Adam, age 10, is extremely distressed at school. Because of obsessional contamination fears, he avoids contact with other children and refuses to eat in the cafeteria. He washes his hands 20 times per day and changes his clothes at least three times daily.
His primary obsessions involve contact with bodily fluids—such as saliva or feces—and excessive concerns that this contamination would cause him serious illness.
Adam’s parents say their son’s worries about dirt and germs began when he entered kindergarten. They sought treatment for him 2 years ago, and he has been receiving outpatient psychotherapy since then. They have brought him to an anxiety disorders specialty clinic for evaluation because his obsessive-compulsive symptoms are worsening,
When treating patients such as Adam, our approach is to use cognitive-behavioral therapy (CBT) and adjunctive drug therapies to relieve their symptoms and help them reclaim their lives. Diagnosis of pediatric OCD is often delayed, and few children receive state-of-the-art treatment.1 The good news, however, is that skillful CBT combined, as needed, with medication is highly effective.
‘Fight OCD, not each other:’ What families need to know
Although family dysfunction does not cause OCD, families affect and are affected by OCD. Control struggles over the child’s rituals are common, as are differences of opinion about how to cope with OCD symptoms. It is important to address these issues early in treatment, as helping the family combat the disorder—rather than each other—is crucial to effective treatment.
Parents need to know that neither they nor the child are to blame. OCD is a neurobehavioral illness, and treatment is most effective when the patient, therapist, and family are aligned to combat it. Families are often entangled in the child’s OCD symptoms, and disentangling them by eliminating their role in ritualizing (such as giving excessive reassurance) is important to address in therapy.
Scaling family involvement is part of the “art” of CBT, and it will remain so until empiric studies determine the family’s role in the treatment plan.2
‘Contaminated’ mother.
Adam becomes distressed when he comes in contact with objects that have been touched by others (such as doorknobs). He is especially anxious when these items are associated with public bathrooms or sick people.
Adam’s mother is a family physician who has daily patient contact. In the last 6 months, Adam has insisted that his mother change her work clothes before she enters his room, touches him, prepares his food, or handles his possessions.
As in Adam’s case, the family often gets caught up in a child or adolescent’s obsessive rituals (Box 1).2 After a detailed discussion with Adam and his parents and because his symptoms were severe, we recommended combined treatment with sertraline and CBT. Adam was willing to consider CBT and medication because he recognized that he was having increasing difficulty doing the things he wanted to do in school and at home.
SNAPSHOT OF PEDIATRIC OCD
Approximately 1 in 200 children and adolescents suffer from clinically significant OCD.3 They experience intrusive thoughts, urges, or images to which they respond with dysphoria-reducing behaviors or rituals.
Common obsessions include:
- fear of dirt or germs
- fear of harm to oneself or someone else
- or a persistent need to complete something “just so.”
Corresponding compulsions include hand washing, checking, and repeating or arranging.
OCD appears more common in boys than in girls. Onset occurs in two modes: first at age 9 for boys and age 12 for girls, followed by a second mode in late adolescence or early adulthood.
Two practice guidelines address OCD in youth: an independent expert consensus guideline4 and the American Academy of Child and Adolescent Psychiatry’s practice parameters for OCD.5
For uncomplicated OCD, these guidelines recommend CBT as first-line treatment. If symptoms do not respond after six to eight sessions, a selective serotonin reuptake inhibitor (SSRI) is added to CBT.
For complicated OCD, medication is considered an appropriate initial treatment. Complicated OCD includes patients who:
- display severe symptoms—such as with scores >30 on the Children’s Yale-Brown Obsessive Compulsive Scale (CY-BOCS)
- or have comorbidity such as depression or panic disorder that is likely to complicate treatment.
KEYS TO SUCCESSFUL TREATMENT
OCD is remarkably resistant to insight-oriented psychotherapy and other nondirective therapies. The benefits of CBT, however, are well-established, with reported response rates of >80% in pilot studies.6,7 Although confirming studies have yet to be conducted, successful CBT for pediatric OCD appears to include four elements (Table 1).
Exposure and response prevention (EX/RP) is central to psychosocial treatment of OCD.7,8 In specialized centers, exposure can be applied intensively (three to five times per week for 3 to 4 weeks).9 In most practices, however, exposure is more gradual (weekly for 12 to 20 weeks). With repeated exposure, the child’s anxiety decreases until he or she no longer fears contact with the targeted stimuli.8,10