ADHD – not OCD – called the key comorbidity in pediatric hoarding

SAN FRANCISCO – Most of the pediatric hoarding literature focuses on hoarding accompanied by obsessive-compulsive disorder. But, “I want to highlight that [attention-deficit/hyperactivity disorder] is across the board something that seems to come up in child hoarding behaviors quite a bit, mirroring the adult literature, which is that hoarding behavior may be much more strongly associated with ADHD than it is with OCD,” Jennifer M. Park, PhD, said at the annual conference of the Anxiety and Depression Association of America.

Multiple studies have established that the prevalence of child hoarding is 2%-3.7%. Onset is typically at age 11-15 years. The course is chronic, and it’s a condition that typically exacerbates over time.

“A lot of the adult literature has shown that hoarding behavior actually starts in childhood. In many retrospective reports, adults say, ‘I’ve had these problems ever since I was a kid,’ ” according to Dr. Park, a psychologist affiliated with Stanford (Calif.) University.

Yet childhood hoarding is not widely perceived as problematic. Indeed, many parents and clinicians view it as developmentally appropriate. That’s to a great extent because the presentation of child hoarding behavior often is very different from and less disturbing than adult hoarding for the obvious reason that parents can limit the amount of clutter in the home.

“I have a bunch of kids who have quite significant hoarding behavior, but the parents are really on top of making sure all of that is left in the closet or within the child’s playroom, or maybe a certain section of the house,” Dr. Park said. “They’re able to keep it contained.”

Also, children and young adolescents lack the resources to accumulate massive clutter. They can’t drive, and have little or no money, so they can’t go on compulsive shopping sprees. “What I have seen in the kids that I work with is they make up for that by collecting things like paper and sticks, rocks, wrappers – anything that might be free, or knickknacks they can pick up along the way,” she said.

The cognitive-behavioral model of hoarding was first described 2 decades ago. It names three main factors as key to maintaining hoarding behaviors: emotional attachment and beliefs associated with one’s possessions, often including anthropomorphization; avoidance behaviors due to severe distress at the prospect of discarding stuff; and information-processing deficits.

“The idea here is that deficits in executive function – things like planning, organization, and inhibition – these are known in an extensive literature to be really strongly associated with ADHD, and executive function deficits link well with hoarding disorder as well,” Dr. Park continued.

Dr. Park was the first author of a recent multicenter study of 431 youths aged 6-17 diagnosed with OCD. They were participants in the OCD Collaborative Genetics Study and the OCD Collaborative Genetics Association Study, during which they completed the Behavior Rating Inventory of Executive Functioning (BRIEF) and the Hoarding Rating Scale–Interview. Clinically significant levels of hoarding compulsions were identified in 113 subjects. Compared with the group with OCD but not hoarding, the OCD/hoarding group had significantly lower scores – meaning problematic deficits – on nearly all of the executive function subscales on the BRIEF, including working memory, emotional control, and planning/organization.

The two groups did not differ significantly in the prevalence of full DSM-IV ADHD. But the hoarding group had significantly more inattention and hyperactivity symptoms, and in a multivariate analysis adjusted for age, sex, and ADHD symptoms, deficits in executive function as measured on the BRIEF instrument were the strongest predictor of hoarding severity in the study population (J Psychiatr Res. 2016 Nov;82:141-8).

In another study by Dr. Park and her coinvestigators involving 99 youth diagnosed with ADHD, the severity of inattention and hyperactivity/impulsivity predicted clinically significant hoarding, whereas nonhoarding OCD symptoms did not (J Atten Disord. 2016 Jul;20[7]:617-26).

In an earlier report by other investigators on 109 children seeking treatment for an anxiety disorder, 22% of the study population proved to have elevated levels of hoarding symptoms. They scored significantly higher than the nonhoarding group on measures of obsession-compulsion, anxiety, inattention, thought problems, rule breaking, aggression, social problems, major depression, and overall functional impairment. But of note, attention problems were a significantly stronger predictor of hoarding symptoms than were OCD or anxiety symptoms (J Anxiety Disord. 2015 Dec;36:9-14).

Discussant Eric Storch, PhD, said that it’s important for clinicians and parents to start taking child hoarding seriously as a legitimate treatment target.

“We know that if you start treatment early, you’re more likely to be successful versus when you start at age 57 and the clutter is 9 or 10 on a scale of 10,” said Dr. Storch, professor of pediatrics and director of clinical research for developmental pediatrics at the University of South Florida, Tampa.

Dr. Park reported having no financial conflicts of interest regarding her presentation.

bjancin@frontlinemedcom.com