Treating obsessive-compulsive disorder in children
By Jennifer Derenne, MD
The term obsessive-compulsive disorder (OCD) can evoke thoughts of quirky, yet likable, television and movie characters such as Monk, Jack Nicholson's character in As Good as it Gets, or Howard Hughes in The Aviator. In reality, people who struggle with OCD have a wide variety of presentations. Some respond well to treatment, while others have marked difficulty holding a job or sustaining interpersonal relationships due to undertreated or persistent symptoms.
OCD has a lifetime prevalence of 2 to 3 percent. The average age of onset is 10 years for children and 20 years for adults. Childhood-onset OCD affects more boys than girls, and there is a high percentage of comorbid attention-deficit/hyperactivity disorder, Tourette's syndrome and pervasive developmental delay (autism, Asperger's disorder). There appears to be an equal number of men and women presenting with adult-onset OCD. Many children and adults present with major depressive disorder, generally because they feel overwhelmed by symptoms or hopeless about their chances for recovery.
In order to meet Diagnostic and Statistical Manual of Mental Disorders, 4th edition, text revised (DSM-IV-TR) criteria for OCD, individuals need to exhibit either obsessive thoughts or compulsive behaviors. Obsessions are recurrent, persistent, unwelcome (ego-dystonic) thoughts that cause distress. Compulsions are repetitive behaviors aimed at reducing the anxiety or distress associated with the obsessive thoughts. Adults must be able to acknowledge that the symptoms are excessive or unreasonable, while children do not need to meet this criterion. Furthermore, symptoms must be time-consuming (greater than one hour per day), cause marked distress and interfere with overall function. Common obsessions include fear of germs or contamination, worries about the safety of self or others and excessive scrupulosity or religiosity. Frequently seen compulsive behaviors include handwashing, checking and making sure items are arranged in a particular, often symmetric, order.
Often, individuals are ashamed of the thoughts and behaviors and may go to great lengths to hide symptoms. Parents may notice that it is taking their child hours to complete homework and that he or she checks it over multiple times and is never satisfied with the work. Others will bring in children with dry, cracked and bleeding hands resulting from frequent, overly aggressive handwashing with harsh soap and extremely hot water. Parents may notice that a previously independent teenager now wants them to sleep in the same room at night. Some families notice that their child seems more quiet and withdrawn, or the child has expressed feeling depressed or suicidal.
Children are more likely to admit to symptoms when they are questioned in a gentle, empathic manner. When you are concerned about psychiatric issues, it generally is helpful to normalize symptoms as much as possible. One approach might be to say, "Some people are worriers. It happens to a lot of people. How about you? What sorts of things do you worry about? Is there anything you can do to make the worries go away? How long does it help?" Another approach would be, "Some kids tell me that they have thoughts that just keep popping into their heads for no good reason. It makes them worry, and it feels bad. Has that ever happened to you?"
The child psychiatrist's job is to try to understand the source and nature of the symptoms. Often, the initial presenting concern is depression, but the core issue is severe anxiety or OCD. Targeting the underlying process will lead to a more effective treatment approach. An initial evaluation can take 90 minutes and relies on information gathered from meetings with both the child and parents. Collateral information from the school or other community supports can be incredibly valuable as well. Assessment tools such as the Yale-Brown Obsessive-Compulsive Scale can be used to objectively quantify OCD symptoms and affect on overall function.
Once the OCD has been confidently diagnosed, treatment approach can vary based on the severity of illness and preference of the child and parent. From a psychopharmacologic perspective, serotonin reuptake inhibitors (SRIs), such as fluoxetine, are the gold standard of treatment. Anxiety disorders may require higher doses of medication than depression. An alternative strategy would be monotherapy with a tricyclic antidepressant such as clomipramine, although this requires blood level monitoring and EKG monitoring not typically needed in SRI treatment. Refractory cases often require augmentation strategies such as combining antidepressants or adding atypical antipsychotics. Due to concerns about antidepressants potentially triggering self-destructive thoughts and behaviors in children and adolescents, these medicines should be used judiciously and under close supervision. Always consult with a child psychiatrist if you have questions or concerns about the use of medications in children and adolescents. In areas without easy access to child psychiatry, it might be advantageous to have families travel for an initial consultation with clear recommendations by the psychiatrist that then can be instituted and followed by the primary care provider, with ongoing telephone consultation between the primary provider and psychiatrist as needed.
Psychotherapy, particularly cognitive behavioral therapy (CBT) and exposure and response prevention (ERP), can be a very effective treatment for OCD, either alone or in combination with medication. The CBT/ERP approach focuses on separating the OCD from the child and having the therapist, child and family work together to diminish the power of the OCD. The therapist gently challenges the child to withstand situations that would typically cause anxiety to skyrocket. An example would be to ask a germaphobic child to touch a bathroom door handle during a session and then resist washing her hands for a specified period of time after doing so. This allows the child to see that the anxiety peaks but then subsides on its own. The most difficult but most effective task is to empower the parents to stop inadvertently reinforcing their child's anxiety by allowing him to participate in rituals of anxiety-reducing behaviors. For example, in the case of the child who wants a parent in his room at night, the parents should gradually remove themselves from the room over time to teach the child that he can withstand the anxiety of sleeping alone at night. Many providers feel that the combination of medication and behavioral therapy is the most effective treatment for OCD.
Clinicians should be alert to the possibility that the abrupt onset of OCD symptoms in a prepubertal patient may represent Pediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcal infections (PANDAS). Swedo et al have described PANDAS in detail. Clinical criteria for PANDAS include presence of OCD or a tic disorder, prepubertal symptom onset, episodic course, neurologic abnormalities (tics, chorea, hyperactivity) and symptom exacerbations that correlate with exposure to a group A beta-hemolytic strep infection. The pathophysiology of PANDAS appears to be related to the phenomenon of molecular mimicry. The body produces antibodies to the M-protein of group A beta-hemolytic streptococcus (GABHS); these nondestructive antibodies localize in the basal ganglia and the striatum (areas of the brain currently thought to be affected in OCD). The treatment of PANDAS is similar to that of nonstrep related OCD and tic disorders. However, in severe or unrelenting cases, chronic antibiotics, intravenous immune globulin, plasma exchange and tonsillectomy have been used with success. As one might imagine, there is substantial debate about the existence of PANDAS and the appropriate treatment for it.
Jennifer Derenne, MD, is a pediatric psychiatrist at Children's
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