Evidence-Based Treatment for Pediatric Obsessive-Compulsive Disorder
Brauer, Lindsay, Lewin, Adam B., Storch, Eric A., The Israel Journal of Psychiatry and Related Sciences
Obsessive-compulsive disorder (OCD) is marked by incessant distressing thoughts or images (obsessions) and/or overt or covert behaviors (or mental rituals) aimed to reduce anxiety (compulsions). The disorder affects 1-2% of children and adults, with up to 80% of adults reporting symptom onset prior to the age of 18 years. Without appropriate intervention, symptoms tend to run a chronic course from childhood into adulthood. Obsessive-compulsive disorder contributes to considerable impairment across multiple domains of functioning, and as a result calls for effective and efficient treatment. To date, both psychological and pharmacological interventions have shown efficacy for pediatric OCD although there are associated advantages and disadvantages that must be considered in treatment planning. The intent of this review is to discuss the current state of literature regarding treatment for pediatric OCD, highlight efficient and cost-effective means of reducing impairment, and conclude with directions for future study.
Obsessive-compulsive disorder (OCD) is an impairing anxiety disorder which afflicts approximatelyl-2% of youth and adults worldwide (1-3). The disorder is marked by distressing and uncontrollable thoughts or images (obsessions) and/ or overt (i.e., washing, ordering) or covert (i.e., praying, counting) behaviors aimed to reduce distress (compulsions). Obsessive-compulsive symptoms are chronic in nature, and when present during childhood interfere considerably with a child's psychosocial development across social, family, and academic domains (4-7). If left inadequately treated, clinically significant obsessive-compulsive symptoms are likely to persist into adulthood and cause future impairment (8). Taken together, this information demonstrates the need for appropriate treatment for children with OCD to curtail the negative developmental trajectory that distinguishes OCD from other anxiety disorders (9).
Traditionally, many clinicians have conceptualized the etiology and treatment of adult and pediatric OCD through a psychodynamic perspective, viewing the obsession and compulsions as a complex set of neuroses arising from intrapsychic conflict (10, 11). Unfortunately, treatments based on this premise are not empirically supported in reducing obsessive-compulsive symptoms and have little face validity in understanding etiological factors or symptom maintenance. Due to the prevalence and precarious nature of OCD, mental health providers have begun to move towards evidence-based intervention modalities for the treatment of OCD, including serotonin reuptake inhibitors (SRI) and cognitive behavioral therapy (CBT) (10). Notably, the limited treatment dissemination may contribute to a number of risks (e.g., medication side effects) and in missing an opportunity to intervene during a developmentally critical time period (12). Many youth with OCD are being prescribed antipsychotic or benzodiazepine medications in the absence of efficacy data. Such widespread prescription practices are conducted in the absence of supporting pediatric data and the possibility of significant adverse metabolic and cardiovascular effects. Indeed, youth taking an atypical antipsychotic medication had an average weight increase of 8.5kg over 10 weeks (13).Thus, lower-risk alternatives should be considered prior to prescription of such medications in children (14). Second, inadequate treatment of OCD symptoms during childhood have been associated with numerous psychosocial sequelae, such as problematic family relations, social dysfunction, and academic distress (4-7), which together disrupt normative development. Third, unresolved OCD symptoms tend to be chronic in nature, result in higher rates of reported unemployment, interpersonal conflict, sleep problems, and chronic distress and impairment in adulthood when compared to nonOCD anxiety disorders (9).Thus, early effective intervention is crucial to improving a child's quality of life and preventing future impairment. …