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Treatment
In this article, we will focus on medication and cognitive-behavioral psychotherapy. There are other psychodynamic, play therapy and family therapy approaches to the treatment of OCD.
Once a child has been diagnosed with OCD, we need to decide which treatment or treatments to use first. Many clinicians prefer to start off with cognitive-behavioral psychotherapy. If there is no response or only a partial response, medication may then be added. There circumstances in which it is appropriate to start medication and psychotherapy simultaneously or even to start with medication alone. Moderate to severe OCD may merit starting with a combined approach. If a child or adolescent is extremely resistant to the idea of psychotherapy, one might consider starting with medication alone.
Cognitive-Behavioral Psychotherapy
It would be difficult to discuss this topic without giving a great deal of credit to John March MD and his collaborators. They have developed, tested, and disseminated specific information that includes a detailed protocol for treatment of childhood OCD.
Near the beginning of this type of therapy, the child and family are educated about the biological basis of OCD. Even young children can gain some understanding of this concept if it is presented in an age-appropriate manner. For young children, I often draw an outline of the brain and let them color round and round to signify the repetitive thoughts and actions. Older children and adolescents may appreciate pictures of brain imaging studies. I have used the pictures in the introduction section of the book, Brain Lock by Jeffrey Schwartz, MD. These pictures vividly show the differences in brain activity between affected and unaffected individuals.
When the child and family realize the biological basis of the disorder, they find it easier to externalize the symptoms. The symptoms are the fault of the disease, not the individual or family. Children continue to need more concrete models and concepts throughout the therapy. Often one may help them conceptualize the OCD or OCD symptoms as an unpleasant or silly creature. The child may also want to give this creature a name. In the illustrated children's book, Blink, Blink, Clop, Clop, Why Do We Do Things We Can't Stop? The OCD is named "OC Flea", and is drawn as an unattractive, silly but non-threatening creature. Subsequent therapy helps the child shrink, squash, boss or drive away the OCD.
As the therapy progresses, the child should begin to expose himself to the anxiety-provoking object or situation and then try to avoid performing the usual compulsion. This is called exposure and response prevention. It may have to be done gradually because it can cause the child to experience significant anxiety. The child himself should have an important role in determining how quickly he wants to move through these steps. The parents can help with this too by reducing and then eliminating reassurances when a child asks obsessive questions. At the same time, they should be supportive and avoid blaming the child if he is unable to avoid performing some of the compulsions.
The child may benefit from learning relaxation techniques and learning mental self-monitoring. Other specific techniques may help individual children tolerate the anxiety engendered by the exposure and response prevention.
When the symptoms are eliminated or at least reduced to a tolerable level, the therapist should talk to the child and parents about the future. Symptoms may start to come back at a later date. They should review the symptoms and discuss how to deal with them. Some individuals come in for intermittent refresher sessions.
OCD Medication
Recent advances in medication have added to our treatment options. In the past few years there have been more studies testing these medications specifically on children. In general, children who need medication respond to the same medications used for adults with OCD. The FDA has approved some of these medications for use in children with OCD. However, a physician may, after discussion with the family, elect to use a medication that technically is only approved for adults.
The main medications used for OCD are Clomipramine (brand name Anafranil) and the Selective Serotonin Reuptake Inhibitors. There are several other medications that may be added if those medications produce only a partial response.
Clomipramine is chemically similar to the older tricyclic antidepressants. Its efficacy in OCD seems to be related to its ability to decrease serotonin reuptake. It used to be the only effective drug for OCD. At this point, it is usually not the first line drug for children with OCD. This is because of several potential side effects. It can be sedating. It can also cause dry mouth and eyes. It has been associated with some changes in EKGs. (A measure of the heart rate and the electrical conduction within the heart.) Because children may be more sensitive to this cardiac effect, we usually monitor EKGs and heart rate in children on Clomipramine. Despite this, when used carefully, it has helped many children and adolescents with OCD.
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