Exploring psychotherapeutic issues and agents in clinical practice
The American Academy of Child and Adolescent Psychiatry (2012) recommends screening all patients for obsessions and/or compulsions. With prevalence of up to 4% (Højgaard et al., 2017) and decreased quality of life (Coluccia, Ferretti, Fagiolini, & Pozza, 2017; Weidle, Jozefiak, Ivarsson, & Thomsen, 2014), knowing how to screen, diagnose, and treat obsessive-compulsive disorder (OCD) is an essential component of child and adolescent psychiatric treatment.
OCD is characterized by obsessions—distressing, intrusive, and recurrent thoughts, urges, and/or images. Compulsions are repetitive behaviors that children complete because they fear what will happen if they do not and include mental repetition (i.e., counting). To meet diagnostic criteria, obsessions and/or compulsions must take up more than 1 hour per day or cause clinically significant distress or impairment (American Psychiatric Association, 2013). In children and adolescents, this distress may escalate to a tantrum or otherwise extremely dysregulated behavior if they are not able to complete a compulsion. Children, unlike adults and adolescents, may lack insight into their fears and believe, for example, that if they do not blink exactly eight times their pet will run away. Parents may not recognize their children's behaviors as a compulsion and find themselves increasingly accommodating requests, such as agreeing to check the closet five times every night or reassuring the child multiple times that his/her food is safe to eat.
Screening questions can be simple, such as “Do you ever have thoughts or pictures in your head that you wish weren't there but that come back over and over?” and “Do you ever feel like you have to do something over and over or something terrible will happen?” Children and adolescents may need reassurance about revealing these thoughts as they may be embarrassing (as in sexual obsessions) or frightening (violent images). A “yes” answer to such questions should prompt a diagnostic assessment with the Children's Yale-Brown Obsessive Compulsive Scale, which is free and available online with detailed instructions (Goodman et al., 1997). Because approximately 75% of children with OCD may have a comorbid disorder and poor school functioning (Agarwal, Yaduvanshi, Arya, Gupta, & Sitholey, 2016), a complete psychiatric evaluation is recommended (American Academy of Child and Adolescent Psychiatry, 2012).
Etiology of OCD is multifactorial, with genetic and environmental components (Brakoulias, Perkes, & Tsalamanios, 2017). Genetic contribution appears to be higher in individuals diagnosed in childhood (American Academy of Child and Adolescent Psychiatry, 2012). There is a subset of acute onset OCD cases that can be attributed to group A beta-hemolitic streptococci known as Pediatric Autoimmune Neuropsychiatric Disorder Associated with Streptococcal Infection (PANDAS) (Table A, available in the online version of this article).
The orbitofrontal cortex (OFC) and cortico-striatal-thalamic-cortical anatomy and physiology are implicated in OCD. Structural and functional alterations have been noted in the OFC, anterior cingulate cortex, and thalamus with reduced connectivity between the OFC and amygdala (Moreira et al., 2017). Recent research shows that glutamate dysfunction in the frontal-striatal region is also associated with OCD (Rajendram, Kronenberg, Burton, & Arnold, 2017).
In 2012, the American Academy of Child and Adolescent Psychiatry published recommendations for treatment of OCD that included cognitive-behavioral therapy (CBT) alone for individuals with mild symptoms and combining CBT and selective serotonin reuptake inhibitors (SSRIs) for individuals with moderate or severe symptoms. However, two recent meta-analyses recommend CBT alone as first-line treatment because patient improvement was equal to combining CBT and SSRI or clomipramine and superior to medication alone (Ivarsson et al., 2015; Öst, Riise, Wergeland, Hansen, & Kvale, 2016). The National Institute for Health and Care Excellence (NICE; 2013) guidelines also support CBT as first-line treatment. CBT for OCD includes psychoeducation of the child and family, cognitive therapy, and exposure and response prevention (ERP), with ERP being the most effective piece of this triad (Bloch & Storch, 2015).
However, for young individuals who do not have access to CBT, will not participate in CBT, or whose symptoms do not remit with high-quality CBT for 12 weeks, medication is advised (Ivarsson et al., 2015; NICE, 2013). SSRIs and the tricyclic antidepressant agent clomipramine have shown efficacy in reducing symptoms. Although clomipramine has shown more efficacy than SSRIs for pediatric OCD, with the risk of cardiac arrhythmia and no head-to-head comparisons, it is recommended that a SSRI be used before clomipramine (American Academy of Child and Adolescent Psychiatry, 2012; Ivarsson et al., 2015; NICE, 2013; Varigonda, Jakubovski, & Bloch, 2016). Side effects of clomipramine include weight gain, orthostatic hypotension, and anticholinergic effects. Cardiac screening prior to starting clomipramine includes history of syncope, shortness of breath, chest pain, dyspnea on exertion, and family history of sudden cardiac death. If any of these concerns emerge, an electrocardiogram is recommended.
In a pooled analysis, sertraline, fluoxetine, and fluvoxamine do not appear to vary in their efficacy for pediatric OCD (Ivarsson et al., 2015). These medications should be trialed at 8 to 12 weeks at the maximum tolerated dose (Bloch & Storch, 2015) (Table). Adult studies have indicated that response is improved at higher doses of SSRIs (Bloch & Storch, 2015).
U.S. Food and Drug Administration–Approved Medications for OCD in Children and Adolescents
Treatment-resistant OCD is defined as nonresponsive to CBT and two adequate trials (maximum tolerated dose) of SSRIs or clomipramine. Augmentation strategies that have shown efficacy in pediatric OCD involve adding antipsychotic agents, clomipramine, or N-acetylcysteine (NAC) to a SSRI. Small studies augmenting a SSRI with aripiprazole in treatment refractory children and adolescents have demonstrated findings of decreased OCD symptoms or impairment (Akyol Ardic et al., 2017; Masi, Pfanner, & Brovedani, 2013). Aripiprazole's agonist effect on 5HT1A may be the reason it has shown efficacy for OCD (Masi, Pfanner, Millepiedi, & Berloffa, 2010). Risks with aripiprazole treatment in children include metabolic syndrome and extrapyramidal symptoms. The Canadian Alliance for Monitoring Effectiveness and Safety of Antipsychotics in Children and Adolescents (CAMESA, 2017) guidelines have been developed by a multidisciplinary team comprising pediatric endocrinologists, epidemiologists, psychiatrists, neurologists, and a nephrologist and cardiologist, and provide monitoring recommendations and forms for specific antipsychotic medications. CAMESA (2017) recommends monitoring height, weight, waist circumference, blood pressure, fasting glucose, lipids, and liver function tests before treatment and at regular intervals. Their forms can be accessed online ( http://camesaguideline.org/who-we-are).
Researchers have looked into pharmacology to address glutamate as a treatment, but to date only augmentation of SSRIs with NAC has shown benefit in the pediatric population. NAC is a naturally occurring amino acid that is available for purchase over the counter and is used in acetaminophen overdose. NAC converts to cysteine, a substrate at the glutamate/cysteine antiporter. This process increases glutamate in the extracellular space, which inhibits release of glutamate from the synapse (Ghanizadeh et al., 2017). NAC is also a powerful antioxidant that crosses the blood–brain barrier and is believed to have a neuroprotective effect (Bavarsad Shahripour, Harrigan, & Alexandrov, 2014). A small, placebo-controlled, double-blind study found statistically significant improvement in the group to which NAC was added to citalopram with attendant increase in quality of life (Ghanizadeh et al., 2017). Patients were titrated up to 2,400 mg per day.
NAC is available as 600-mg tablets or capsules. Patients can be started at 600 mg twice daily and increased by 600 mg per day every 1 to 2 weeks up to 1,200 mg twice daily. NAC is generally well-tolerated, with most frequently reported side effects of nausea, diarrhea, and vomiting (Bavarsad Shahripour et al., 2014). NAC has shown good results in the OC-related disorders of trichotillomania (Rodrigues-Barata, Tosti, Rodríguez-Pichardo, & Camacho-Martínez, 2012) and excoriation disorder (Grant et al., 2016), and has also been associated with a significant decrease in nonsuicidal self-injury in adolescents (Cullen et al., 2017). Therefore, if patients have any of these comorbid conditions, NAC may be a good augmentation option. Clomipramine <75-mg add-on to SSRI is also used in clinical practice (Bloch & Storch, 2015).
Duration of Treatment with Medication
No discontinuation trials in pediatric OCD have been performed; however, currently, 6- to 12-month maintenance treatment is considered baseline (Bloch & Storch, 2015). Discontinuation in young individuals should be introduced slowly in periods of low stress, in collaboration with the patient and his/her family who can assess for rebound of symptoms (Bloch & Storch, 2015).
OCD is a satisfying disorder to treat because CBT skills are empowering and effective in all types of anxiety, as the basics are facing fears without avoidance or rituals and noticing, through a substance use disorder scale, that the distress eventually fades. At each therapy session, the child and therapist determine what skills or fears the patient will focus on at home for the coming week. This treatment can be reinforced during psychopharmacology appointments by checking in with the parent and patients about their progress and giving positive attention to their achievements in ending compulsions. Sometimes compulsions recur during stressful times, such as an adolescent patient who eventually only had compulsions during winter examinations, which she was able to address on her own or with booster sessions. Health care professionals have the opportunity to monitor early signs of recurrence and encourage patients and parents to address first through cognitive-behavioral skills, then medication if needed.
For more about OCD, the International OCD Foundation provides resources for clinicians and patients on its website (access https://iocdf.org/professionals). The Foundation also offers specific information for children, teenagers, and parents as well as referrals to therapists, support groups, and residential treatment programs.
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U.S. Food and Drug Administration–Approved Medications for OCD in Children and Adolescents
|Medication||Type||Start Dose (mg/day)||Target Dose (mg/day)||Age (Years)|
|Fluoxetine (Prozac®)||SSRI||10 (child)
20 (adolescent)||20 to 80||≥7|
|Sertraline (Zoloft®)||SSRI||25 (child)
|A small group of those diagnosed with obsessive compulsive disorder (OCD) have a subset of the disease called Pediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcal Infection (PANDAS) or Pediatric Acute Onset Neuropsychiatric Symptoms (PANS). PANS is associated with bacterial or viral infections, such as influenza or M. pneumonia, or Lyme disease (Cooperstock, Swedo, Pasternack, & Murphy, 2017). The symptoms, course, diagnosis, and treatments of PANS/PANDAS differ from a typical childhood onset OCD.|
|Symptoms include the following: abrupt, dramatic onset of OCD symptoms and/or severely restricted food intake, and two or more of the following: anxiety, emotional lability/depression, irritability/oppositionality/aggression, behavioral/developmental regression, deterioration in school performance with attention-deficit/hyperactivity disorder (ADHD) symptoms/memory deficits/cognitive changes, sensory or motor abnormalities, somatic signs or symptoms (sleep disturbances/enuresis/urinary frequency); symptoms cannot be explained by a known neurological or medical disorder (Chang et al., 2015). Symptoms are usually severe and may correspond to diagnoses of OCD, ADHD, Tourette's, depression, or bipolar disorder (Chang et al., 2015). Symptoms follow an episodic course, and are often accompanied by severe separation anxiety. Up to 25% of children with OCD may have hallucinations (Thienemann et al., 2017). Diagnosis is one of exclusion.|
|The history may include a recent strep infection in the perianal region, vulvar area, throat, or skin lesions. Family history may include recent infection, and first-degree relatives are more likely to have increased rates of tic disorders, OCD, and rheumatic fever, and mothers are particularly likely to have autoimmune disease (Chang et al., 2015). Mental status examination may reveal self-injurious thoughts and behaviors, incongruent laughter and mood, emotional lability, and speech regression (i.e., “babytalk,” mutism) (Chang et al., 2015). Up to 80% of patients will evidence neuroinflammation or postinfectious auntoimmunity (Swedo, Frankovich, & Murphy, 2017).|
|Treatment is tripartite and addresses psychiatric symptoms, source of infection, and immune system alterations with immunotherapies or anti-inflammatories. Because multiple behavioral symptoms may exist, behavioral and psychopharmacological interventions are based on the symptoms that are most acute (Swedo et al., 2017). Some children with PANS/PANDAS may also restrict food or hydration or be so aggressive that they require hospitalization. Thienemann et al. (2017) recommend considering benzodiazepine or antipsychotic agents or diphenhydramine if youth are aggressive secondary to encephalitis. Detailed information about laboratory workup and treatment of infection is available from Cooperstock et al. (2017). When symptoms resolve, treatment can be discontinued with the knowledge that they may recur and treatment can be restarted.|