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Instant Help for www.InstantHelpBooks.com Children and Teens with Obsessive Compulsive Disorder © 2005 by Instant Help Publications About Instant Help Charts This chart is intended to provide a summary of the critical information available on helping children with OCD to insure that every child gets the most appropriate and comprehensive consideration. Defining the Problem According to the American Psychiatric Association Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, (DSM-IV) obsessive compulsive disorder (OCD) is an anxiety disorder characterized by recurrent obsessions or compul- Assessing OCD sions that are severe enough to be time consuming simply excessive worries about real-life problems. Obsessive behaviors included in the definition There are no laboratory tests to determine the presence of OCD. Therefore, a number of sources are used in the basic assessment of a child’s symptoms. Assessment should minimally include: are repeated thoughts about contamination, doubts, a need to have things in a particular order, z Direct observation of the child aggressive or horrific impulses, and sexual imagery. Compulsions are defined as repetitive z Interviews with the child, parents, (more than one hour per day), cause distress, or interfere with a child’s normal routine, academic functioning, social activities or relationships. Obsessions are defined as persistent ideas, thoughts, impulses, or images that are experienced as intrusive and inappropriate; they are not behaviors or mental acts, the goal of which is to prevent or reduce anxiety or stress rather than to provide pleasure or gratification. Compulsions included in the definition are hand washing, ordering, checking, praying, counting, or repeating words silently. OCD usually involves both obsessions and compulsions, but it is possible for a child with OCD to have one or the other. (continued on p. 2) Counseling Children and Teens with OCD The most effective treatment for children and teens with OCD appears to be exposure and response prevention (E/RP) with cognitive behavioral therapy (CBT). Children learn to change their thoughts and behaviors through repeated exposure to anxiety-provoking stimuli. Goals in Developing a Treatment Plan z To reduce obsessive thoughts and compulsive behaviors z To develop methods to keep symptoms from affecting school and social functioning z To assimilate isolated children by teaching them prosocial skills z To teach family members how to slowly stop participating in the child’s OCDrelated rituals without causing anxiety in the child CBT is usually implemented in 13–20 weekly individual or family sessions, depending on the child’s age. The therapist and child work together to determine the child’s comfort level and ability to participate in anxiety-provoking situations. In addition to practicing newly acquired skills in the therapist’s office, children are given “homework” so they can practice new skills in real-life situations. A new treatment plan is developed each week based on the child’s improvement. Specific skills are taught through: z Gradual exposure to OCD-provoking situations z Self-talk exercises that intentionally elicit obsessive thoughts while refraining from acting on the resulting compulsive response z Relaxation techniques z Self-administered positive reinforcement z Modeling and shaping the desired behavior and teachers z Review of school records and reports z Verbal reports from classmates and friends A more thorough assessment might also include: z Structured interviews with the child z Intelligence and achievement testing to determine the need of special education services z Mental status examination Commonly used assessment tools include: z Clark-Beck Obsessive Compulsive Inventory, Harcourt z Children’s Yale-Brown Obsessive- Compulsive Scale, Plenum z Maudsley Obsessive-Compulsive Inventory, Plenum z State Trait Anxiety Inventory I and II, Consulting Psychologists Press z Beck’s Depression Inventory, Basis-32, Psychological Corporation z Beck Anxiety Inventory, Harcourt z Fear of Negative Evaluation Survey, Lexi-Comp A complete evaluation should gather information from multiple sources. Defining the Problem (continued) The signs and symptoms of OCD vary in both type and severity among children and can begin as early as age two. Younger children may not recognize that their beliefs or actions are illogical; those who do are often secretive about their symptoms. For this reason, OCD often goes unrecognized and therefore undiagnosed. Without treatment, OCD is usually a lifelong problem with symptoms improving and worsening periodically. It is estimated that at least one-third of children with one anxiety disorder meet the criteria for two or more anxiety disorders. Conditions usually comorbid with OCD include other anxiety disorders, depression, disruptive behavior disorders, learning disorders, tic disorders, trichotillomania, and body dysmorphic disorder. OCD symptoms occurs after a stressful event; for example, the remarriage of a parent or death of a relative or friend. z The incidence of the disorder is higher z Fear of contamination is thought to be among first-degree relatives of children the most frequent obsession associated with OCD, particularly fathers. However, with OCD. An overly exaggerated children who develop OCD generally awareness of germs, disease, or dirt experience different symptoms from results in compulsions performed to those experienced by family members. reduce the existence of these “feared” For example, a child with OCD may be contaminants. Excessive hand washing obsessive about germs and compuland cleaning are commonly associated sively wash his hands. The child’s escape compulsions. Other common father may be obsessive about order compulsions are counting, checking, and compulsively arrange the garage. and hoarding; these are usually related z Estimates suggest that OCD occurs in to obsessions involving moral doubts, approximately 1 in 100 children and loss of control and order, respectively. equally affects both males and females. z Children with OCD may experience z Some cases of OCD may be associated stress-related symptoms, such as with streptococcus infection in children. headaches and upset stomachs. These These cases, referred to as Pediatric may be related to inadequate sleep or Autoimmune Neuropsychiatric poor nutrition resulting from the time Disorders Associated with Streptococcal and effort needed to perform Infections (PANDAS), are characterized compulsive rituals. by an abrupt onset of OCD symptoms z Most children with OCD experience after a strep infection. Antibiotics may pathological doubts, such as “If I don’t be helpful. do this, something bad will happen (to z In about 50% to 70% of cases, onset of me, my family, etc.).” Fast Facts What Parents Need to Know Because OCD tends to get worse without treatment, it gradually disrupts a child’s behavior more and more. Hiding these behaviors becomes complex and stressful, and they may only become apparent long after the child first began experiencing the signs of OCD. Although families do not actually cause OCD, family members’ reactions to the disorder affect the symptoms. Factors within the family dynamics that can intensify OCD behaviors include a recent family move, divorce, new stepparent or stepsiblings, changes in school, death of a family member or close friend, as well as other anxiety-inducing situations. There are several things that parents can do to help children with OCD: 1. Reduce the child’s OCD behaviors. Everyone in the family must be educated about the disorder so they can recognize the symptoms of OCD and help the child control compulsive behaviors. 2. Determine how their parenting style may contribute to the child’s behaviors. Punishment and negative feedback for OCD-related behaviors can create stress and increase symptoms. Instead, parents should focus on accomplishments and reinforce the child’s attempts to control OCD symptoms. 3. Reduce family and environmental stressors that contribute to the child’s behavior. This includes establishing daily routine and a calm, structured environment with clearly defined rules. Parents must eliminate unnecessary sources of stress in the child’s home and outside environment and be willing to make changes in the family lifestyle to accommodate the child with OCD. 4. Develop a support system of openness and understanding. Children need to feel comfortable talking about their symptoms and how those symptoms affect them. Parents must create a line of communication with their children that does not involve criticism or punishment for OCD behaviors. 2 • Instant Help for Children and Teens with Obsessive Compulsive Disorder Instant Help Publications (www.InstantHelpBooks.com) The Dos and Don’ts of Communicating DON’T DO • Make negative comments about OCD-related • Offer calm, understanding support. • Learn as much as you can about the disorder and behaviors. • Ignore the signs and symptoms of OCD. • Refuse to participate in the symptoms. • Criticize thoughts or actions associated with the child’s OCD. • Make unexpected changes in the child’s routine. • Blame the child for the OCD behaviors. • Assume you know how the child is feeling. discuss it with the child. • Work with the child in developing a strategy to disengage you from participating in OCD-related behaviors. • Praise successful attempts to resist OCD. • Discuss any changes that may directly or indirectly affect the child. • Reassure the child that the symptoms can be overcome. • Listen to the child and ask what you can do to help. What Teachers Need to Know Teachers are often the first to become aware of a child’s or teen’s compulsive behavior but may misattribute the child’s actions to laziness or stubbornness. Refusal to attend school, repeated tardiness, poor concentration, excessive focus on having belongings neat and tidy, frequent trips to the bathroom, avoidance of physical contact with others, repeated sharpening of pencils, and slow, deliberate, or partial completion of assignments are all common examples of how a child may exhibit signs of OCD in the classroom. With an understanding of OCD, teachers can help children find effective ways of managing their maladaptive behaviors, without adding undue pressure that could make the symptoms worse. Accommodating the behaviors related to OCD is essential. Here are some ways that teachers can assist children with OCD: z Reducing triggers of compulsive rituals Situations that provoke anxiety, such as unclear expectations, complex assignments, or changes in schedule,are likely to trigger compulsive rituals. Giving the student clear explanations, making assignment modifications, and providing advanced notification of changes in the regular class routine are accommodations that can help the student with OCD. z Time management Teachers should allow adequate time for completing tasks, assignments, and tests. Make a contract with the student detailing what is acceptable: how much time is allotted to complete the assignment; how much rewriting is permissible; and whether in-class assignments may be completed at home. z Communication with the OCD student Teachers should frequently talk with the student determine what support or assistance might be needed. Develop strategies for dealing with negative social situations or confrontations. z Redirection Rather than using punishment, a system for redirecting the student’s behavior should be implemented. z Development of a support system Designate a mentor within the school system who understands OCD and can be available for the student to regularly talk with. z Educating classmates Conduct a peer education programs, designate a “study buddy,” and structure class activities so that students with OCD who have trouble with peer relationships or are socially isolated are involved. Teachers should communicate with the child’s therapist to find out what the treatment plan involves and how the school might help the student. Work with the child and the family to help reduce OCD symptoms by using suggested treatment plans. If the disorder significantly interferes with learning or behavior, children with OCD may qualify for special education services. Instant Help Publications (www.InstantHelpBooks.com) Instant Help for Children and Teens with Obsessive Compulsive Disorder • 3 This Instant Help Chart was written by Leslie Burling-Phillips Instant Help for Children and Teens with Obsessive Compulsive Disorder Published by Instant Help Publications 4 Berkeley Street Norwalk, CT 06850 www.InstantHelpBooks.com Medication and OCD Medication Protocol Treatment with medication should be considered when a child is experiencing significant OCD-related impairment or distress and when CBT is not successful or is only partially effective. A frequent and ongoing evaluation of the child is necessary to plan, modify, and monitor treatment. Important steps include: z Assessment of symptom severity. z Review of the success of CBT. z Physical and psychiatric evaluation. Laboratory tests are necessary before and during treatment with Anafranil but not with other SSRIs, particularly for children with preexisting heart disease. z Consideration of how medication will be supervised at home and school. z Review of possible side effects. Research indicates that all SSRIs are equally effective in the treatment of OCD and have similar side effects that include nervousness, insomnia, restlessness, nausea, and diarrhea. z The implementation of a monitoring schedule that will collect data on both therapeutic benefits and side effects. Weekly appointments are usually necessary at the beginning of treatment to develop a treatment plan and to monitor symptoms, medication doses, and side effects. Once an optimal treatment schedule is established, monthly follow-up visits are recommended for at least six months and continued treatment for at least one year before attempting to discontinue medication or CBT. z Counseling the child and parents about the medication, possible side effects, interactions, and adverse withdrawal effects. Research shows that selective serotonin reuptake inhibitors (SSRIs) can be an effective treatment for OCD. These medications increase and regulate the level of serotonin in the brain. However, when medication is discontinued, symptoms usually return to the predrug level of severity. In October 2004, the Food and Drug Administration warned that use of antidepressant drugs, including SSRIs, may increase the risk of suicidal ideation and suicidal behavior in a small number of children and adolescents. Examples of commonly prescribed SSRIs include: z Anafranil z Prozac z Luvox z Paxil z Zoloft z Celexa Occasionally, when SSRIs prove ineffective, the monoamine oxidase inhibitor (MAOI), Nardil, may be prescribed. It usually takes from two to three months of medication treatment to see significant improvements in OCD symptoms. The success rate of medication alone in the treatment of OCD is less than 20%. For this reason, medication is almost always combined with CBT to achieve optimal results. The Brain and OCD Although the precise neuropsychological causes of OCD are unknown, research indicates that there is increased activity in the frontal lobes, basal ganglia, and cingulum of the OCD-affected brain. These brain structures use the chemical messenger serotonin for communication. It is believed that abnormal levels of serotonin are involved in OCD. Resources for Helping Children and Teens with OCD Books for Parents Obsessive Compulsive Disorder: New Help for the Family. Herbert L. Gravitz, Partners Publishers Group, 2004 Worried No More: Help and Hope for Anxious Children. Aureen Pinto Wagner, Lighthouse Press, 2005 Freeing Your Child from ObsessiveCompulsive Disorder: A Powerful, Practical Program for Parents of Children and Adolescents. Tamar E. Chansky, Three Rivers Press, 2001 What to Do When Your Child Has Obsessive-Compulsive Disorder: Strategies and Solutions. Aureen Pinto Wagner, Lighthouse Press, 2002 Helping Your Child with OCD: A Workbook for Parents of Children with ObsessiveCompulsive Disorder. Lee Fitzgibbons and Cherry Pedrick, New Harbinger, 2003 Wagner and Paul A. Jutton, Lighthouse Press, 2004 A Thought Is Just a Thought: A Story of Living with OCD. Leslie Talley, Lantern Books, 2004 Mr. Worry: A Story about OCD. Holly L. Niner and Greg Swearingen, Albert Whitman and Company, 2004 Books for Children and Teens Up and Down the Worry Hill: A Children’s Book about Obsessive-Compulsive Disorder and Its Treatment. Aureen Pinto Books for Professionals Obsessive Compulsive Disorder: Theory, Research, and Treatment. Richard P. Swinson,et al (Eds.), Guilford Press, 2001 4 • Instant Help for Children and Teens with Obsessive Compulsive Disorder Treatment of Obsessive Compulsive Disorders. G. Steketee, Guilford Press, 1996 Cognitive Therapy for ObsessiveCompulsive Disorder: A Guide for Professionals. Aaron T. Beck, New Harbinger, 2006 release Cognitive-Behavioral Therapy for OCD. David A. Clark, Guilford Press, 2003 OCD in Children and Adolescents: A Cognitive-Behavioral Treatment Manual. John S. March, Karen Mulle, Guilford Press, 1998 Instant Help Publications (www.InstantHelpBooks.com)