by Jennifer L. Shoenfelt, MD; and Christina G. Weston, MD; Series Editor: Paulette Marie Gillig, MD, PhD
Editor’s Note: All cases presented in the series “Psychotherapy Rounds” are composites constructed to illustrate teaching and learning points, and are not meant to represent actual persons in treatment.
Author Affiliation: All are from the Department of Psychiatry, Wright State University, Dayton, Ohio.
Abstract
Obsessive compulsive disorder (OCD) in children and adolescents is much the same as in adults with regard to symptoms and basic treatment modalities. There are some distinct considerations to note in the approach to treatment methods. Empirically supported treatments include both medications and cognitive behavioral therapy (CBT). It is important that psychotherapeutic treatment be tailored to the developmental level of the child. In this article, we will present, through case example, samples of varying the psychotherapeutic approach used for both child and adolescent cases of OCD. We will focus on exposure and response prevention techniques.
Key Words: obsessive compulsive disorder, psychotherapy, cognitive behavioral psychotherapy, exposure and response prevention, children, adolescents
Psychiatry 2007;4(5):47-53
Introduction
Obsessive compulsive disorder (OCD) can be a profoundly life-disrupting illness for anyone. But for a developing child, the impact is even more significant. Children with OCD readily notice their behavior as odd and distinctly different from their peers. They worry that they may be “crazy.” Their daily routines of eating, dressing, sleeping, getting to school, participating in sports and activities, doing homework, and generally enjoying the freedoms of childhood are markedly altered by their illness.[1] Family life becomes disrupted, and parents often are frustrated and unsure of how to handle their child’s behavior. Siblings often suffer when their parents pay more attention to their sibling with OCD and may retaliate against the affected child with teasing, taunting, and anger. In addition, children with OCD are more likely to have comorbid psychiatric disorders, such as tic disorders, anxiety disorders, disruptive behavior disorders, and learning disorders that further complicate the clinical picture.[2]
It is estimated that approximately 1 in 200 children have OCD resulting in a prevalence rate of roughly 1 to 4 percent.[3,4] OCD is believed to be underdiagnosed in children. Results of several studies support the findings of the 1984 Epidemiological Catchment Area Survey, which placed OCD as the fourth most common psychiatric disorder (preceded by phobias, substance use disorders, and major depressive disorder) with a lifetime prevalence of 2.5 percent.[5,6]
Pediatric OCD is divided into classifications of early onset (<10 years) and late onset (>12 years). There is typically a male preponderance of 3:2, with males tending to have an earlier onset than females. Earlier onset may also be associated with OCD in a first-degree relative.[7,8] By adolescence, girls and boys are affected equally. Symptoms tend to wax and wane throughout the lifetime. However, Geller and colleagues have postulated that some children may outgrow their illness, as adult prevalence seems to be about equal to that of the child and adolescent population.[9] Swedo and colleagues described a subtype of OCD in children that begins before puberty and typically exhibits severe exacerbations of an episodic nature. This subtype has been associated with Group A beta-hemolytic streptococcus infections and has been named pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections (PANDAS).[7,24]
Case Presentation
Taylor is a nine-year-old boy who was brought to the clinic by his parents at the beginning of his fourth grade year of school. The family had recently moved, and Taylor had started going to a new school. About one month into the school year, both Taylor’s parents and his teacher noticed that Taylor was washing his hands excessively. He frequently asked to be excused from class to wash his hands and had to have a supply of liquid hand sanitizer available at all times. He also convinced his parents to send disinfecting wipes to school to wipe his desk numerous times during the day. Each morning before school, he spent an inordinate amount of time in the shower. To get in and out of the shower, Taylor had to put on shoes so as not to be contaminated by the floor. He had a specific routine for washing in the shower, which could not be varied or he would need to start the process all over again. He had a specific order for putting on his clothing and had to have his bed arranged to particular specifications before leaving home and before retiring for the night. No one was allowed in his room to touch anything for fear they would contaminate the area and get Taylor sick. Everything that Taylor came into contact with had to be decontaminated. This included his book bag, notebooks, and coat. Each item had to be sprayed with an antibacterial/antiviral spray if it came into contact with anything other than Taylor’s clean hands. Even the family dog had to be decontaminated by shampooing or spraying it with a disinfectant. If an object was not decontaminated, Taylor would become very distressed, and he would request his mother disinfect the object for him. If this did not occur, he would dissolve into tears and a tantrum until his mother complied out of pity and frustration. Taylor’s father refused to assist him in his disinfecting, often telling him to “grow up” and “snap out of it.” As time went on, the entire family became involved in Taylor’s obsessions and compulsions. Taylor’s “meltdowns” about needing help to decontaminate items eventually consumed the majority of his waking hours and all of the family’s time together. Taylor became unable to hug or touch family members, with the occasional exception of his mother. Taylor’s older siblings would taunt him and purposely “contaminate” his room by going in and touching things. Classmates and friends were asking Taylor why he had to keep cleaning things and washing his hands. Taylor could only respond, “I don’t know.”
Practice Point—DSM IV criteria for OCD in children is largely the same as for adults. However, diagnosing and treating OCD in children and adolescents requires special attention to the developmental stage of each particular patient.
In children, most common obsessions are a fear of contamination, fear of harm to oneself or others, and urges related to a need for symmetry and exactness. Compulsions in children are usually excessive washing and cleaning, checking, counting, repeating, touching, and straightening.10 DSM IV-TR criteria for children are the same as for adults, with the exception that children do not have to recognize that their obsessions are unreasonable and compulsions are grossly out of the ordinary from normal behavior (specified as “poor insight” in adults). Key to the diagnosis of OCD are the criteria that symptoms must be “distressing, time consuming (taking more than an hour a day), or must significantly interfere with school, social activities, or important relationships.”[10]
It is vital to recognize that, developmentally, children go through various stages in which they exhibit obsessive and compulsive-like behaviors.[9,11] At about age two, toddlers often engage in ritualistic behaviors that may be related to eating, bathing, and bedtime. At ages 3 to 5 years, children tend to enjoy repetitive kinds of play behaviors. In the elementary years, superstitions, collecting, and focused interest in hobbies are common. By adolescence, one may see developmentally appropriate, intense interests, such as in trendy activities, celebrities, or types of music. It is also important to recognize the influence of cultural and religious beliefs that may seem extreme and out of the mainstream of beliefs, but that are commonly accepted in the child’s family and social environment.[10,12] Recognizing deviation from these normal developmental stages that fits the criteria previously outlined is central to diagnosing OCD in children and adolescents.
Once diagnosed, choices of treatment must be addressed with the patient and family. Empirically supported treatments include individual, family, and group cognitive behavioral therapy (CBT)[13–15] and pharmacotherapy with serotonin reuptake inhibitors (SRIs)[16–19] or any combination of these. Cognitive and behavioral strategies may be used separately or in combination. Barrett, et al., actually found that at 12 and 18 months following individual and group CBT, 70 percent of those subjects who had received individual therapy and 84 percent of those having received group therapy had maintained their gains and no longer met diagnostic criteria for OCD. Those with more severe disease and worse family dysfunction had a worse long-term outcome.15 Marche and Mulle have formulated a particularly helpful manualized treatment approach utilizing cognitive-behavioral strategies, with a specific focus on exposure response prevention.[10] This approach has been studied for individual use and has also been modified for group use, both with positive outcomes that are at least equal or more efficacious than medication alone. CBT has also decreased relapse rates more effectively than sertraline alone.[13] Current recommendations for treatment focus on utilizing psychotherapy as a first line treatment with consideration for concurrent use of medications according to symptom severity. Likewise, risk versus benefit must be considered in light of the Food and Drug Administration (FDA) black box warning now on antidepressants. These recommendations are also used for PANDAS-affected children.[20]
Case Continued
Initial evaluation. The initial evaluation with Taylor and his family revealed remarkable upheaval in the family and in Taylor’s daily life that was rendering him almost nonfunctional. The psychiatrist recommended both pharmacotherapy with a selective SRI and cognitive behavioral therapy to address the severity of the patient’s symptoms. The parents were not comfortable with medications and opted to decline them. The parents attempted to secure a therapist in a location more convenient than the psychiatrist’s office. However, Taylor could not tolerate the outside appearance of the office they chose. He was eventually convinced to enter, but found the disarray of the therapist’s office completely disconcerting and refused to return.
While searching for a therapist more conveniently located, Taylor’s parents continued to bring him to the initial psychiatrist, who was able to provide suggestions to the parents as to how to handle Taylor’s requests for them to participate in his compulsions. The parents and psychiatrist also discussed ways to handle severe crying episodes and tantrums.
To assist in these matters of how to deal with Taylor, considerable psychoeducation had to take place between the psychiatrist and the family.9 OCD was described to the family in terms of a medical or neurobiologic illness. The illness was compared to traditional medical illnesses, such as diabetes or asthma, where treatment involves medication and psychosocial interventions for healthy outcomes.10 Taylor’s father felt that his son’s compulsions were entirely under the boy’s control, and he often chastised Taylor or poked fun at him, telling him to “grow up” and “just cut it out.” This only increased the stress level in the home. Taylor’s mother, on the other hand, was reinforcing Taylor’s compulsions by providing disinfecting materials and assisting Taylor in disinfecting items so that she did not have to listen to crying and could hasten the morning routine to get him out of the house to school on time. Some cognitive therapy was also initiated with Taylor to explore the events and behaviors in his life.
Eventually, due to a strong working alliance that developed between the psychiatrist and patient and family, the psychiatrist became the therapy provider and initiated weekly CBT sessions for Taylor.
Manualized therapy begins. The family continued to be hesitant about starting medications, so it was mutually decided to undertake CBT utilizing the March and Mulle manual.[10] Initial sessions focused on performing baseline evaluation measures, such as the Children’s Yale-Brown Obsessive Compulsive Scale (CY-BOCS), National Institute of Mental Health Global Obsessive Compulsive Scale (NIMH OC), and Clinical Global Improvement Scale (CGI). Taylor was encouraged to “name” his OCD to assist him in “externalizing” his illness. The technique of exposure and response prevention was introduced, and the stage was set for the “battle” Taylor and his family would be taking against OCD, with the therapist acting as a coach and the patient and family taking on the fight. The parents were encouraged to practice differential reinforcement of behavior (DRO) and to not give advice to Taylor. DRO involves reinforcing mutually pleasant interactions and avoiding negative interactions (e.g., playing games while avoiding commenting on OCD rituals).[10] Each week new concepts were introduced to work on giving Taylor more control over his OCD. The idea of having a “tool kit” with which he could fight off the OCD was introduced and developed. Taylor gradually learned to rate the level of anxiety he felt when obsessions would start to take over his mind. He easily understood and attempted cognitive training techniques, such as constructive self talk, cognitive restructuring, and cultivating detachment. Constructive self talk involves identifying and correcting negative self talk. Cognitive restructuring involves analyzing a child’s catastrophic estimation of danger and identifying his overestimation of its likelihood. Cultivating detachment involves getting a child to accept that OCD is an external problem from himself. During this time, Taylor also experienced some shifts in his obsessions with the addition of having nighttime fears of an intruder and a fear of spiders. In later sessions, the psychiatrist introduced specific graded exposure and response prevention (E/RP) exercises that Taylor was assigned to work on at home. Taylor was actively involved in determining the tasks of E/RP in order to encourage success, adherence, and control of his progress. Periodic family meetings were held, which included Taylor’s siblings. Also, regular administration of the CGI and the NIMH OC scale was performed to monitor progress.
Taylor responded quite well to approximately 12 sessions of manualized CBT and eventually achieved remission of all of his OCD symptoms. Further steps in manualized treatment as set forth by March and Mulle encourage generalization of techniques used and relapse prevention sessions followed by booster sessions as needed.
Practice Point—Based on the results of the Pediatric OCD Treatment study (POTS), it is recommended that children and adolescents with OCD either receive a combination CBT with an SSRI as first line treatment or CBT alone, as these treatments were superior to treatment with an SSRI alone or placebo.21
POTS was funded by the NIMH and was a multicenter, randomized, clinical trial to study the efficacy and long-term benefit of four potential treatments for children and adolescents with OCD: Sertraline alone, CBT alone, combination of sertraline and CBT, and placebo. The study involved three centers and 112 children, equally distributed between males and females and children ages 7–11 and 12–17. An intent to treat model was utilized. The study lasted a total of 28 weeks. Approximately 54 percent of the subjects treated with combination therapy and 39 percent of those treated with CBT alone achieved excellent clinical response with final CY-BOCS ratings of less than or equal to 10. This compares to 21 percent of the sertraline-only group and three percent of the placebo group.[21,22]
Case continued—Sample therapy session with Taylor early in treatment.
Taylor: This week at school was really hard. OCD would not leave me alone. I sit by this really smelly kid, Danny, who is always coughing. I just know he is getting germs everywhere on my desk. I try to set up folders to protect my desk, but then I know he is making my folders germy and then I have more stuff to clean.
Therapist: Tell me what OCD has been bullying you to do when your neighbor coughs or touches your desk.
Taylor: Well, I have to get a wipe and wash down the whole desk. Then I try to wipe my books and folders. Next I have to use a lot of hand sanitizer. If I can’t do this right away I start to feel very upset and sometimes I cry. The kids all look at me funny and ask me what’s wrong.
Therapist: It sounds as if you could use some practice bossing back that OCD. Let’s give it a try.
Taylor: Ok. It will probably be hard for me, but I know I can do it. I bet I can use the tool kit I have now.
Therapist: Yep, that sounds great. Can you rate your fear of Danny’s germs harming you on your fear thermometer?
Taylor: It’s about 7 out of 10. I am really frightened that I will take those germs home and my family could get sick and die from them.
Therapist: That sounds pretty scary. So let’s get started. You can’t avoid Danny, right? So we need to find a way to talk back to OCD so that you don’t feel as if you have to clean so much or even right away.
Taylor: Well, I think I’d have to clean something. But I might be okay with trying to wait longer to clean, so that I could maybe get some of my class work done.
Therapist: Good thinking. What do you think you’d rate that on your fear thermometer—just waiting a little longer to clean?
Taylor: Probably about a 5.
Therapist: So this week let’s try having you wait each time you feel the need to disinfect your belongings or yourself because of Danny’s germs. Keep some of your therapy homework sheets in your desk. After each minute that passes, write down your fear thermometer rating for that moment. When your rating gets down to about a 2, you may clean your belongings.
Taylor: That sounds kind of hard. I think I am going to need to use some of my special weapons against OCD while I am waiting. Maybe I could tell myself that “it’s just OCD again, being a pest. Get out of here, OCD. I am going to do something else while I wait for you to go away.” Then I can concentrate on my assignment and keep rating my fear. What do you think?
Therapist: I think you’ve really got it, Taylor! I am so proud of how you are talking back to OCD and taking charge.
In the therapy illustration, the ER/P technique being used is “uncontrived exposure,” wherein the child attempts to prevent rituals in response to OCD triggers that cannot be avoided. By referring to OCD as something over which the child will gain control, the therapist demonstrates “externalization” of the illness and “cultivates nonattachment.” The child also utilizes constructive self talk. Note that the child selects the task that he can tolerate. If this proves to be too overwhelming for him, the therapist will adjust the task, with his input, for the next week.
Table 1 outlines a sample progression of treatment sessions adapted from the March and Mulle protocol.
Treatment of OCD in Taylor as an adolescent. Taylor is now 17 years old. He has had some minor relapses of his OCD symptoms over the past years, but has generally done quite well and has not been impaired to any significant degree by his residual symptoms. He has had booster sessions of CBT, which have assisted him to control his OCD at the onset of relapses.
Following a recent minor motor vehicle accident, in which Taylor was driving, he began experiencing a new set of obsessions and compulsions. Taylor complained of feeling as though he must repeatedly turn around and retrace his route to make sure he did not hit something. Taylor’s mother relates an incident where his usual 10 minute trip to his aunt’s home took over two hours due to his multiple stops to retrace parts of his route where he felt he may have hit something or someone. Taylor also reports a similar urge when walking somewhere. He will suddenly have the feeling that he bumped into something or someone and will feel the urge to stop and turn around to look behind him. He states he rarely actually turns around. Instead he talks himself out of the fact that he could have actually bumped into something. In addition, Taylor is having mild symptoms of panic in association with worry about how he will complete large school projects. To quell his anxiety, he frequently starts organizing for projects weeks in advance and mentally prepares a detailed schedule for completing various steps of the project. His panic is manifested by chest pressure, shortness of breath, internal feelings of restlessness, anxiety, flushing, and tachycardia.
Sample therapy interaction with Taylor.
Therapist: Taylor, you have done remarkably well. You have used your skills to fight off the OCD with much success. I am really proud of you.
Taylor: Yes, but I am having some trouble now.
Therapist: Try not to get discouraged. Remember, we talked about the likelihood that you would have “slips” or “relapses” and that they typically go away after some time. This is the course of OCD. Let’s go back to one of our techniques that seemed to help you in the past. Recall one of your most recent experiences that required you to turn around and retrace your route. As you tell me about the incident, I would like you to be very detailed. Tell me what you saw, heard, and smelled. Describe the emotions you were feeling and the physical sensations you had. I will have you stop briefly every one or two minutes to rate your anxiety at that moment.
Taylor: That sounds difficult. But I’ll try.
Therapist: Remember that you can use your thinking strategies when your anxiety level increases. You can also use the relaxation techniques you learned. When your anxiety level is at zero, we can stop the exercise.
After completing the imaginal exposure exercise twice, relating two separate incidents, the therapist provides homework for Taylor.
Therapist: This week, remember to use your cognitive strategies to handle the OCD and your anxiety. In addition, remember the methods you learned for “breaking the rules” of OCD.
Taylor: Oh yeah, I almost forgot those. Isn’t that doing things like delaying my rituals, shortening them, and doing them differently?
Therapist: You have a good memory. Don’t forget your deep breathing and distraction techniques, too. Come back next week and give me an update, okay?
Key Point—A pivotal factor in the success of any CBT protocol relies upon the ability of the therapist to modify techniques and approaches based on the developmental level of the child or adolescent.23
In the case of Taylor as a nine-year-old child, making OCD the “enemy,” putting therapy in terms of a battle, and utilizing a “fear thermometer” all enabled his progress in conquering OCD. Graduated E/RP exercises done as homework and in the therapist’s office were utilized along with cognitive techniques utilizing age-appropriate vocabulary. These techniques are less threatening to younger children than those techniques used when Taylor was an adolescent.5 Results in at least one study by March, et al., found that nine out of 15 children treated with these techniques experienced at least a 50-percent reduction in symptoms, which endured for 18 months.5,10
When Taylor returned as a teen, he was encouraged to utilize more extensive cognitive techniques and imaginal exposure to address his new symptoms and to prevent further relapses. Terminology was adapted to his developmental level. The combination of response prevention and flooding seem to be particularly effective for adolescents and adults with compulsions. Reported improvement rates are close to 90 percent for moderate to complete improvement.5
Summary
Psychotherapeutic interventions for OCD in children and adolescents are the mainstay of treatment. The development of manualized treatment protocols, make these interventions easily accessible to mental health professionals.10 With careful attention to the developmental level of the pediatric patient, these techniques can be customized to benefit most patients with OCD. While it is sometimes easier to quickly treat OCD with a medication, this case illustrates that when the patient, family, and physician invest the time in psychotherapy, the benefits can be long-lasting.
References
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19. Riddle MA, Reeve EA, Yaryura-Tobias JA, et al. Fluvoxamine for children and adolescents with obsessive-compulsive disorder: A randomized, controlled, multicenter trial. J Am Acad Child Adolescent Psychiatry 2001;40(2):222–9.
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