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OCD in children


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Clinical picture, diagnosis and treatment of obsessive compulsive disorder in children

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OCD in children

  1. 1. OCD in Children Dr. Shewikar El Bakry
  2. 2. Overview 2 • Family dysfunction does 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. 3. Children at Risk OCD affects 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. 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. 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. 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. 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. 8. Obsessions Compulsions Fear/Anxiety Reduction in Distress The Obsessive-Compulsive Cycle Negative Reinforcement (Piacentini et al, 2006) 8
  9. 9. Common OCD symptoms in 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. 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. 11. Symptoms at Home 11 • Resistance to stopping the obsessions of compulsions • Concern that they are “crazy” because of their thoughts
  12. 12. Symptoms at School 12 Families often seek treatment once symptoms affect school performance Difficulty concentrating – problem finishing or initiating school work Social Isolation Low self-esteem
  13. 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. 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. 15. Symptoms at School 15 • Avoid touching certain “unclean” things • Withdrawal from activities or friends
  16. 16. Signs of OCD in 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. 17. Signs of OCD in 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. 18. OCD is a neuropsychiatric 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. 19. OCD and medical conditions (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. 20. Treatment 20 “There is nothing that is wrong with me that what's right with me can’t fix”
  21. 21. Dysfunctional cognitions • Black and 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. 22. Dysfunctional cognitions • Thought/action fusion (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. 23. Psychoeducation • Provide information on 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. 24. Treatment of OCD in 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. 25. CBT for pediatric OCD • 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. 26. Development of a Symptoms Hierarchy • 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. 27 OCD Hierarchy SUDS Level 99 Touching an 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. 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. 29. CBT with children Trigger Obsession Compulsion Temp 1-10 Symptom List (Stimulus Hierarchy)
  30. 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. 31. Pharmacotherapy • SSRI • Augementing clomipramine 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