown abnormalities in the sub-orbital
cortex (the underside of the front part of the brain)
and the basal ganglia. A striking abnormality
was increased activity in the sub-orbital cortex.
When patients were successfully treated, whether
with psychotherapy or medication, the brain scan
studies resembled those individuals without OCD.
Serotonin seems to be involved in mediating the interaction
between these two parts of the brain.
Some cases of OCD may be associated with Tourette's
Disorder. Tourette's is characterized by multiple
tics. (Involuntary rapid movement or vocalization)
Individuals with Tourette's may also have OCD symptoms,
and Attention Deficit Disorder. Tourette's is often
inherited. Relatives of individuals with Tourette's
may have OCD without the tics. Finally, recent research
has suggested that some cases of OCD may be related
to the bacteria, B-hemolytic streptococcus. This
syndrome is referred to as PANDAs. Antibodies may
attack segments of the brain to produce an acute
onset of OCD symptoms. Similar antibodies may cause
rheumatic heart disease. More research is needed
in this area. However, if the OCD starts suddenly,
around the same time as an upper respiratory illness,
one might consider a throat swab to check for the
presence of B-hemolytic streptococcus infection.
If the bacteria are present, further tests, treatment
with an antibiotic and a referral to a specialized
center might be considered.
Associated disorders
Tourette's Disorder is more likely to be present
in boys and in children who develop OCD at a younger
age. It is important to identify this disorder because
treatment may need to be modified. Children and adolescents
with OCD are more likely to have Attention Deficit
Disorder, learning disorders oppositional behavior,
separation anxiety disorder and other anxiety disorders.
Some of the anxiety disorders have similarities to
OCD and are called obsessive-compulsive spectrum
disorders. These include tricotillomania, (compulsive
hair pulling and twirling, ) body dysmorphic disorder
(the obsession that part of one's body is unattractive
or misshapen) and habit disorders such as nail biting
and scab picking. The exact relationship between
these two spectrum disorders and true OCD is not
yet entirely clear.
Consequences of OCD
If not treated, OCD tends to be a long-term disorder.
Some individuals experience waxing and waning symptoms
over the years. Others experience progressive worsening
of their OCD until they are housebound and spend
much of their days involved in obsessions and rituals.
Chronic anxiety disorders may lead to depression.
If a child spends a great deal of time obsessing
or engaging in mental rituals, he or she may have
trouble focusing on the school lessons. Individuals
who need to repeatedly erase and rewrite assignments
may need to spend hours of time of homework and lose
time for friends and family. This same individual
may not be able to finish projects because the work
is never "just right." Some children and
teens may become oppositional if others attempt to
interrupt their rituals. For the large number of
individuals who manage to hide their symptoms, the
cost may simply be years of anxiety and low self-esteem.
Children and Adolescents are Different from
Adults
The DSM-4 criteria for children and adults differ
for the criterion on insight. An adult generally
is at least intermittently aware that the obsessions
or compulsions are unrealistic. Most of the time,
this is also true for children and adolescents. However
some children, particularly young ones, may not have
the cognitive capacity to understand the nature of
the obsessions or compulsions. Oppositional children
or adolescents may not want to admit that there is
something awry with their behavior. In that case,
a therapeutic alliance with a clinician may enable
him or her to discuss his or her real feelings about
the symptoms. Family issues are different for children. The
child’s cognitive development necessitates
some changes in the psychotherapeutic approach. If
medications are used, the physician must consider
the child’s smaller size and different metabolism.
Treatment
In this article, we will focus on medication and
cognitive-behavioral psychotherapy. There are other
psychodynamic, play therapy and family therapy approaches
to the treatment of OCD.
Once a child has been diagnosed with OCD, we need
to decide which treatment or treatments to use first.
Many clinicians prefer to start off with cognitive-behavioral
psychotherapy. If there is no response or only a
partial response, medication may then be added. There
circumstances in which it is appropriate to start
medication and psychotherapy simultaneously or even
to start with medication alone. Moderate to severe
OCD may merit starting with a combined approach.
If a child or adolescent is extremely resistant to
the idea of psychotherapy, one might consider starting
with medication alone.
Cognitive-Behavioral Psychotherapy
It would be difficult to discuss this topic without
giving a great deal of credit to John March MD and
his collaborators. They have developed, tested, and
disseminated specific information that includes a
detailed protocol for treatment of childhood OCD.
Near the beginning of this type of therapy, the child
and family are educated about the biological basis
of OCD. Even young children can gain some understanding
of this concept if it is presented in an age-appropriate
manner. For young children, I often draw an outline
of the brain and let them color round and round to
signify the repetitive thoughts and actions. Older
children and adolescents may appreciate pictures
of brain imaging studies. I have used the pictures
in the introduction section of the book, Brain
Lock by Jeffrey Schwartz, MD. These pictures
vividly show the differences in brain activity between
affected and unaffected individuals.
When the child and family realize the biological
basis of the disorder, they find it easier to externalize
the symptoms. The symptoms are the fault of the disease,
not the individual or family. Children continue to
need more concrete models and concepts throughout
the therapy. Often one may help them conceptualize
the OCD or OCD symptoms as an unpleasant or silly
creature. The child may also want to give this creature
a name. In the illustrated children’s book, Blink,
Blink, Clop, Clop, Why Do We Do Things We Can’t
Stop? The OCD is named "OC Flea", and
is drawn as an unattractive, silly but non-threatening
creature. Subsequent therapy helps the child shrink,
squash, boss or drive away the OCD.
As the therapy progresses, the child should begin
to expose himself to the anxiety-provoking object
or situation and then try to avoid performing the
usual compulsion. This is called exposure and response
prevention. It may have to be done gradually because
it can cause the child to experience significant
anxiety. The child himself should have an important
role in determining how quickly he wants to move
through these steps. The parents can help with this
too by reducing and then eliminating reassurances
when a child asks obsessive questions. At the same
time, they should be supportive and avoid blaming
the child if he is unable to avoid performing some
of the compulsions.
The child may benefit from learning relaxation techniques
and learning mental self-monitoring. Other specific
techniques may help individual children tolerate
the anxiety engendered by the exposure and response
prevention.
When the symptoms are eliminated or at least reduced
to a tolerable level, the therapist should talk to
the child and parents about the future. Symptoms
may start to come back at a later date. They should
review the symptoms and discuss how to deal with
them. Some individuals come in for intermittent refresher
sessions.
Medication
Recent advances in medication have added to our treatment
options. In the past few years there have been more
studies testing these medications specifically on
children. In general, children who need medication
respond to the same medications used for adults with
OCD. The FDA has approved some of these medications
for use in children with OCD. However, a physician
may, after discussion with the family, elect to use
a medication that technically is only approved for
adults.
Clomipramine, (Anafranil) ages 10 and up
Fluvoxamine, (Luvox) ages 8 and up.
Sertraline, (Zoloft) ages 6 and up.
Fluoxetine, (Prozac) approved for adults, approved
for treatment of deprssion in children aged 8 and
up.
Paroxetine (brand name Paxil) approved for adults.
(not recommended for children: warning sent out June
2003.)
Citalopran and Escitalopran (Celexa and Lexapro)
approved for adults
Venlafaxine (Effexor and Effexor XR) not recommended
for children-advisory sent out by Wyeth August 2003.
The main medications used for OCD are Clomipramine
(brand name Anafranil) and the Selective Serotonin
Reuptake Inhibitors. There are several other medications
that may be added if those medications produce only
a partial response.
Clomipramine is chemically similar to the older tricyclic
antidepressants. Its efficacy in OCD seems to be
related to its ability to decrease serotonin reuptake.
It used to be the only effective drug for OCD. At
this point, it is usually not the first line drug
for children with OCD. This is because of several
potential side effects. It can be sedating. It can
also cause dry mouth and eyes. It has been associated
with some changes in EKGs. (A measure of the heart
rate and the electrical conduction within the heart.)
Because children may be more sensitive to this cardiac
effect, we usually monitor EKGs and heart rate in
children on Clomipramine. Despite this, when used
carefully, it has helped many children and adolescents
with OCD.
There are now several SSRI medications. They include Fluoxetine (brand
name Prozac) Fluvoxamine (brand name Luvox) Paroxetine (brand name Paxil) and
Sertraline (brand name Zoloft). All seem to be effective at reducing the symptoms
of OCD, but different ones may be best for individual patients. Several of
these medications are available in liquid form, but you may have to special-order
them. Using the liquid, one can start at very small doses and titrate the dose
gradually. Common side effects of these medications include headache, GI complaints,
tremor, agitation, drowsiness and insomnia. These medications may affect how
other drugs are broken down in the liver. One must use caution when mixing
medications. If a child taking an SSRI, it is a good idea to consult one’s
physician or pharmacist before taking other prescription or even non-prescription
medications. Many children take a long time to achieve a good response to medication.
10 to 12 weeks is not uncommon. Some children will respond to one medication
but not to another.
Dealing with Recurrences
Education about OCD often an early part of the therapy.
Both parents and child are included. It is important
for them to continue the education process. A good
understanding of the disorder can help the child
and family feel a greater sense of mastery and control.
The process of education should extend on after the
end of the therapy. It can occur through reading
age-appropriate books, attending support groups or
having group therapy with peers. I have listed some
recommended books and support groups at the end of
the article. Secrecy and shame are common in individuals
with OCD. Education and the support of others can
help the individual keep the disorder in perspective.
Children and families should be aware that OCD can
be chronic and that symptoms may return months or
years later. Some children will schedule "check
up" sessions every six months or each year.
If symptoms reoccur, they may return to therapy for
a shortened version of their previous treatment.
Courtesy of : Carol
E. Watkins. MD (Pyschiatrist) in the U.S.A.
Suggested readings and Internet Links
Brain Lock: Free Yourself from Obsessive-Compulsive
Behavior by Jeffrey M. Schwartz 1996, Regan Books. This book is primarily aimed
at adults. However, I have found it useful for adolescents and for relatives
of the child or adolescent with OCD. Dr. Schwartz discusses both the causes
and symptoms of OCD. He then suggests a four-step self-help approach to help
the individual deal with the symptoms of OCD. For those who do not want to
read the entire book, he provides a summary of the basics of the four steps
near the end of the book. Some individuals may be able to use the book to deal
with the OCD by themselves. I prefer to use it with patients as an adjunct
to therapy and as a reminder between sessions.
Blink, Blink, Clop, Clop: Why Do We Do Things We Can't Stop? by
Moritz and Jablonsky, ChildsWork, ChildsPlay (1998) This illustrated book explains
OCD to elementary-aged children. It uses the metaphor of farm animals who are
tormented by "O.C.Flea." It can be a useful story early on in the
child's therapy. This book is probably best read with or to a child. Some of
the concepts and vocabulary are more advanced and should be explained.
OCD in Children and Adolescents: A Cognitive-Behavioral
Manual by John March and Karen Mulle1998, The Guilford Press. This book is
fairly technical and is aimed at psychiatrists and other mental health professionals.
This book contains the excellent cognitive-behavioral protocol that Dr. March
has been using successfully with children and adolescents with OCD. The book
also discusses in more depth special considerations in treating OCD as it occurs
in children.
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