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Child and adolescent OCD: obsessive compulsive disorder (OCD) in children and adolescents.

Obsessive compulsive disorder (OCD) is beginning to be recognised as one of the most common psychiatric illnesses affecting children and adolescents, (1) and the World Health Organization rates it as one of the 20 most debilitating diseases. (2) It was previously thought to only affect adults, but is now accepted as affecting children as young as six or seven years old. It occurs in one in 100 children, (3,4) and most adults report onset of symptoms in childhood or adolescence.

Paediatric and adult OCD share similarities, but differ in a number of ways. For example, children can often lack insight into the unreasonable nature of their obsessions. Due to its debilitating nature, symptoms can cause substantial impairments. (5) Some children might have sleep problems or miss extended periods of school. Without treatment, symptoms generally persist and things can deteriorate. There is good evidence that treatment with medication and/or cognitive behavioural therapy (CBT) can be effective, (6,7) and so an obvious need to raise awareness for early assessment and intervention.

Clinical presentation

OCD is characterised by recurrent obsessions and/or compulsions (see Table 1). For a clinical diagnosis, a degree of impairment is needed in terms of either the time consumed with OCD symptoms (over one hour per day), distress, or interference in everyday functioning. It should also be differentiated from other disorders, and from what are simply excessive worries about real problems. (9)

Obsessions

Obsessions can be described as recurrent and persistent thoughts, images or impulses that are intrusive. In most cases, they are acknowledged as being senseless, but this is not always true. Obsessions are generally accompanied by distressing negative effects, such as fear, disgust, doubt or a feeling of incompleteness. (8)

Compulsions

Compulsions can be described as repetitive, purposeful behaviours, often performed according to certain rules or in a stereotyped fashion so as to neutralise or alleviate obsessions and their accompanying negative effects. Compulsions are often observable behaviours such as washing, but they can also be mental rituals such as counting. (8)

Associated conditions

Other psychiatric conditions often co-exist with OCD--in one study, 80% of 112 children tested had a co-morbid psychiatric disorder. (10) Identifying this is important, since the co-morbid condition may warrant its own specific intervention.

Anxiety and depression

Internalising disorders are very common in young people and children with OCD. One study found that 63% of a sample of 112 children and adolescents had anxiety or depression. (10) There is some suggestion that while anxiety might be present before the onset of OCD, depression generally develops around the same time or slightly after the onset of OCD. (11)

Tourette syndrome and tic disorders

In one study, 34% of a sample of 30 children and adolescents had chronic tics or Tourette syndrome. (11) A more recent study reported 16% with co-morbid tic disorder. (10) OCD and tic disorders might share genetic underpinnings, and it has been suggested that the best described subgroup in OCD are those with a lifetime history of tic disorders. (12)

ADHD and other disruptive disorders

Many children with OCD exhibit disruptive behaviour disorders such as attention deficit hyperactivity disorder (ADHD), oppositional defiant disorder and conduct disorder. In one study, one-third of a sample of 30 children and adolescents were found to have co-morbid ADHD. (11)

Assessment

Using assessment measures at the start of treatment can be advantageous, as it gives a measure of severity as well as acting as a baseline from which to monitor progress.

Diagnostic interviews

The interview involves specific questions to assess symptoms according to criteria outlined in the DSM-IV. They can be used to provide a diagnosis and to determine differential diagnosis, but require extensive training and can take time to administer. (13)

Clinician-administered measures

Perhaps the most favoured assessment form, clinician-administered measures enable trained clinicians to make informed judgments about the patient's level of impairment as compared to other patients they have seen. (13) The most commonly used measure of paediatric OCD is the children's version of the Yale Brown OCD Scale (CY-BOCS). (14) This is a semi-structured inventory of symptoms and severity over the previous week, administered to both child and parent, separately or jointly.

Child self-report and parent-report measures

Child and parent reports are often used as screening questionnaires, as they can be completed quickly. They could safeguard against under- (or over-) reporting of symptoms in clinical interviews, since patients may feel more at ease. (13) They may also be re-administered to assess posttreatment change. Two well-used child-and parent-report measures are the Children's Obsessive-Compulsive Inventory (Ch-OCI) (15) and the children's version of the Leyton Obsessional Inventory. (16)

Differential diagnosis

Normal variation

Some obsessions and compulsions are developmentally appropriate, including bedtime rituals. Two- to four-year-olds engage in more compulsive-like behaviours (repetitive and 'just-right') than older or younger children. (17) In addition, intrusive thoughts and obsessive compulsive (OC) behaviours are prevalent in the general population, so it is important that assessment measures a degree of impairment.

Other OC spectrum disorders

Other OC disorders can be difficult to distinguish from OCD. For example, body dysmorphic disorder involves obsessions relating to imagined or slight imperfections in appearance, and a compulsion to check in the mirror and camouflage their appearance. Trichotillomania is the compulsive removal of individual head hairs, often resulting in exaggerated hair loss. However, it is important to note that these may also co-occur with OCD.

Autism spectrum disorder

A diagnosis of autism spectrum disorder (ASD) is made when there are impairments in social skills, communication deficits and rituals or obsessions. This last feature can appear to be very similar to OCD in some children. It is the presence of a social communication deficit that can distinguish ASD from OCD. However, it is also true that OCD and ASD can co-occur.

PANDAS

Pediatric autoimmune neuropsychiatric disorder associated with streptococcus (PANDAS) refers to when children with streptococcal infections as well as OCD and/or a tic disorder experience prepubertal symptom onset, sudden onset or abrupt exacerbations, association with neurological abnormalities during exacerbations (adventitious movements or motoric hyperactivity), and temporal association between exacerbations and infections. (18)

Aetiology

OCD was once thought of as a psychological disorder based on unconscious defence mechanisms. However, brain imaging and immunological studies indicate that dysfunction in the central nervous system has a role to play. (19) Structural neuroimaging studies show increased size of the basal ganglia in the brain. Regional cerebral blood flow studies demonstrate increased metabolic activity in the pre-frontal cortex and basal ganglia. Genetic studies have also estimated heritability of obsessions and compulsions to be 26% to 55%. (20,21) This points to an interplay between genetic and environmental factors in the development of OCD. For example, intra-uterine, birth and postnatal experiences (such as prolonged labour) may be a risk factor. (22)

Treatment

Treatment should be considered immediately after diagnosis due to its documented success and evidence that early intervention promotes a more successful outcome. Family involvement is particularly important in the treatment of paediatric OCD. Treatment should be evidence based and begin at the least intrusive level. (2,23)

Psychoeducation

Psychoeducation is an essential part of treatment and helps inform the child and family about OCD. The more they know about OCD, the more they feel in control of it. A brief explanation of the biological basis of OCD can help to stop the child being labeled as 'naughty' by the parents and help them to start 'fighting it' together. In some early or mild cases, they may require no further intervention

Cognitive behavioural therapy

CBT has been found to be highly effective in treating adults with OCD, and research suggests that this is also the case for children. A good treatment manual, such as that by March and Mulle, (8) describes the stages of CBT for OCD in children.

The first step involves psychoeducation, which helps to 'externalise' the OCD so that the child can 'boss back' this enemy.

The second stage involves cognitive training. This is like giving the child a 'tool kit' of cognitive tactics in order to resist the OCD. These tools include cognitive resistance (bossing back) and self-administered positive reinforcement that can be used during exposure and response prevention (E/RP).

Stage three involves mapping the child's experience of OCD. This process involves finding out about specific obsessions, compulsions, triggers, avoidance behaviours and consequences. A hierarchy of obsessions and compulsions can be built, and the least anxiety provoking can become the first target for E/RP.

Steps two and three will include easy trial E/RP, but it is step four that really implements the core of CBT for anxiety disorders--graded E/RP.

In E/RP, the child exposes themselves to the feared object, thought or action and then the response, the compulsion or avoidance behaviour is prevented. Therapy should be dynamic and interactive to encourage confidence and remembering of strategies, such as using role-play and visual aids. It is important to stress that the CBT approach should be collaborative, so the child can experience some motivation to get better.

Medication

Serotonin reuptake inhibitors (SRIs) are the most common pharmacological treatment for OCD. These include tricyclic antidepressants such as clomipramine and selective SRIs (SSRIs) like fluvoxamine, sertraline and fluoxetine.

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A meta-analysis of randomised controlled trials in children and adolescents with OCD found clomipramine to be superior to other SRIs. However, other SRIs--including SSRIs--were also found to be significantly better than placebo and comparably effective. (24)

One recent study found that a combined treatment of CBT and an SSRI was more effective than either CBT or the SSRI alone. CBT and the SSRI did not differ from each other, but were significantly more effective than a placebo. (10)

Prognosis

Due to the developments and availability of treatment for children and adolescents with OCD, research into prognosis is slightly dated and may not represent the true outcome of the disorder at this time. However, one 40-year follow-up study did find that most individuals with OCD do improve over time, and a more recent meta-analysis of long-term outcome studies found that only 41% of patients had full OCD at follow up. (1,25)

A number of factors predict poorer outcome, including earlier age of onset, longer duration of illness, in-patient status, poor response to initial treatment and co-morbidities. (1)

Discussion

Children and adolescents with OCD are often seen as naughty or stubborn because of their behaviour. Parents can become angry with them, and often end up colluding with the child and exasperating their OCD. For this reason, it is important that parents are an intrinsic part of treatment. They need to be encouraged to help their child 'fight' the OCD and not collude with it.

Healthcare professionals need to be aware of signs and symptoms so that the child can be assessed by services such as local child and adolescent mental health services. Early detection of OCD can be crucial, as research has shown that duration of illness can affect the long-term persistence of symptoms. Educating the family about OCD can sometimes be enough to alleviate milder symptoms. However, the availability of effective CBT is essential in most cases. Although CBT has been shown to be a safe and effective treatment, there is unfortunately a shortage of trained therapists available who can offer this therapy.

Further information

Parents may be encouraged to contact local and national OCD support services via OCD Action, 22/24 Highbury Grove, Suite 107, London N5 2EA, or email: info@ocdaction.org.uk

References

(1.) Stewart SE, Geller DA, Jenike M, Pauls D, Shaw D, Mullin B, Faraone SV. Long-term outcome of pediatric obsessive compulsive disorder: a meta-analysis and qualitative review of the literature. Acta Psychiatrica Scandinavica, 2004; 110(1): 4-13.

(2.) Heyman I, Mataix-Cols D, Fineberg NA. Obsessive compulsive disorder. British Medical Journal, 2006; 333(7565): 424-9.

(3.) Valleni-Basile LA, Garrison CZ, Jackson KL, Waller JL, McKeown RE, Addy CL. Frequency of obsessive-compulsive disorder in a community sample of young adolescents. Journal of American Academy of Child and Adolescent Psychiatry, 1994; 33(6): 782-791.

(4.) Heyman I, Fombonne E, Simmons H, Meltzer H, Goodman R. Prevalence of obsessive compulsive disorder in the British nationwide survey of child mental health. British Journal of Psychiatry, 2001; 179: 324-329.

(5.) Valderhaug R, Ivarsson T. Functional impairment in clinical samples of Norwegian and Swedish children and adolescents with obsessive-compulsive disorder. European Child and Adolescent Psychiatry, 2005; 14(3): 164-173.

(6.) Rapoport JL, Inoff-Germain G. Treatment of obsessive compulsive disorder in children and adolescents. Journal of Child Psychology and Psychiatry, 2000; 41(4): 419-431.

(7.) Heyman I. Children with obsessive compulsive disorder. British Medical Journal, 1997; 315(7106): 444.

(8.) March JS, Mulle K. OCD in children and adolescents: a cognitive-behavioural treatment manual. New York: Guildford, 1998.

(9.) American Psychiatric Association. Diagnostic and statistical manual of mental disorders (fourth edition) (DSM IV). Washington DC: American Psychiatric Association, 1994.

(10.) Pediatric OCD Treatment Study (POTS) Team. Cognitive-behavior therapy, sertraline, and their combination for children and adolescents with obsessive-compulsive disorder: the Pediatric OCD Treatment Study (POTS) randomized controlled trial. Journal of the American Medical Association, 2004; 292(16): 1969-76.

(11.) Geller DA, Biederman J, Griffin S, Jones J, Lefkowitz TR. Comorbidity of juvenile obsessive compulsive disorder with disruptive behavior disorders. Journal of American Academy of Child and Adolescent Psychiatry, 1996;35 (12): 1637-46.

(12.) Diniz JB, Rosario-Campos MC, Hounie AG, Curi M, Shavitt RG, Lopes AC, Miguel EC. Chronic tics and Tourette syndrome in patients with obsessive compulsive disorder. Journal of Psychiatric Research, 2006; 40(6): 487-93.

(13.) Merlo LJ, Storch EA, Murphy TK, Goodman WK, Geffken GR. Assessment of pediatric obsessive-compulsive disorder: a critical review of current methodology. Child Psychiatry and Human Development, 2005; 36(2): 195-214.

(14.) Scahill L, Riddle MA, McSwiggin-Hardin M, Ort SI, King RA, Goodman WK, Cicchetti D, Leckman JF. Children's Yale-Brown Obsessive Compulsive Scale: reliability and validity. Journal of American Academy of Child and Adolescent Psychiatry, 1997; 36(6): 844-52.

(15.) Shafran R, Frampton I, Heyman I, Reynolds M, Teachman B, Rachman S. The preliminary development of a new self-report measure for OCD in young people. Journal of Adolescence, 2003; 26(1): 137-42.

(16.) Berg CJ, Rapoport JL, Flament M. The Leyton Obsessionality Inventory-Child Version. Journal of the American academy of Child and Adolescent Psychiatry, 1986; 25(1): 84-91.

(17.) Evans DW, Leckman JF, Carter A, Reznick JS, Henshaw D, King RA, Pauls D. Ritual, habit, and perfectionism: the prevalence and development of compulsive-like behavior in normal young children. Child Development, 1997; 68(1): 58-68.

(18.) Snider LA, Swedo SE. Post-streptococcal autoimmune disorders of the central nervous system. Current Opinion in Neurology, 2003; 16(3): 359-65.

(19.) Rosenberg DR, Hanna GL. Genetic and imaging strategies in obsessive-compulsive disorder: potential implications for treatment development. Biological Psychiatry, 2000; 48(12): 1210-22.

(20.) Jonnal AH, Gardner CO, Prescott CA, Kendler KS. Obsessive and compulsive symptoms in a general population sample of female twins. American Journal of Medical Genetics, 2000; 96(6): 791-6.

(21.) Hudziak JJ, van Beijsterveldt CEM, Althoff RR, Stanger C, Rettew DC, Nelson EC, Todd RD, Bartels M, Boomsma DI. Genetic and environmental contributions to the Child Behavior Checklist Obsessive-Compulsive Scale: a cross-cultural twin study. Archives of General Psychiatry, 2004; 61(6): 608-16.

(22.) Vasconcelos MS, Sampaio AS, Hounie AG, Akkerman F, Curi M, Loes AC, Miguel EC. Prenatal, perinatal, and postnatal risk factors in obsessive-compulsive disorder. Biological Psychiatry, 2007; 61(3): 301-7.

(23.) National Institute for Health and Clinical Excellence. Obsessive compulsive disorder. London: National Institute for Health and Clinical Excellence, 2005.

(24.) Geller DA, Biederman J, Stewart SE, Mullin B, Martin A, Spencer T, Faraone SV. Which SSRI? A meta-analysis of pharmacotherapy trials in pediatric obsessive-compulsive disorder. American Journal of Psychiatry, 2003; 160(11): 1919-28.

(25.) Skoog G, Skoog I. A 40-year follow up of patients with obsessive-compulsive disorder. Archives of General Psychiatry, 1999; 56(2): 121-7.

Anita Marsden

Assistant psychologist, Bedfordshire and Luton Mental Health and Social Care Partnership Trust

Uttom Chowdhury

Consultant in child and adolescent psychiatry, Bedfordshire and Luton Mental Health and Social Care Partnership Trust
Table 1: Obsessions and compulsions

Obsessions Compulsions

Contamination Washing or cleaning
Aggressive Checking
Sexual Repeating
Hoarding Counting
Magical thoughts Ordering
Somatic Arranging
Religious Hoarding
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Title Annotation:CLINICAL UPDATE
Author:Marsden, Anita; Chowdhury, Uttom
Publication:Community Practitioner
Article Type:Report
Geographic Code:4EUUK
Date:Nov 1, 2009
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