The treatment of pediatric patients should be guided by input from specialists in child and adolescent psychiatry. Treatment sequencing depends on a careful assessment of benefits and risks, and patient/ family choice, bearing in mind the available evidence. Be careful to clearly document any treatment decisions and that you have fully discussed benefits and risks with the parent(s) or guardian(s), and patient as appropriate in light of their age.
As a general principle, when a patient has a co-morbid moderate-severe depressive or anxiety disorder, focus on treating that first (rather than the OC spectrum disorder). OC symptoms often improve as a consequence. Once the mood and/or anxiety disorder has been addressed, move on to targeted treatment of the OC spectrum disorder itself.
Forms of psychotherapy shown to be useful in adult patients with OC and related disorders are also generally believed to be useful for non-adults, although there are fewer rigorous trials. In all cases, psychotherapy will need to be modified so that it is age appropriate: consider use of language and communication styles, and whether any reinforcements and rewards are age-appropriate.
Disorder-specific psychological options for each condition are considered below:
- • Obsessive Compulsive Disorder. CBT with Exposure and Ritual Prevention (ERP) is used in children and adolescents and has a reasonable evidence base. ERP is undertaken in a gradual fashion and requires a good understanding of the underlying OCD symptoms and a sensitive therapist skilled in communicating with young people. This process should include sessions involving parent(s) and the setting of age and development appropriate homework assignments. The use of positive reinforcements (e.g., small rewards from parents or the therapist) for progress can be helpful.
- • Hoarding Disorder. There are only a few case reports examining psychological treatments specifically for childhood hoarding. In the absence of rigorous trials, we recommend that CBT with ERP be utilized, based on positive experiences in child OCD patients, including child OCD patients with hoarding symptoms.
- • Tic Disorders. Childhood Tic Disorders are amongst the best studied in terms of psychological treatment options. The available evidence supports the use of habit reversal training (HRT), a short-term behavioral intervention that focuses on helping individuals to be more aware of their tics and to use competing responses (CRs). HRT was first established in the 1970s. The therapist typically begins by making a list of current tics from most bothersome to least bothersome, from the sufferer’s perspective. Tics that have clear preceding feelings/urges and which lead to a simple “conditioned” response are most likely to be amenable to treatment, and one such is selected from the list to begin with. Children are then taught “awareness training” to recognize the onset of premonitory urges/feelings before the given tic; this includes homework in which the child spends time at home monitoring their tics for a defined period each day. Next, the therapist works with the child to develop alternative responses to be undertaken during premonitory urges or when tics first initiate (competing response or CR). For example, one CR could be moving one’s head to a midline position and then tilting the chin and head down. Essentially, the CR should be less noticeable than the tic and incompatible with the tic. For vocal tics, slow steady breathing can be a useful CR. Again, practice is needed at home. Parents can be included in the therapeutic process by encouraging children to make use of the technique and providing small rewards or reinforcements for good progress.
- • Trichotillomania and Excoriation (Skin Picking) Disorder. Habit reversal training (HRT), described above for Tic Disorders, has a good evidence base in the treatment of Trichotillomania in children, albeit in a slightly different format. For awareness training, the individual focuses on acts that precede pulling, such as moving one’s head to the side and moving one’s arm towards the eyebrows. For competing responses, examples include clenching one’s fist or placing hands under one’s
legs. Unlike in HRT for tics, an additional technique used for Trichotillomania is stimulus control: modifying the environment to reduce exposure to hair pulling-related cues. Again, parents can be enlisted to encourage children to use the techniques and reward good progress, and homework is integral to the treatment along with considering social aspects (encouragement of social engagement and hobbies). While not well studied, HRT is likely to be useful for Excoriation Disorder as well as for Trichotillomania.
- • Illness Anxiety Disorder (Hypochondriasis). There are very few (if any) trials examining structured therapies for Hypochondriasis in children. In general terms, psychological treatment should focus on education, reinforcement, and coping skills. Education involves considering the link between psychological and physical states, both in terms of the child and in terms of dynamics between the child and wider family; including family members, especially parents, in therapy is critical. In terms of reinforcement, children should be rewarded (both verbally by parents and also potentially with small physical rewards) for engaging in positive activities while possible “reinforcers” for maladaptive illness behavior should be identified and removed. Coping skills can include families spending time together on fun activities when the child presents as being relatively symptom free. Parents should be seen by the therapist both with the child and separately. Treatment is likely to be difficult for parents since it may entail ignoring certain behaviors despite considerable agitation on the part of the child, hence the need to provide them, as well as the child, with supportive input.
- • Body Dysmorphic Disorder. CBT can be useful in the treatment of childhood Body Dysmorphic Disorder (BDD), provided it is appropriately tailored, and incorporates Exposure and Ritual Prevention (ERP). Such CBT can include making lists of the pros and cons of changing BDD behaviors to start with, along with making an “anxiety hierarchy” of BDD-related scenarios. The child can then work with the therapist on exposing themselves to these situations while not ritualizing, starting with the least anxiety-provoking situation. This would include homework assignments. Some studies have incorporated perceptual retraining, helping children to see their entire body when looking in mirrors, rather than honing in on specific details in a compulsive fashion. Parents can be enlisted in helping children with homework activities, and can give small rewards for positive results. CBT should also incorporate psychoeducation and encourage the use of distraction techniques, along with re-engagement with social and other enjoyable activities.
When considering drug treatments for pediatric OC spectrum
• Be sure to assess for suicidal thoughts and thoughts of self-harm at baseline and during treatment (there is some evidence that SSRIs can increase suicidal ideations in depressed non-adults, and this should be mentioned where relevant).
- • Warn patients and their families that
- • Side effects are more common when treatment is first started. If side effects can be tolerated, they often settle down with time.
- • OC symptoms may get worse initially (over the first 1-2 weeks of treatment).
- • Beneficial effects take time to show themselves; for most OC spectrum disorders, medication at a therapeutic dose for 8-12 weeks is needed before deciding whether or not the treatment has led to benefits.
- • Monitoring is needed for some kinds of medication (e.g., with antipsychotic medication, which would require physicals, blood tests, and ECG/EKG).
Disorder-specific pharmacological options for pediatric OC spectrum disorders are summarized below in Table 10.1. You should also refer to the disorder-relevant chapter elsewhere in this book.