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- sions that are severe enough to be time consuming (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 simply excessive worries about real-life problems. Obsessive behaviors included in the definition are repeated thoughts about contamination, doubts, a need to have things in a particular order, aggressive or horrific impulses, and sexual imagery. Compulsions are defined as repetitive 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. This Instant Help Chart was written by Leslie Burling-Phillips Research shows that selective serotonin reuptake inhibitors (SSRIs) can be an effective treatment for OCD. These medica- tions 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 anti- depressant 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: Anafranil Prozac Luvox Paxil Zoloft Celexa Occasionally, when SSRIs prove ineffec- tive, the monoamine oxidase inhibitor (MAOI), Nardil, may be prescribed. It usually takes from two to three months of medication treatment to see signifi- cant 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. 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: Assessment of symptom severity. Review of the success of CBT. Physical and psychiatric evaluation. Laboratory tests are necessary before and during treatment with Anafranil but not with other SSRIs, particularly for chil- dren with preexisting heart disease. Consideration of how medication will be supervised at home and school. 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. 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 treat- ment 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. Counseling the child and parents about the medication, possible side effects, interactions, and adverse withdrawal effects. 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 Obsessive- Compulsive 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 Obsessive- Compulsive Disorder. Lee Fitzgibbons and Cherry Pedrick, New Harbinger, 2003 Books for Children and Teens Up and Down the Worry Hill: A Children’s Book about Obsessive-Compulsive Disorder and Its Treatment. Aureen Pinto 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 Professionals Obsessive Compulsive Disorder: Theory, Research, and Treatment. Richard P. Swinson,et al (Eds.), Guilford Press, 2001 Treatment of Obsessive Compulsive Disorders. G. Steketee, Guilford Press, 1996 Cognitive Therapy for Obsessive- Compulsive 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 Resources for Helping Children and Teens with OCD Medication Protocol Instant Help for Children and Teens with Obsessive Compulsive Disorder Instant Help for Children and Teens with Obsessive Compulsive Disorder 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. 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: Direct observation of the child Interviews with the child, parents, and teachers Review of school records and reports Verbal reports from classmates and friends A more thorough assessment might also include: Structured interviews with the child Intelligence and achievement testing to determine the need of special education services Mental status examination Commonly used assessment tools include: Clark-Beck Obsessive Compulsive Inventory, Harcourt Children’s Yale-Brown Obsessive- Compulsive Scale, Plenum Maudsley Obsessive-Compulsive Inventory, Plenum State Trait Anxiety Inventory I and II, Consulting Psychologists Press Beck’s Depression Inventory, Basis-32, Psychological Corporation Beck Anxiety Inventory, Harcourt Fear of Negative Evaluation Survey, Lexi-Comp A complete evaluation should gather information from multiple sources. Assessing OCD About Instant Help Charts 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. 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: Gradual exposure to OCD-provoking situations Self-talk exercises that intentionally elicit obsessive thoughts while refraining from acting on the resulting compulsive response Relaxation techniques Self-administered positive reinforcement Modeling and shaping the desired behavior Goals in Developing a Treatment Plan To reduce obsessive thoughts and compulsive behaviors To develop methods to keep symptoms from affecting school and social functioning To assimilate isolated children by teaching them prosocial skills To teach family members how to slowly stop participating in the child’s OCD- related rituals without causing anxiety in the child Medication 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. The Brain and OCD (continued on p. 2) 4 • Instant Help for Children and Teens with Obsessive Compulsive Disorder Published by Childswork/Childsplay © 2005 Childswork/Childsplay Childswork/Childsplay A Brand of The Guidance Group 1.800.962.1141 www.guidance-group.com