Differences between Childhood OCD and Adult OCD

Unlike many disorders, OCD in children and adolescents is quite similar to OCD in adults. For example, the types of OCD symptoms (washing, checking, arranging, doubting, etc.) and the relative frequency of these symptoms is very consistent across the age range. A few differences do exist between OCD in children and adults, however, having important implications for treatment. Most of these differences are related to the developmental limitations of younger children compared to adults. First, the relationship between obsessions and compulsions is much less clear in children than in adults. Most adults are able to describe specific obsessions and to say that the purpose of their compulsions is to make these obsessions go away. Children, on the other hand, are typically unable to describe specific fears, often reporting that they don't know why they perform their rituals. Children are also much less likely than adults to describe their OCD symptoms as senseless or unreasonable, possibly because they may show less insight. Although youngsters with OCD may say that they don't like having OCD or that their OCD is "stupid" or "icky," they often insist that their rituals are necessary. From a developmental perspective, young children are more present-oriented than adults and, as a result, may be less motivated to engage in difficult activities to achieve a future reward. This reluctance is especially important for children starting behavior therapy for OCD since the motivating aspect of future improvement is likely to be heavily outweighed by the high degree of anxiety and distress associated with the initial treatment exercises. Related to the developmental limitations described above, many children with OCD have poor frustration tolerance and coping skills, so when they feel stressed by their symptoms they may respond with shouting, arguing, tantrums or even aggressive outbursts.

Another difference between OCD in children and adults is that children with OCD are much more likely than adults to involve other family members in their rituals. While mothers are most commonly involved, some children with OCD have developed compulsions that incorporate their entire families. Common examples of family involvement include requiring the mother or father to repeat certain reassuring words or phrases, demanding excessive washing of clothes or other belongings, prohibiting family members from using certain objects or words or from engaging in certain activities that might be upsetting and not allowing the family to eat certain foods for fear of illness or contamination. If left unaddressed, family involvement can result in distortions in family roles and relationships as well as negative feelings toward the OCD child by both parents and siblings, leading to heightened levels of family conflict.

Numerous research studies have shown behavior therapy (BT) to be a very effective treatment for OCD in adults. Although fewer studies have been conducted with children and adolescents, the results have been positive and suggest that this treatment can be equally successful with youngsters as it has been with adults. In general, behavior therapy for children with OCD is closely based on that for adults; however, the treatment has been modified to make it more appropriate for use with younger patients. This modified version of behavior therapy has been used to successfully treat OCD in children as young as five years of age.

Cognitive Behavior Therapy for Childhood OCD

Similar to behavior therapy for adults with OCD, cognitive-behavior therapy (CBT) for children with OCD is based on a technique called exposure plus response prevention (ERP). The first step in treatment consists of developing a rank-ordered list of all of the child's fears and rituals along with the situations in which these symptoms are most likely to occur. Youngsters are then systematically exposed to these situations starting with the least anxiety-provoking and working up to those that are most difficult. During the exposure, which leads to an initial increase youngsters are encouraged to resist their urges to ritualize. As the feared consequence of not ritualizing fails to occur, the child learns that his or her fears are not based on reality and they diminish in intensity. Thus, children learn that their anxiety returns to normal levels even when they don't perform their rituals. Through repeated exposures, the child's anxiety and fear decrease further, a process called autonomic habituation. Habituation is a process by which an individual gradually becomes accustomed to something over time. For example, most people living close to an airport will, at first, be greatly bothered by noise from the airplanes. Over time, however, they will gradually get used to the noise until after a few weeks, they may no longer notice the noise at all. In treatment, repeated exposure to obsessions leads to a weakening and oftentimes dramatic reduction in obsessive fears and compulsive behaviors.

Modifications for Children and Adolescents

As described earlier, the original exposure plus response-prevention program has been modified to address the unique developmental needs of children and adolescents with OCD. These modifications include increased reliance on cognitive techniques to facilitate an understanding of the illness and increase motivation for treatment including cognitive coping strategies for dealing with anxiety (hence the name Cognitive Behavior Therapy). Furthermore, the use of charts and graphs provide visual feedback of progress while behavioral rewards enhance compliance with in-session and homework tasks. Also, greater family involvement in therapy brings additional benefits. These modifications are described more fully below.

Cognitive restructuring throughout treatment helps youngsters change the way they think about their OCD. Children learn to "distance" themselves from their OCD symptoms in order to manage extreme anxiety during exposure and response-prevention exercises. Along these lines, patients learn how to recognize and relabel their obsessive thought, urges and feelings in a more realistic fashion. Their thought pattern may be, "I'm not really going to get sick if I touch this; it's just my OCD talking." To increase motivation toward treatment, children and their families learn to redirect negative feelings about themselves or each other to their OCD instead. For example, When you feel mad at your mom because she won't let you wash your hands, get mad at your OCD instead. It's not your mom's fault; it's your OCD's fault. Within each session and during homework, children graph their anxiety ratings on charts or graph paper. Younger children typically color and decorate their charts, while older adolescents may use regular graph paper. Graphing provides the children with immediate and easily understood feedback regarding habituation, also aiding in identification of success areas or difficulty in treatment.

A behavioral-reward program, in which children are systematically rewarded for completing in-session tasks and homework assignments, also enhances treatment compliance. This reward program is especially important for younger children who are less able to balance the future benefits of treatment against the increased initial anxiety associated with exposure treatment. As youngsters develop a greater sense of mastery over their symptoms, concrete rewards such as stickers, candy, baseball cards or other reward items are phased out and increased emphasis is placed on praise and encouragement from the therapist and family members. At the end of each session, patients are given daily homework assignments consisting of 30-60 minutes of exposure and response-prevention to situations and objects addressed in session. Patients graph homework exposures daily, followed by review and reward at each session. In the UCLA program, parents and other family members meet with the therapist regularly over the course of their child's treatment. During these meetings, the therapist educates the family about OCD, working to establish guidelines for resisting the OCD child's attempts to include family in his or her rituals. The therapist also helps the parents to develop strategies for dealing with any coexisting behavior problems the child may have. Open trials of CBT have yielded treatment response rates of 60 percent to 80 percent with mean synptom reductions of up to 60 percent.

Other Treatment Approaches

Like CBT, the majority of pharmacotherapy treatment research for OCD has been conducted with adults. While psychodynamic and other insight-oriented therapies have been found to be of limited benefit, the efficacy of serotonin reuptake inhibitors (SRI's) and cognitive-behavior therapy in treating OCD in adults is well-documented. Although less adequately studied, the available evidence suggests that treatment with either SRIs or ERP are similarly effective for children and adolescents. Clomipramine, fluvoxamine, and sertraline have all been found safe and effective in controlled multicenter studies with pediatric populations and are FDA approved for childhood OCD. Similar results have been found for fluoxetine in smaller single-site controlled trials. A controlled multicenter discontinuation study of paroxetine for childhood OCD is currently underway although the medication has shown efficacy in open trials. Generally speaking, controlled trials using the SRIs have yielded treatment response rates ranging from 50 percent to 75 percent with average symptom reductions (as typically measured using the Children's Yale-Brown Obsessive-Compulsive Scale, or CYBOCS) of 20 percent to 40 percent. In some but not all cases, the initial therapeutic response can emerge relatively rapidly. In the controlled trials described above, for example, the effects of active treatment were usually distinguishable from the placebo condition by the second to fourth week of treatment.

Researchers at the NIMH have recently identified a subgroup of children with OCD associated with Group A beta-hemolytic streptococcal (GABHS) infection. This subtype, named PANDAS (Pediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcal infections), is characterized by an acute and dramatic onset of OCD or tic symptoms at an early age, a relapsing-remitting course, associated neurological abnormalities, and evidence of recent GABHS infection. In these individuals, treatment of the underlying GABHS infection may lead to dramatic improvement in OCD symptomatology. The NIMH group has reported successful treatment of PANDAS with both plasmapheresis and intravenous immunoglobulin.

John Piacentini