Chapter 3 Obsessive-Compulsive Disorder in Children

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Lisa W. Coyne, Jennifer B. Freeman, Abbe M. Garcia, Henrietta L. Leonard: Chapter 3. Obsessive-Compulsive Disorder in

Children, in Gabbard’s Treatments of Psychiatric Disorders, 4th Edition. Edited by Glen O. Gabbard. Copyright ©2009

American Psychiatric Publishing, Inc. DOI: 10.1176/appi.books.9781585622986.250710. Printed 5/10/2009 from

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Gabbard’s Treatments of Psychiatric Disorders > Part I. Disorders Usually First Diagnosed in Infancy, Childhood, or

Adolescence >

Chapter 3. Obsessive-Compulsive Disorder in Children

INTRODUCTION

Although it has been almost a century since obsessive-compulsive disorder (OCD) was first

described in children and adolescents (Janet 1903), only recently has the illness been

systematically studied in younger populations. In this chapter, we address the treatment of

pediatric OCD, including investigational interventions.

Epidemiological findings suggest that childhood OCD affects approximately 1 in 200 children

(Douglass et al. 1995; Flament et al. 1990; Valleni-Basile et al. 1994). For many children, the

disorder significantly impairs academic, social, and family functioning yet is often underdiagnosed

and undertreated (Leonard et al. 1993). Despite an apparent core set of symptoms, systematic

studies have found considerable heterogeneity in the onset, course, and specific symptom picture

among children and adolescents with OCD (Flament et al. 1990; Hanna 1995; Swedo et al. 1989;

Thomsen 1995).

TREATMENT

Selection of Treatment(s)

The “Expert Consensus Guideline” series (March et al. 1997) and the American Academy of Child

and Adolescent Psychiatry (1997), (1998) practice parameters also provide important information

about treatment. Based on these guidelines, only two treatment modalities have been shown

empirically to be effective in treating OCD symptomatology: 1) cognitive-behavioral therapy (CBT;

specifically the technique of exposure with response prevention) and 2) pharmacological treatment

with serotonin reuptake inhibitors (SRIs)—or a combination of the two. Cognitive-behavioral

treatment has the advantages of apparent durability of treatment effects and avoidance of potential

side effects of medication. In specific cases, however, an antiobsessional medication may be the

initial treatment method because of concerns with urgency, expense, anxiety associated with

behavioral treatment, lack of trained clinicians, insufficient cognitive ability to participate in CBT,

lack of family support, or individual factors.

Cognitive-Behavioral Treatment

Only in the past 10 years has the effectiveness of CBT—and, in particular, exposure with response

prevention—been carefully reviewed and studied in children and adolescents (Franklin et al. 1998;

March 1995; Piacentini 1999). In addition to expert consensus about using CBT as a first-line

treatment of choice in children and adolescents, the publication of the large Pediatric OCD

Treatment Study (POTS) reported that CBT or CBT plus an SRI were efficacious in treating pediatric

OCD (POTS Team 2004).

Overview of Exposure With Response Prevention

In exposure with response prevention, the patient is exposed to the feared situation, and the

response (i.e., the ritual or avoidance behavior) is prevented until anxiety decreases. For example,

the child with contamination fears and washing rituals may be asked to touch items in the garbage

and then not be allowed to wash his or her hands. The effectiveness of exposure with response

prevention is most often attributed to the theoretical concepts of habituation and extinction.

Patients gradually learn that their anxious response decreases over time and that with prolongedPrint: Chapter 3. Obsessive-Compulsive Disorder in Children http://www.psychiatryonline.com/popup.aspx?aID=250714&print=yes…

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exposure to the stimulus, the anxiety can be reduced without performing compulsions (Francis and

Gragg 1996).

Overall, it is extremely important that exposures continue until anxiety is significantly reduced and

that children and adolescents feel control over progression through their hierarchies. Exposure

itself can be either imaginal or in vivo. Imaginal exposure may be used first because it is less

anxiety-producing for the patient (e.g., imagining touching items in the garbage before actually

trying it). However, imaginal exposure is also necessary for obsessions that occur in the absence of

corresponding rituals or that cannot be enacted in vivo (e.g., harming another person).

Exposure most commonly progresses in a graded manner according to a symptom hierarchy of

increasingly anxiety-producing stimuli. The patient and therapist work together in early sessions to

generate items for the hierarchy (e.g., by listing all symptoms) and rate the severity of anxiety on a

scale. This collaboration serves to decrease the child’s fear of the unknown and allows him or her to

gain mastery. Although new items are frequently added to the hierarchy and anxiety ratings

altered, the list ideally represents the total picture of the patient’s OCD symptomatology and

provides a model of how treatment will progress over time.

Overview of Cognitive-Behavioral Therapy Trials for Pediatric

Obsessive-Compulsive Disorder

The largest completed randomized controlled trial to date of CBT for OCD in children evaluated the

efficacy of CBT and sertraline in comparison with CBT alone, sertraline alone, and a pill placebo for

a duration of 12 weeks. The CBT manual included both exposure and response prevention in

addition to cognitive interventions such as psychoeducation about OCD. Results indicated that

patients treated with CBT either alone or in combination with sertraline showed a substantial

improvement in OCD symptoms (POTS Team 2004). These findings suggest that children and

adolescents with OCD should begin treatment with CBT alone or CBT in combination with an SRI,

depending on severity and comorbidity.

The role of the family in the individual behavior therapy of patients with OCD is particularly

important and only recently has received empirical attention (Piacentini et al. 1994; Scahill et al.

1996). Frequently, parents participate in rituals in response to their child’s requests or distress

(e.g., providing reassurances, tying “dirty” shoelaces) and sometimes overreact to the child’s

behavior. Although ultimate treatment success is dependent on the child’s cooperation, recent

studies suggest that concurrent family intervention focused on removing parents from their

children’s rituals is important. Interestingly, preliminary evidence also suggests that parents can

play a role as co-therapists in the behavioral treatment and still not be “overinvolved” or

“enabling” (Knox et al. 1996). In the families of younger children with OCD, this is particularly

important. Care must be taken to implement developmentally sensitive interventions that address

the special concerns of this population. For example, younger children may be less capable of

reporting distress related to symptoms and may be more dependent on parental guidance in

engaging in treatment. Researchers at Brown University recently designed a family-based CBT

treatment manual addressing these concerns and evaluated its feasibility in a small randomized

controlled trial, comparing it with a relaxation treatment for young children (ages 5–8 years) with

OCD. Preliminary results are promising and suggest the need for further treatment research in this

vein (Freeman et al. 2003).

Other Cognitive-Behavioral Interventions

Although techniques such as relaxation training, breathing-control training, and cognitive

restructuring have all proven effective with other child anxiety disorders (Kendall 1994), these

added components do not appear to directly affect obsessions or compulsions (Piacentini 1999).

Instead, relaxation and other techniques are thought to help children cope with the high anxiety

produced by exposure with response prevention tasks (Kearney and Silverman 1990).

Other cognitive therapy techniques (e.g., satiation, hypnosis) have been tried in children with

varying success (March 1995). Notably, thought stopping has been included in the treatments ofPrint: Chapter 3. Obsessive-Compulsive Disorder in Children http://www.psychiatryonline.com/popup.aspx?aID=250714&print=yes…

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obsessions only or obsessional slowness (March 1995). Additional behavioral techniques (e.g.,

flooding, habit reversal) also may play some role in an overall treatment package. Flooding (i.e.,

prolonged exposure to the most anxiety-provoking stimuli) has been used successfully in

adolescents with OCD (Harris and Wiebe 1992); however, expert consensus is that children should

receive graded exposure with response prevention, with goals under the control of the patients

(March and Mulle 1998). Habit reversal may have a role for patients with comorbid tic or

trichotillomania symptoms or complex tic-like rituals (March 1995). Children and adolescents with

obsessional slowness or primarily obsessions without rituals also may respond to techniques such

as modeling or shaping (Ratnasuriya et al. 1991).

Conclusions Regarding Cognitive-Behavioral Therapy

Overall, research done to date supports the efficacy of exposure with response prevention–based

methods for pediatric OCD. Improvement tends to be largely maintained at follow-up, but more

data and longer-term follow-up are clearly needed. The role of combined psychopharmacological

treatment also needs more intensive study. Because relapse commonly follows medication

discontinuation (Leonard et al. 1989), March et al. (1994) suggested that booster behavior therapy

may prevent relapse when medications are discontinued. Unfortunately, despite its applicability in a

majority of cases, behavior therapy is frequently not implemented for OCD when appropriate.

Dynamic and Family Psychotherapy

Although insight-oriented dynamic psychotherapy has historically been the primary intervention for

the obsessional patient, the disorder has, for the most part, been refractory to this approach

regardless of patient age, and this therapy would no longer be considered the primary or sole

treatment of choice (March et al. 1995a; Salzman and Thaler 1981).

Systematic family intervention has become a recognized component of OCD treatment for children

and adolescents (Knox et al. 1996; Piacentini et al. 1994). Although there are no efficacy data for

children and adolescents, a multifamily group behavioral treatment (in which patients and family

members jointly participate in group sessions) was shown to be effective with adults (Van Noppen

et al. 1997). Less is known, however, about the efficacy of non-CBT-based family treatment models.

These models, however, deserve further study, particularly in the area of

early-onset/early-childhood OCD. In particular, family therapy may be useful in identifying and

addressing obstacles to treatment, such as family discord, marital difficulties, and inappropriate

roles and boundaries between parents and their children with OCD.

Pharmacotherapy

Systematic studies have reported that the SRIs are effective in treating OCD symptoms in children

and adolescents. Currently, the medications with a U.S. Food and Drug Administration

(FDA)–approved indication for OCD include clomipramine (in children 10 years or older), fluoxetine

(in children 8 years or older), sertraline (in children 6 years or older), paroxetine (in adults), and

fluvoxamine (in children 8 years or older).

Clomipramine

Clomipramine, a tricyclic antidepressant (TCA) and a potent SRI, was the first thoroughly studied

antiobsessional agent in pediatric OCD. Flament et al. (1985) reported that clomipramine was

superior to placebo in a double-blind crossover study. DeVeaugh-Geiss et al. (1992) concluded that

clomipramine was effective; the patients receiving clomipramine had a mean reduction in their OCD

severity score of 37% compared with 8% in those receiving placebo. In a controlled trial comparing

clomipramine with desipramine, clomipramine was found to be superior in ameliorating OCD

symptoms at 5 weeks of treatment (Leonard et al. 1989). Clomipramine is generally well tolerated

in children (controlled trials in patients age 6 years and older) and adolescents, and an

anticholinergic side-effect profile was reported (DeVeaugh-Geiss et al. 1992; Leonard et al. 1989).

Because of the potentially cardiotoxic effects of all TCAs (Elliott and Popper 1991), baseline and

periodic electrocardiograms are suggested, and concerns about tachycardia, change in axis, orPrint: Chapter 3. Obsessive-Compulsive Disorder in Children http://www.psychiatryonline.com/popup.aspx?aID=250714&print=yes…

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prolongation of intervals should be noted. Particular attention to the QTc interval is recommended

(Riddle et al. 1993).

Clinical discussion has focused on whether clomipramine is more effective than the selective

serotonin reuptake inhibitors (SSRIs) and whether it should be used with patients who have more

severe symptoms. A recent meta-analysis of systematic studies in pediatric OCD reported that

clomipramine was significantly superior to each of the SSRIs (Geller et al. 2003). The “Expert

Consensus Guidelines” (March et al. 1997) suggest that it be used when a patient has failed to

respond to two or three adequate trials of an SSRI in combination with CBT.

Selective Serotonin Reuptake Inhibitors

Many of the SSRIs have been evaluated in systematic efficacy studies as a treatment option for

pediatric OCD. Through this body of work, they have been established as the first-line

psychopharmacotherapeutic agent for OCD. SSRIs are preferable to clomipramine due to their

fewer anticholinergic side effects. Systematic efficacy studies have demonstrated that fluoxetine,

fluvoxamine, and sertraline were superior to placebo for children and adolescents with OCD.

Fluoxetine was superior to placebo in two randomized controlled trials (Geller et al. 2001;

Liebowitz et al. 2002). It is reasonably well tolerated in children and adolescents (Riddle et al.

1992). However, one must bear in mind that with the long half-life of the parent drug and its

metabolite, steady state is not reached for 2–3 weeks, and the drug is not completely eliminated

from the system for up to 6 weeks after discontinuation. Fluvoxamine has been approved for the

treatment of OCD in adults and children 8 years and older. The trials of its safety and efficacy in

120 children and adolescents with OCD leading to FDA approval were completed, and preliminary

data have been published (Riddle et al. 1996, 2001). Sertraline is currently approved by the FDA for

the treatment of depression in adults and for OCD in children 6 years and older. The recent

multisite placebo-controlled trial of 187 children and adolescents reported the superiority of

sertraline over placebo (March et al. 1998). Other SSRIs are under study for their safety and

efficacy in pediatric OCD.

Choice of Medication

In general, the SSRIs have become the first-line medication for the treatment of OCD in children.

The specific choice of agents requires consideration of the systematic studies to date, risk–benefit

ratio, side-effect profile, comorbid diagnoses, and use of concomitant medications. Although

information about the pharmacokinetics of the SSRIs in children is limited, a consideration of

whether a relatively longer-half-life (fluoxetine) or a shorter-half-life (paroxetine, fluvoxamine,

and sertraline) medication is needed is relevant for some. The most common side effects of SSRIs

include sedation, nausea, diarrhea, insomnia, anorexia, hyperstimulation, tremor, and sexual

dysfunction (March and Curry 1998; Riddle et al. 2001). Rare adverse reactions include

extrapyramidal symptoms, serotonin syndrome, hypomania, and apathy syndrome. Children and

adolescents may be more vulnerable to behavioral activation while on SSRIs, although this issue

has received study only recently. The FDA has warned that children and adolescents on

antidepressants may potentially develop suicidality, worsening of symptoms, anxiety, agitation,

panic, insomnia, irritability, hostility, impulsivity, akathisia, and hypomania. In addition, the FDA

has added a “black box” warning to describe the potential risk of suicidality, and new

recommendations stipulate that children and adolescents be frequently assessed for emergent

“activation” or worsening of symptoms while on an SSRI.

The SSRIs can inhibit one or more of the cytochrome P450 enzyme systems; therefore, drug–drug

interactions are possible. The clinician should inquire about all prescriptions, over-the-counter

medications, and health supplements that the patient may take. In general, combinations of the

SRIs are rarely used in children because the metabolism of one medication is often inhibited,

leading to increased serum levels (Szegedi et al. 1996).

Augmentation Strategies

For patients who have had a partial response to an SRI, augmentation trials with an additionalPrint: Chapter 3. Obsessive-Compulsive Disorder in Children http://www.psychiatryonline.com/popup.aspx?aID=250714&print=yes…

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agent are receiving attention. Antipsychotics—and, more recently, the atypicals—have shown some

positive additional benefit when used as augmentative agents (McDougle et al. 2000). Although

many medications have been reported to augment SRIs successfully, only clonazepam and

haloperidol have proved effective in systematic studies in adults (McDougle et al. 1994; Pigott et al.

1992). McDougle et al. (1990) noted that the augmentation was particularly successful if patients

had a comorbid tic disorder or schizotypal personality disorder. Because of the long-term risks of

antipsychotic treatment, an antipsychotic would be the second choice for augmentation strategies.

However, the increasing evidence of the efficacy of CBT and the widely held belief that gains made

with CBT are more durable than those attained with pharmacotherapy alone makes it a first-line

preference for an augmentative treatment. A large multisite trial evaluating CBT as an

augmentation strategy for pharmacotherapy is currently under way.

Combined Treatments

The Expert Consensus Guidelines (March et al. 1997) and the American Academy of Child and

Adolescent Psychiatry (1998) Practice Parameters for OCD both recommend starting treatment in

children with CBT, or CBT plus an SSRI, depending on severity and comorbidity. Both guidelines

recommend that patients started on SSRI monotherapy and who are partial responders be given a

trial of CBT.

Investigational Treatments

Data suggest that a distinctive subgroup of OCD patients exists in which autoimmunity may

mediate symptoms. A diagnosis of pediatric autoimmune neuropsychiatric disorders associated with

streptococcal infections (PANDAS) (Swedo et al. 1997, 1998) should be considered when symptom

presentation meets the following criteria: 1) presence of OCD or a tic disorder, 2) prepubertal onset

of symptoms, 3) episodic course of symptom severity, 4) association with group A beta-hemolytic

streptococcal (GABHS) infection, and 5) association with neurological abnormalities (Swedo et al.

1997, 1998). Additionally, in these cases, the comorbid symptoms of emotional lability, acute

separation anxiety, motoric hyperactivity, impulsivity, and distractibility are often episodic and are

related to GABHS infections (Swedo et al. 1998).

A child with a symptom presentation suspicious for PANDAS (acute onset or a significant, dramatic,

unexplained clinical exacerbation of OCD, with or without tics) requires a thoughtful assessment of

possible streptococcal infection. A documented positive throat culture usually would be treated with

antibiotics or as per general community standards. Serological titers must be interpreted in the

clinical context and are particularly useful if results from multiple time points are available. Without

a positive throat culture, antibiotics are not indicated. Of specific note, it is important to distinguish

between a diagnosis of Sydenham’s chorea and one of PANDAS, since the former is a known variant

of rheumatic fever and requires cardiological evaluation and prophylaxis against GABHS, whereas

the PANDAS diagnosis does not.

A placebo-controlled, double-blind crossover trial of oral penicillin prophylaxis in children with

PANDAS did not provide justification for penicillin prophylaxis in the ongoing care of children with

PANDAS (Garvey et al. 1999). However, a subsequent study comparing antibiotic prophylaxis with

azithromycin or penicillin V-K in a double-blind randomized, controlled trial indicated significant

decreases in streptococcal infections and neuropsychiatric exacerbations in both the penicillin and

the azithromycin groups. Investigators concluded that both penicillin and azithromycin were

effective in reducing both streptococcal infections and associated neuropsychiatric symptoms

(Snider et al. 2005). For the most severe PANDAS cases, investigational intravenous

immunoglobulin or plasmapheresis trials should be considered (Perlmutter et al. 1999).

PROGNOSIS

Follow-up studies of children and adolescents with OCD have noted a range of outcomes: a recent

meta-analysis of 16 samples followed for 1–15 years reported that the long-term persistence of

pediatric OCD may be lower than what has been reported previously (Stewart et al. 2004).

However, some children remain severely debilitated by this disorder (Leonard et al. 1993). With thePrint: Chapter 3. Obsessive-Compulsive Disorder in Children http://www.psychiatryonline.com/popup.aspx?aID=250714&print=yes…

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new treatment interventions of the SRIs—and, in particular, the positive findings from trials of

combined CBT and SSRI treatment—it is hoped that the long-term outcome might be improved for

children and adolescents with OCD. A prospective follow-up study (Leonard et al. 1993) reported

that most children with OCD could expect significant improvement, but probably not remission, over

time. These findings are consistent with early reports that significant difficulties remained in a

small group of patients despite treatment interventions (Pleeter et al. 1996). Further research is

needed to determine whether certain treatment interventions offer long-term benefits.

CONCLUSION

OCD can be a chronic, debilitating disorder, even with the treatments outlined in this chapter.

Nevertheless, what follow-up has been done indicates that there have been true advances in

available treatments (Flament et al. 1990; Leonard et al. 1993). Most patients will require some

combination of behavioral and pharmacological therapies, and the art of treatment will be in

balancing the timing of and focus on any one treatment over time.

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