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

1. OCD in Children
Dr. Shewikar El Bakry

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. 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. 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. 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. 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. 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. Obsessions
Compulsions
Fear/Anxiety
Reduction in
Distress
The Obsessive-Compulsive Cycle
Negative Reinforcement
(Piacentini et al, 2006)
8

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. 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. Symptoms at Home
11
• Resistance to stopping the obsessions of
compulsions
• Concern that they are “crazy” because of their
thoughts

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. 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. 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. Symptoms at School
15
• Avoid touching certain “unclean” things
• Withdrawal from activities or friends

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. 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. 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. 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. Treatment
20
“There is nothing
that is wrong with
me that what's right
with me can’t fix”

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. 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. 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. 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. 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. 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
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. 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. CBT with children
Trigger Obsession Compulsion Temp 1-10
Symptom List (Stimulus
Hierarchy)

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. 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