Transcript Obsessive Compulsive Disorder in Children:

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
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Clinical examples
How childhood OCD might first
appear
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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 can’t stop doing
something
Child asks the same or similar question over
(and over)
OCD is an Anxiety Disorder
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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
Types of anxiety disorders found
in children
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Separation anxiety disorder
Post traumatic stress disorder
Phobias
Panic disorder
Social anxiety disorder
Generalized anxiety disorder
Obsessive-compulsive disorder
Catastrophic Thinking
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Danger = Fight or flight
response
What is OCD?
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Thoughts, images (obsessions) +
Actions (compulsions) +
Impairment
What is Obsessive-Compulsive
Disorder?
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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
Obsessive-Compulsive Disorder,
definition, cont.
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Behaviors or mental actions (covert)
done to get rid of 'bad thought', reduce
the anxiety
Compulsions: repetitive behaviors (handwashing, 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
All repeating behavior is not
OCD
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Differs from normal temporary worries or
needs for sameness that some children have
(bedtime rituals, lining up toys)
To differentiate, identify
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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
Obsessive-Compulsive Disorder,
definition, cont.
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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
“Functional impairment”
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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
Contamination Compulsions:
Washers/cleaners
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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 haven’t gotten it all off”,
“I/someone else will become contaminated (or
die) if I am not clean”, “I can’t stand this, I’ll go
crazy”
Checkers
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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?”
Repeaters
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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)
Orderers
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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”
Hoarders
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Situations that cause distress: throwing
things away, change to one’s collection,
removal of a part of something, leaving
something somewhere
Thoughts/Images: “What if I need this and
I don’t have it, what will I do then?” “What
if I can’t find it?” “I will go crazy if I cannot
keep this” “I have to have this”
Pure Obsessionals (Worriers,
Thinking Ritualizers)
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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, “I’ve made mistake/I did that all wrong”
“Something terrible will happen” “Something I do/don’t
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 I’m gay?” “I’m going to kiss her/she’s going to
touch me”
Childhood OCD
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Prevalence is estimated at 1-3% of population,
or 1-3 in 100 children and adolescents
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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
Childhood OCD, cont.
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Boys more likely
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To have prepubertal onset
To have a family member with OCD or
Tourette’s syndrome
To show tic-like symptoms
Girls more likely
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To have onset during adolescence
To have more phobic symptoms
Childhood OCD, cont.
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Frequently unidentified or untreated,
called “the hidden epidemic” (Jenike,
1989)
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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’
Childhood OCD characteristics
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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
Related Problems
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Depression (26%)
Social anxiety disorder
Generalized anxiety disorder
Disruptive behavior disorders
(ADHD/ODD)
Other Related Problems
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Habit disorders: Trichotillomania (hair
pulling), skin picking, nail biting
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Body dysmorphic disorder, Eating
disorders
Tic disorders (30%)
Learning disorders: At risk for dysgraphia,
dyscalculia, poor expressive written
language, reduced processing speed,
inefficiency
OCD is a brain disorder:
How do we know this?
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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
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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
PANDAS:
Pediatric Autoimmune Neuropsychiatric
Disorders Associated with Strep
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Sudden or dramatic OCD symptom and/or tic
disorder onset
Illness diagnosed or suspected
 strep throat infection (Group A beta hemolytic
streptococcal infection – GABHS)
 Sydenham’s chorea (neurological variant of
rheumatic fever) – symptoms are tic-like writhing
in extremities
Not characteristic of most childhood OCD
Developmental Course
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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
6 most common obsessions in
childhood OCD
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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
6 most common compulsions in
childhood OCD
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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)
Some observations from my
office
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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
What I see regarding young children’s
obsessions or rituals :
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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
Other problems
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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
Family involvement & symptoms
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History of parental compensation
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‘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
How can I tell it's OCD?
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Never begin an evaluation looking for one
category or diagnosis, use general
assessment diagnostic tools
Clinical interview
Instruments
Clinical Interview
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Distress of parent
 “I’m walking on eggshells” “I don’t have a life
anymore” “I can’t stand my child much of the
time” “S/he’s always trying to control me”
“S/he tantrums about everything” “I haven’t
slept solidly for years” “S/he just won’t stop”
Child concerns
 “My parents are always mad at me” “I can’t
stop” “I don’t have any control over this”
Listen, ask child & parents to describe minutely
each of their experience (‘mapping OCD’)
Diagnostic Procedure
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*NIMH/Children’s Yale Brown OCS
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Therapeutic nature of this interview
*Achenbach Child Behavior Checklist (CBCL),
Parent & teacher
Conners Rating Scales: Parent & Teacher
*Children’s Depression Inventory
Anxiety Disorders Interview Schedule for
Children
Multidimensional Anxiety Scale for Children
Treatment
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Psychoeducation (P&C) + CBT (P&C)
+ Medication
Psychoeducation
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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
Treatment
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Success rate of CBT therapy 40-85%
CBT > Medication for long term
success
CBT + Medication important for some
cases
Treatment: Pharmacotherapy
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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
OCD & Cognitive Therapy
Thoughts – feelings (anxiety &
depression) – and behavior are tightly
related
Thoughts
(Obsessions)
Feelings
Behaviors
(Distress)
(Compulsions)
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Relationship between anxiety
and ritual/compulsion
70
60
50
40
Anxiety
Ritual Beh
30
20
10
0
O
/
bs
ht
g
ou
h
T
in
5
m
10
30
Treatment:
Cognitive-Behavioral Therapy
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Relaxation, stress reduction, incl. real life
changes
Behavior: Ritual prevention (like response
prevention)
Cognitive: Reframing and accepting
thoughts
Treating Family: Reframe child’s behavior
Incorporating family: Stop participation,
encourage child
Cognitive Behavioral Therapy
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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
Cognitive Behavioral Therapy
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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”
Behavioral Therapy
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Trigger the child's obsessions and fears,
encourage them NOT to do the
compulsion
Exposure and Ritual Prevention (E/RP)
“…blah, blah, blah..do the thing you’re afraid
of…” [or, NOT do it]
“…blah, blah, blah..the more you do it the
easier it gets.”
Gwen Franklin, Age 6
Conceptualization behind E/RP
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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.
Relationship between anxiety
and ritual/compulsion
70
60
50
40
Anxiety
Ritual Beh
30
20
10
0
O
/
bs
ht
g
ou
h
T
in
5
m
10
30
Prevention of Ritual
(Habituation Process)
O
bs
/T
ho
ug
ht
5
m
in
10
m
in
15
m
in
20
m
in
25
m
in
30
m
in
35
m
in
40
m
in
80
70
60
50
40
30
20
10
0
Anxiety
Ritual Beh
Anxiety Hierarchies and SUDS
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List stressful situations
Develop awareness of triggers
*Self-monitoring of thoughts/behaviors
Competing responses: what else can you
do besides the compulsion?
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Identify Subjective Units of Distress
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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
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Imaginal (pretend) exposure/Response
delay
In vivo (real) exposure/Response delay
Overpracticing/Changing the response
Competing responses: what else can you
do?
CBT & the family
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Help child to “talk back” to OCD
Positive self statements “There’s my OCD
again; I’m not going to let it ruin this day”
“I will control my OCD, it won’t control me”
“If I can’t remember it, it didn’t 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
CBT & the family
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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?”
CBT & the family and other
important adults
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***Unhook from the rituals and
compulsions (gently refuse to participate)
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Address parents’ catastrophic thoughts
Reframe their lack of response as helpful
Encourage cheerleading – lots of positive
acknowledgement for achievements
Rewards for related behaviors
CBT & the family & others
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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.
Conclusions
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OCD is frequently missed or misdiagnosed in
young children: Don’t ask & I won’t 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
Unanswered questions:
OCD thought content &
developmental course
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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?
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, 2nd Ed. NY: Guilford Press.
Swinson, R. P. et al. (1998). Obsessive Compulsive Disorder: Theory,
Research, and Treatment. NY: Guilford Press.
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Anxiety Disorders Association of America
ADAA www.adaa.org
Obsessive Compulsive Foundation
www.ocfoundation.org
www.bpchildresearch.org (search for CY-BOCS)
www.effectivechildtherapy.com