Pediatric OCDJoe Edwards, Psy.D.Stephanie Eken, M.D.David Causey, Ph.D.CognitiveBehaviorTherapy(CBT)inthetreatmentofOCD认知行为疗法（CBT）在治疗强迫症Prevalence of OCD in childrenzOCD is considerably more common than once thoughty 1 in 200 are thought to suffer from OCDy 3 or 4 in each elementary school have ity Up to 20 adolescents in an averaged-sized high school have OCDy 7 million in the US will suffer OCD during their lifetime (15 million OCD spectrum disorders)CognitiveBehaviorTherapy(CBT)inthetreatmentofOCD认知行为疗法（CBT）在治疗强迫症Prevalence of OCD cont.zUnfortunately, only 4 of 18 children found to have OCD were under professional mental health care (Flament et al., 1988), of those 18 had been identified as having OCDzOCD has been called the “hidden epidemic” (Jenike, 1989) CognitiveBehaviorTherapy(CBT)inthetreatmentofOCD认知行为疗法（CBT）在治疗强迫症Factors contributing to underdiagnosis of OCDzFactors in OCD: secretiveness & lack of insightzFear of being seen as CrazyzFactors with healthcare providers: incorrect dx.s, lack of familiarity with (or unwillingness to use) proven treatments, differentiating variants of OCD symptomszAccess to good treatment CognitiveBehaviorTherapy(CBT)inthetreatmentofOCD认知行为疗法（CBT）在治疗强迫症DSM-IV criteria for OCDzOCD is characterized by recurrent obsessions and/or compulsions that cause marked distress and interference with social or role functioningzChildren may present with either obsessions or compulsions (most have both)zIn youth, the types of symptoms, can change rapidly CognitiveBehaviorTherapy(CBT)inthetreatmentofOCD认知行为疗法（CBT）在治疗强迫症DSM-IV criteria for OCD z OCD behaviors can occur in a child without meeting criteria for OCDz DSM-IV specified OCD symptoms must cause distress, being time-consuming ( than 1 hr/day) , or must significantly interfere with school, social activities, or important relationshipsCognitiveBehaviorTherapy(CBT)inthetreatmentofOCD认知行为疗法（CBT）在治疗强迫症DSM-IV criteria for OCDz Obsessions are more than simply excessive worries about real life problemsz Obsessions originate from within the mindz At some point in the illness, the person recognizes that the O/C are excessive and unreasonableCognitiveBehaviorTherapy(CBT)inthetreatmentofOCD认知行为疗法（CBT）在治疗强迫症DSM-IV criteria for OCDz Specific content obsessions are not related to another Axis I disorder (obsessions about food in an eating disorder or guilty thoughts with ruminations in depression)CognitiveBehaviorTherapy(CBT)inthetreatmentofOCD认知行为疗法（CBT）在治疗强迫症Common OCD symptoms in childrenObsessionszContamination themeszHarm to self or otherszAggressive themeszSexual themeszScrupulosity/religiosityzForbidden thoughtszSymmetry urgeszNeed to tell, ask, confessCompulsionszWashing or cleaningzRepeatingzCheckingzTouching zCountingzOrdering/arrangingzHoardingzPrayingCognitiveBehaviorTherapy(CBT)inthetreatmentofOCD认知行为疗法（CBT）在治疗强迫症Common OCD symptoms in childrenz OCD symptoms frequently change over timez By the end of their adolescence most all of the classic symptoms have been experienced by the childCognitiveBehaviorTherapy(CBT)inthetreatmentofOCD认知行为疗法（CBT）在治疗强迫症Assessment of OCDz*See Merlo et al., 2005z Clinical Interviewz Be sure to include:yImpact on activities (which ones)yImpact on family (and family dynamics)yAccomodation behaviors (see scale)yChilds attitude toward symptoms (ego- dystonic versus ego-syntonic)CognitiveBehaviorTherapy(CBT)inthetreatmentofOCD认知行为疗法（CBT）在治疗强迫症Diagnostic InterviewszAnxiety Disorders Interview Schedule (Silverman & Albano, 1996) not high agreement between child and parentzSchedule for Affective Disorders and Schizophrenia for School-Age Children (Kaufman et al., 1997)CognitiveBehaviorTherapy(CBT)inthetreatmentofOCD认知行为疗法（CBT）在治疗强迫症MeasureszChildren Yale-Brown Obsessive Compulsive Scale (CY-BOCS) (Scahill et al., 1997) yClinician Rated (past week)yAssess severity of symptoms, controlzSome evidence that clinician-rated is superior to subject-rated (Stewart et al., 2005)CognitiveBehaviorTherapy(CBT)inthetreatmentofOCD认知行为疗法（CBT）在治疗强迫症MeasureszLeyton Obsessional Inventory-Child Version (Berg et al., 1988)yIncludes a short formzChildrens Obsessional Compulsive Inventory (Shafran et al., 2003)zChildrens Yale-Brown Obsessive-Compulsive Scale-Child Report and Parent Report (Storch et al., 2004)CognitiveBehaviorTherapy(CBT)inthetreatmentofOCD认知行为疗法（CBT）在治疗强迫症MeasureszCBCL Obsessive-Compulsive Scale(Storch et al., 2005)y6 items; adequate psychometricszChild Obsessive Compulsive Impact Scale (Piacentini & Jaffer, 1999)*ySchool activities, home/family activities, social activitieszFamily Accomodation Scale (Calvacoressi et al., 1995)*yCorrelation with severity and family dysfunctionCognitiveBehaviorTherapy(CBT)inthetreatmentofOCD认知行为疗法（CBT）在治疗强迫症What is not OCDzDevelopmental Factorsy Most children exhibit normal age-dependent obsessive-compulsive behaviors (Liking things done “just so” or insist on elaborate bedtime rituals (Gessell, Ames, & Ilg, 1974) y By middle childhood, these behaviors are replaced by collecting, hobbies and focused interestsCognitiveBehaviorTherapy(CBT)inthetreatmentofOCD认知行为疗法（CBT）在治疗强迫症What OCD is not z Individuals who display excessive worry that does not cause severe discomfort or disrupt daily lifez O-C PDobsessive people who are punctual and/orderly (but perfectionism, stinginess, or aloofness can interfere with their life or the quality of relationships)zCompulsive eaters, Pathological Gambling, Promiscuous sex, or Drug abuse (these people derive pleasure from the compulsive activity)CognitiveBehaviorTherapy(CBT)inthetreatmentofOCD认知行为疗法（CBT）在治疗强迫症Comorbidity with OCD zMore than one disorder is often present (the Dx. of OCD is not exclusionary)zMany children become so distressed and overwhelmed by OCD symptoms that they develop MDDCognitiveBehaviorTherapy(CBT)inthetreatmentofOCD认知行为疗法（CBT）在治疗强迫症Comorbidity with OCDzTic disorders, anxiety disorders, LD, & disruptive behavior disorders are not uncommon zOCD is a spectrum disorderzDisorders on the OCD spectrum include: ytrichotillomaniaybody dsymorphic disorderyTourette Syndrome/tic disorders zOnly a small number exhibit signs of OC personality disorderCognitiveBehaviorTherapy(CBT)inthetreatmentofOCD认知行为疗法（CBT）在治疗强迫症What does not cause OCDz Overly strict toilet training z Watching a parent or sibling carry out OCD rituals (those without a genetic predisposition) CognitiveBehaviorTherapy(CBT)inthetreatmentofOCD认知行为疗法（CBT）在治疗强迫症Factors that may be related to OCD z Early life experiences (Rachman & Hodgson, 1980) found that excessively harsh punishment for making mistakes may predispose individuals to develop obsessive doubts and checking ritualszLife stress (psychosocial distress) (Findley et al., 2003) stress differentiate clinical OCD from nonclinical groupCognitiveBehaviorTherapy(CBT)inthetreatmentofOCD认知行为疗法（CBT）在治疗强迫症OCD is a neuropsychiatric disorderNeuropsychology has identified the following symptoms: y Non-verbal skills Verbal Reasoning skills(which place kids at risk for dysgraphia, dyscalculia, poor written language skills, & reduced processing speed & efficiency)y Association with Asperger Syndrome yAlso included on “list” of symptoms found in “Childhood Bipolar Disorder” CognitiveBehaviorTherapy(CBT)inthetreatmentofOCD认知行为疗法（CBT）在治疗强迫症OCD is a neuropsychiatric disorderzSuccessful treatment utilizes serotonin reuptake inhibitors (SSRIs) y The “serotonin hypothesis” (OCD)y “Grooming behavior gone awry”zNeuroimaging studies implicate abnormalities in circuits linking the basal ganglia to the cortex-these circuits have responded to both BT and SSRIs.CognitiveBehaviorTherapy(CBT)inthetreatmentofOCD认知行为疗法（CBT）在治疗强迫症OCD and medical conditions (PANDAS, SC) zPediatric Autoimmune Neuropsychiatric Disorder Associated with Strep (PANDAS)y In a subgroup of children, OCD symptoms may develop or be exacerbated by strep throat zWith Sydenhams chorea (a variant of rheumatic fever-RF) y OC behaviors are common, OCD is more common in RF patients when chorea is present CognitiveBehaviorTherapy(CBT)inthetreatmentofOCD认知行为疗法（CBT）在治疗强迫症OCD associated with PANDAS or RF/Sydenham choreaGroup A antigens may cross react with basalganglia neural tissue resulting in OCD or tic symptoms zIf there has been a rapid onset of OCD or Tic symptoms, or a dramatic exacerbation of these symptoms, following PANDA or RF, the patient should be worked up for Group A strep infection, since antibiotic therapies may benefit select patientsCognitiveBehaviorTherapy(CBT)inthetreatmentofOCD认知行为疗法（CBT）在治疗强迫症History of Behavior TX with OCDzTraditional behavior therapy involving Systematic Desensitization did not produce good results with OCD patientszIn 1966, Dr. Victor Meyer (a British psychiatrist) instructed nurses working on a Psych. Ward to actively prevent patients from carrying out their rituals14/15 patients shows rapid improvement CognitiveBehaviorTherapy(CBT)inthetreatmentofOCD认知行为疗法（CBT）在治疗强迫症The active ingredients for Behavior TxE/RPzExposure (E)confronting a situation you fearzResponse Prevention (RP)keeping yourself from acting on the compulsions afterwardsCognitiveBehaviorTherapy(CBT)inthetreatmentofOCD认知行为疗法（CBT）在治疗强迫症Principles for E/RP1.Confront the things you fear as often as possible2.If you feel like you need to avoid something dont3.If you feel like you have to perform a ritual to feel better, dont4.Continue steps 1, 2, & 3 for as long as possibleCognitiveBehaviorTherapy(CBT)inthetreatmentofOCD认知行为疗法（CBT）在治疗强迫症Habituation zHabituation comes from the Latin word habitus, for habit (to make familiar by frequent use or practice)zAfter long familiarity with a situation that at first produces a strong emotional reaction, our bodies learn to get used to or ignore that situationCognitiveBehaviorTherapy(CBT)inthetreatmentofOCD认知行为疗法（CBT）在治疗强迫症Setting Goals recommendations by Lee Baer, Ph.D.1.Work on one major goal at a time2.Carefully choose the 1st symptom to work onwhat symptom do you have the best chance with success with?3.Convert symptoms to goals4.Set realistic goals5.Rank your Goals6.Be aware of “Flat Earth Syndrome”7.Set long-term goalsby the end of treatment, “I want to be able to_” CognitiveBehaviorTherapy(CBT)inthetreatmentofOCD认知行为疗法（CBT）在治疗强迫症Setting Practice Goals1.I will expose myself to X, without doing Y2.Put practice goals in writing3.Ask the 80% question”If I practiced this goal 10 times, would I likely be successful 8?4.Use Subjective Units of Distress (SUD) ratings to guide practice goals5.Strive to achieve but be forgiving6.Notice small gains7.Set practice goals each sessionCognitiveBehaviorTherapy(CBT)inthetreatmentofOCD认知行为疗法（CBT）在治疗强迫症Techniques to assist E/RP by Lee Baer, Ph.D.1.Practice with your helpera) discuss your goals openly with helperb) accept encouragement for even partial accomplishmentsc) ask any reasonable question (not for reassurance, and trust their opinion) d) do not argue or get angry with your helperCognitiveBehaviorTherapy(CBT)inthetreatmentofOCD认知行为疗法（CBT）在治疗强迫症Techniques to assist E/RP2.You will feel anxiety if you are doing the exposures and response prevention correctly (but it will be less than feared)3.Keep reminders hand (index cards)4.Reward yourself for success5.Visualize your long-term goals6.Let obsessions pass through your mind (do not try and block themdue to rebound)CognitiveBehaviorTherapy(CBT)inthetreatmentofOCD认知行为疗法（CBT）在治疗强迫症Techniques to assist E/RP7.Maintain standards in E/PR (avoid keeping fingers crossed, saying a prayer or smoking a cigarette to reduce anxiety during an exposure)8.Hints for RPbreak down goals into small steps9.Use Audiotapes (for idiosyncratic ones) and Videotapes to intensify exposures10.Set aside “worry time” for obsessions11.In working with kids, parents must be involveda reward system can be helpful CognitiveBehaviorTherapy(CBT)inthetreatmentofOCD认知行为疗法（CBT）在治疗强迫症Treatment of OCD in childrenAssessment of OCD:Individualized diagnostic assessment: yreview of OCD symptoms yr/o co-morbid disorders (depressive or disruptive disorders, other spectrum dx.s)yreview of psychosocial factorsCognitiveBehaviorTherapy(CBT)inthetreatmentofOCD认知行为疗法（CBT）在治疗强迫症Treatment of OCD in childrenTreatment of choice for OCD in children: is a combined treatment (CT) approach-CBT & SSRIs Expert consensus treatment guidelines for 1st line treatmentsy Prepubescent children: CBT (mild or severe OCD)y Adolescents: CBT for milder OCD; CBT & SRI (or SRI alone) for severe OCDCognitiveBehaviorTherapy(CBT)inthetreatmentofOCD认知行为疗法（CBT）在治疗强迫症Treatment of OCD in childrenCBT alonezCBT is a remarkably effective & durable TX for OCD (Dar & Greist, 1992)zWhile “booster” sessions may be necessary, those who are successfully treated with CBT alone tend to stay wellMedication alonezRelapse is more common following the discontinuance of medicationszMarch (1994) found that improvement persisted in 6 of 9 CT responders following withdrawal from medication (CBT helps inhibit relapse)CognitiveBehaviorTherapy(CBT)inthetreatmentofOCD认知行为疗法（CBT）在治疗强迫症Treatment of OCD in childrenzClinical Interview (including a review of developmental level, temperament, level of adaptive functioning-current and pre-morbid)zScreening Measures (CBCL & TRF & CDI)zAssessment of OCD symptomsyIf possible should be administered to both primary caregiver and child (independently)yShould be done initially and be periodically re-administered to measure progress CognitiveBehaviorTherapy(CBT)inthetreatmentofOCD认知行为疗法（CBT）在治疗强迫症Treatment of OCD in childrenzGoals of the 1st evaluative sessionyReview of symptomsyObtain history (standard) yAssessment yDiagnosis yRecommendations might include:1) additional assessment (psychological or medical)2) CBT3) medication4) academic and/or other behavioral interventionsCognitiveBehaviorTherapy(CBT)inthetreatmentofOCD认知行为疗法（CBT）在治疗强迫症CBT with childrenzStep I: PsychoeducationyThe family and patient need to have an understanding of OCD within a neurobehavioral model yA review of the risks and benefit of CBTyBegin to externalize OCD as the “enemy” and treatment involves “bossing back” OCDCognitiveBehaviorTherapy(CBT)inthetreatmentofOCD认知行为疗法（CBT）在治疗强迫症CBT with childrenzStep 2: Cognitive Training (a training in cognitive tactics for resisting OCD)yGoals of CT include: increasing self-efficacy, predictability, controllability, and self-attributed likelihood of a positive outcome with Exposure & Response Prevention yTargets for CT include: reinforcing accurate information about OCD & TX., cognitive resistance “bossing back OCD,” and self-administered positive reinforcement & encouragement. CognitiveBehaviorTherapy(CBT)inthetreatmentofOCD认知行为疗法（CBT）在治疗强迫症CBT with childrenzStep 3: Mapping OCDOCDChildAfter TreatmentOCDChildBefore TreatmentTransition ZoneTransition ZoneCognitiveBehaviorTherapy(CBT)inthetreatmentofOCD认知行为疗法（CBT）在治疗强迫症CBT with childrenzStep 3: Mapping continued10 - No Way!8 - Really Hard6- Im not sure4 - Hard2- Im unease0 - No problemFear ThermometerCognitiveBehaviorTherapy(CBT)inthetreatmentofOCD认知行为疗法（CBT）在治疗强迫症CBT with childrenzMay also use analogies that child relates to directly due to interests in daily life:zCartoons, sports, hobbies, etc.zExample:ySpongebob - easierySquigwart mediumyMr. Crabs - hardCognitiveBehaviorTherapy(CBT)inthetreatmentofOCD认知行为疗法（CBT）在治疗强迫症CBT with childrenSymptom List (Stimulus Hierarchy)CognitiveBehaviorTherapy(CBT)inthetreatmentofOCD认知行为疗法（CBT）在治疗强迫症CBT with childrenzStep 4: Graded Exposure & Response Prevention (E/RP)z“Exposure” occurs when children expose themselves to the feared object, action, or thoughtz“Response Prevention” is the process of blocking rituals and/or minimizing avoidance behaviors CognitiveBehaviorTherapy(CBT)inthetreatmentofOCD认知行为疗法（CBT）在治疗强迫症CBT with childrenzTips in executing E/PR yOCD is the enemy and all parties work against it yOnly the child can battle against OCD, however, he can use his allies (therapist, parents or friends) and newly learned strategies (CT and E/RP) to combat OCD CognitiveBehaviorTherapy(CBT)inthetreatmentofOCD认知行为疗法（CBT）在治疗强迫症CBT with childrenzWhat is the role of parents?yParents are an important part of the CBT treatment processyWhile they cant combat OCD for their child, they can encourage the child to “boss back” OCD and not engage in behavior that helps reinforce OCD symptoms.yParents should have adequate psychoeducation about OCD and should be involved in the childs treatment CognitiveBehaviorTherapy(CBT)inthetreatmentofOCD认知行为疗法（CBT）在治疗强迫症Questions about the Tx of OCD1.How long will CBT take? Weekly, then bimonthly, and eventually monthly over 6 months (Dr. Hurley at MGH) xIf they are very determined and motivated to work hardxIf less motivated patients stay in treatment longerxMost important how willing is the patient to work on Exposure and Response Prevention?CognitiveBehaviorTherapy(CBT)inthetreatmentofOCD认知行为疗法（CBT）在治疗强迫症Questions about the Tx of OCD2.Will CBT eliminate all OCD symptoms? No3.Is BT is affective for children as for adults? Yes4.Are all types of OCD are as easy to treat as another type? Nocleaning or contamination types are the most straight forward to apply E/RP 5.What are the most difficult types of OCD to treat? Compulsive slowness and mental ritualsCognitiveBehaviorTherapy(CBT)inthetreatmentofOCD认知行为疗法（CBT）在治疗强迫症Other approacheszMetacognitive therapy: initial results appear to be positive (Simons et al., 2006)z“Family-based CBT”: positive results reported (Storch et al., 2007)CognitiveBehaviorTherapy(CBT)inthetreatmentofOCD认知行为疗法（CBT）在治疗强迫症Family InvolvementzFamily education (noted above)zFamily accomodation behaviorszImpact of family parent distresszFamily dynamicsCognitiveBehaviorTherapy(CBT)inthetreatmentofOCD认知行为疗法（CBT）在治疗强迫症Helpful TipszWhats “GOOD” and whats “BAD” about the OCD behaviors? (Compare lists)zExternalize the problem, give it a nameyE.g., Mr. Worry, OC Flea, etc.zUse analogies to describe what the OCD doesyE.g., redial button (hang up)CognitiveBehaviorTherapy(CBT)inthetreatmentofOCD认知行为疗法（CBT）在治疗强迫症Helpful TipszWork with parents on what they do that is: “helpful” and “not helpful”? (Moritz)zHelpful: positive self-talk, avoid over-involvement, look for positives, etc.zNot Helpful: punishment, criticism, blaming and shame, accommodating, etc.CognitiveBehaviorTherapy(CBT)inthetreatmentofOCD认知行为疗法（CBT）在治疗强迫症A Contrast in Cases (1):zAge/Gender: 7 year old boyzSymptom onset: evident since age 2zCharacterized by: moderate and chronic; obsessions symmetry, exactness, order, moralzAttitude toward OCD: ego-syntonic patient angry about therapy; tantrum at 1st appt.zFamily: chronic / consistent accomodation; occasionally refused to do as he requested, parents each with OC tendencieszOther issues: strong willed, controlling childCognitiveBehaviorTherapy(CBT)inthetreatmentofOCD认知行为疗法（CBT）在治疗强迫症A Contrast in Cases (2):zAge/Gender: 10 year old boyzSymptoms onset: typical, gradual onset, “last 6 months”zCharacterized by: mild-moderate; obsessions worry thoughts / compulsions - checking and countingzAttitude toward OCD: ego-dystonic wanted to exclude parents and resolve with therapistzFamily: typical responses - some accomodation, some frustration, some refusal to support, etc.yDynamic with older sisteryFrequent inconvenience to familyzOther issues: consider issue of excluding parents in tx.CognitiveBehaviorTherapy(CBT)inthetreatmentofOCD认知行为疗法（CBT）在治疗强迫症A Contrast in Cases (3):zAge/Gender: 13 year old girlzSymptom onset: OC tendencies for years, dramatic onset for about 1 month near beginning of 7th gradezCharacterized by: severe disruption; obsessions moral, exactness, order, contamination / compulsions cleaning, rituals, counting, confession, reassurance seeking, checkingzAttitude toward OCD: ego-dystonic patient initially worried about being “crazy”, embarrassedzFamily: healthy, typical mixed response, strong and positive investment by mother and others in tx.zOther issues: patient later showed trichotillomania CognitiveBehaviorTherapy(CBT)inthetreatmentofOCD认知行为疗法（CBT）在治疗强迫症Treatment Approach: Case 1zList symptomszPatient willing to rate how upset he feels if he cant do them: 0 3 rating scalezStarted dialogue re: distress/angerzFocused on parents:yMinimizing accommodation behaviors with a focus on issues child rated as 1-2 on scaleyDiscussed ways to provide alternatives to child to reduce tantrums, but then instructed parents to expect tantrumsyAlso suggested we closely monitor overall level of distress as we do this (some children develop heightened stress with no reduction in symptoms over time)yDeveloped a plan for differential reinforcementzOutcome: parents reporting progress with limited distressCognitiveBehaviorTherapy(CBT)inthetreatmentofOCD认知行为疗法（CBT）在治疗强迫症Treatment Approach: Case 2zList obsessions and compulsionszDeveloped rating symptom: 0-10 related worry/distresszEducated child and family about OCD; some normalizingzExternalize the problem: Mr. WorryzDeveloped E/RP plan; separate sheet for each specific problem; some conducted in office (e.g., faucet)zAssisted parents with family dynamics, their own coping behaviors, consequences for “being late”zProgress monitored by parent observation (and report) and child self-reportzOutcome: significant reduction in checking behaviors; some issues resolved without specific interventionCognitiveBehaviorTherapy(CBT)inthetreatmentofOCD认知行为疗法（CBT）在治疗强迫症Treatment Approach: Case 3zList obsessions and compulsionszEducation and normalizing: “youre not crazy”zDeveloped rating symptom: 0-10 related to worry/distresszEducated child and family about OCD; OCD bookzStrategies: E/RP; worry plan, “worry time”, relaxation, differential reinforcement (planned ignoring), E/RP in office (e.g., bubble sheets, writing)zDue to severity, distress and impact on school med. referralzProgress monitored by parent observation (and report) and child self-reportzOutcome: significant reduction in OCD; still a bit embarrassed but developed sense of humor; some mild evidence of symptoms; no obvious impact on daily life at this time; still some trichotillomania, “amnesia” about some of past OC behaviorszDiscussed and developed relapse prevention planCognitiveBehaviorTherapy(CBT)inthetreatmentofOCD认知行为疗法（CBT）在治疗强迫症