Child Onset Obsessive Compulsive Disorder (OCD)

Shauna, Heather and Kathryn

Childhood Onset ObsessiveCompulsive Disorder (OCD)

Shauna

Overview and description of OCD

Heather

Theoretical conceptualization of OCD Issues related to OCD

Kathryn

Current research studies and information on OCD

Overview and Description of OCD

Shauna

Tina A Case Example

7 year old girl in Grade 2

No history of previous behaviours exhibited First behavioural consultation: Pediatrician

Developed severe hand washing rituals and fear of contamination

Parents accommodated rituals

to ease Tinas distress and anxiety

Snider and Swedo (2000)

Obsessive-Compulsive Disorder
Characterized by the presence of obsessions, compulsions, or both, that cause marked distress or interfere with a persons life.
Obsessions are persistent and recurrent images, thoughts, or impulses that are intrusive and distressing. Compulsions are repetitive, purposeful mental acts or behaviours that a person is driven to perform to prevent or reduce distress, or to prevent some feared event or situation.

OCD and the DSM-IV-TR

A Either obsessions or compulsions B Realization/awareness that their symptoms are excessive and unreasonable (Does not apply to children) C Obsessions and compulsions cause marked distress, are time-consuming, or significantly interfere with the persons normal routine, occupational (or academic) functioning, or usual social activities or relationships D Obsessions and compulsions are not restricted to another Axis I disorder (if present) E Disturbance not due to direct physiological effects of a substance or a general medical condition
DSM-IV-TR (2000) Pages 422-423

Childhood Onset OCD

OCD began in adolescence for to of cases of adults who suffer from the disorder, appearing in a form virtually identical to that seen in adults.
(Rappaport, 1986)

Estimates indicated that 1 in 200 children and adolescents have OCD, and only of them ever receive professional evaluation and treatment. Why is this?

Why is OCD not Diagnosed in Children More Often?

Children have poor insight Limited verbal expression Inability to describe and identify symptoms Family compensation and accommodation

Parents and adolescents often first seek medical attention for behavioural or physical consequences of the ritualistic behaviours not for OCD itself!

What Kinds of Obsessions or Compulsions Do Children Engage In?

(Some examples)

Preoccupation with Danger, Disease and Doubt Fear of Separation Fear of Contamination Compulsive Washing and Grooming Checking Hoarding Fear of Harm or Disaster for Self or Others

Gender Differences?

Pediatric clinical studies of children and adolescents with OCD show a predominance of males
(which settles out in adolescence).

Boys are more likely to have pre-pubertal onset of OCD, and girls are more likely to have pubertal-onset of OCD.

Mean age of onset between 7.5 and 12.5 years (average 10.3 years).

The presence of normal developmental rituals does not indicate the presence of OCD!
Developmentally normal rituals
are not excessive do not interfere with a childs functioning can be interrupted without significant emotional distress typically abate by 8 or 9 years of age

Theoretical Conceptualizations
Heather

OCD Subtypes
Contamination/Decontamination

(Washing)

Fear being harmed or spreading harm to others through contamination Feel discomfort or contaminated by substances, without fear of harm
Harm

Obsessions/Checking

Harm, aggression, and sexual obsessions results in checking rituals to reduce anxiety
Obsessions

without Compulsions

Hoarding

Development of OCD
Genetic

Studies

Heritability studies 26% - 65% Early onset OCD

Environmental

Effects

Perinatal risk factors Trauma Parenting/Family environment

Parenting

style (over-control, over-protection, expressed emotion, emotional rejection) Childhood trauma (emotional abuse, physical neglect) Obsessive Compulsive Symptoms

Cognitive

Model

Cognitive dysfunction Cognitions elicit compulsions

Neurodevelopmental Model of OCD

Rosenberg & Keshavan (1998)
Is OCD a neurodevelopmental disorder?
80%

onset Childhood vs. Adulthood Comorbidity of other neurodevelopmental disorders, Tourettes Disorder

of OCD cases have a childhood or adolescent

Which neuroanatomical structures are involved in OCD?

Ventral

Prefrontal Cortical and Striatal Circuits Repetitive thoughts and ritualistic behaviour due to deficit in inhibition

Frontal-Striatal-Thalamic Model
MacMaster, ONeill & Rosenberg (2008)

Frontal Cortex
visual

attention, executive functioning, response suppression. Ganglia-Frontal Cortex: obsessive and compulsive symptoms.

Striatum
Basal

Thalamus Developmental changes

Pruning

Issues in the Conceptualization of OCD

No one model fits all Models and Theories are vital
Interventions

and at-risk populations

Cross-cultural Studies
Okasha, Saad, Khalil, Dawla & Yehia (1994) Phenomenology of OCD dependent upon:
Culture: Religion involves certain and specific rituals, compulsions and checking. Beliefs that Psychosocial factors: More men seek help than women More tolerance for obsessive compulsive symptoms Lack of insight

Current Research in OCD

Kathryn

Current Research March J.S. & Foa, E. (2004)

The

This article examined the efficacy of CBT alone and medical management with SSRI (sertraline) alone and CBT and sertraline combined.

Pediatric OCD Treatment Study (POTS) randomized controlled trial

Results:

CBT statistically superior to sertraline alone, just behind combination treatment Sertraline statistically superior to placebo Combined statistically superior to sertraline and CBT alone (small margin)

Implications: Children with OCD should begin treatment with CBT alone or with CBT plus an SSRI

Current Research
Ginsburg,

Kingery, Drake and Grados (2008) This article examined predictors of treatment response in pediatric OCD Results:
Predictors in CBT studies Predictors in SRI studies Predictors in combination studies Implications

Current Research
Sloman,

Gallant and Storch (2007)

Examines a school based problem- solving model that school psychologists can utilize to conceptualize, assess and treat OCD.

Borrows from the Schwanz and Barbour (2005) model

Best Practices for School Based Treatment

1.

Define the Problem 2. Develop an Assessment Plan 3. Analyze Assessment Results and Set Goals 4. Develop and Implement the Intervention Plan 5. Analyze the Intervention Plan

Future Research (results of all 3 studies)

Examine

barriers for transporting CBT from specialty clinics to community practice Examining the partial response to medication monotherapy using CBT augmentation Examination broader outcomes (situation specific) Assessment of treatment for Specific subtypes of OCD (hoarding) Data on predictors of treatment response to CBT is extremely limited, and more extensive research needs to be done in this area

Up and Down the Worry Hill Author: Aureen Pinto Wagner, Ph.d

Discussion
1.

Based on the DSM-IV-TR criteria for a diagnosis of OCD (specifically particular subtypes), what are some challenges that teachers could face when a student is dealing with his/her difficulties in the classroom?

2.

As school psychologists what do you think our role is in ensuring that children with OCD are treated for their presenting symptomology and not for another co morbid disorders which arise due to the behavioral and physical consequences of OCD?

References
Albano, A.M., Chorpita, B.F. and Barlow, D.H. (2003). Childhood Anxiety Disorders, In: Child Psychopathology, ed. E.J. Mash and R.A. Barkley. New York: Guilford Press, pp 287-289. American Psychiatric Association. Diagnostic and statistical manual of mental disorders, Fourth Edition, Text Revision (2000). Washington, DC, American Psychiatric Association, pp 456-463. Berg, C.Z., Rapoport, J.L., Whitaker, A. et al. (1989). Childhood ObsessiveCompulsive Disorder: A Two-Year Prospective Follow-up of a Community Sample. Journal of the American Academy of Child and Adolescent Psychiatry,28, 4:528-533. Castle, D.J., Deale, A., Marks, I.M. (1995). Gender Differences in ObsessiveCompulsive Disorder. Australian and New Zealand Journal of Pyschiatry, 29:1, 114-117. Gefken, G., Sajid, M.,Macnaughton, K. (2005). The Course of Childhood OCD, Its Antecedents, Onset, Comorbidities, Remission and Reemergence: A 12-Year

References
Geller, DA, Biederman, J., Faraone, S. et al (2001). Developmental Aspects of Obsessive-Compulsive Disorder: Findings in children, adolescents and adults. Journal of Nervous and Mental Disorders, 180, 7:471-477. Geller, DA (2007): The promise and challenge of obsessive-compulsive research.

Biological Psychiatry 61, 2:263-265.

Geller, D.A. (2006). Obsessive-Compulsive and Spectrum Disorders in Children and Adolescents. Psychiatric Clinics of North America, 29, 2: 353-370. Ginsburg, G.S., Newman-Kingery, J., Drake, K.L. & Grados, M.A. (2008).

Predictors of treatment response in pediatric obsessive-compulsive disorder. American Academy of Child and Adolescent Psychiatry, 47, 868-878.

Leonard, L.L., Freeman, J., Garcia, A. et al. (2001). Obsessive-Compulsive Disorder and Related Conditions. Pediatric Annals, 30, 3:154-157.

References
MacMaster, F.P., ONeill, J. & Rosenberg, D.R. (2008). Brain imaging in pediatric obsessive-compulsive disorder. American Academy of Child and Adolescent Psychiatry, 47, 1263-1273. Mathews, C.A., Kaur, N., & Stein, M.B. (2008). Childhood trauma and obsessivecompulsive symptoms. Depression and Anxiety, 25, 742-751.

Okasha, A., Saad, A., Khalil, A.H., Dawla, A.S.E., & Yehia, N. (1994). Phenomenology of obsessive-compulsive disorder: a transcultural study. Comprehensive Psychiatry, 35, 3, 191-197.
Rapoport, J.L. and Inoff-Germain, G. (2000). Practitioner review: Treatment of Obsessive-Compulsive Disorder in Children and Adolescents. Journal of Child Psychology and Psychiatry, 41, 4:419-431. Schwanz, K.A., & Barbour, C.B. (2005). Problem-solving teams: Information for educators and parents. Available from http://www.nasponline.org/publications/cq338probsolve.html

References
Sloman, G.M., Gallant, J. $ Storch, E.A. (2007). A school based treatment model for pediatric obsessive-compulsive disorder. Child Psychiatry, 38, 303-319. Snider, L.A., Swedo, S.E.(2003). Childhood Onset Obsessive-Compulsive Disorder and Tic Disorders: Case Report and Literature Review. Journal of Child and Adolescent Psychopharmacology, 13, Supplement 1: S81-S88. Snider, L.A., Swedo, S.E. (2000). Pediatric Obsessive-Compulsive Disorder. Journal of the American Medical Association, 284, 24:3104-3106. Sookman, D., Abramowitz, J.S., Calamari, J.E., Wilhelm, S., & Mckay, D. (2005). Subtypes of obsessive-compulsive disorder: Implications for specialized cognitive behavior therapy. Behavior Therapy, 36, 393-400.

Wilcox, H.C., Grados, M., Samuels, J., Riddle, M.A., Bievenu III, O.J., Pinto, A., Cullen, B., Wang, Y., Shugart, Y.Y., Liang, K.L., & Nestadt, G. (2008). The association between parental bonding and obsessive compulsive disorder in offspring at high familial risk. Journal of Affective Disorders, 111, 31-39.