Clinical considerations when tailoring cognitive behavioral treatment for young children with obsessive compulsive disorder.(Report)

Abstract

Research on the effectiveness of cognitive-behavioral therapy, and in particular, exposure with response prevention for Obsessive-Compulsive Disorder (OCD), has only been systematically evaluated in children and adolescents ages 7-17. These treatments do not address the unique characteristics of young children with OCD. This paper discusses clinical considerations for treating OCD in young children (ages 5-8), including cognitive developmental differences, family context, unique symptom correlates, and initial contact with the mental health system. A family-based treatment program consisting of psychoeducation about OCD in young children, parent education, and exposure with response prevention for young children and their parents is described. Issues to consider regarding implementation of this treatment, research with a young population, and future directions for research are presented.

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Obsessive-Compulsive Disorder (OCD) is a serious and significant psychiatric disorder in early childhood, affecting as many as 2-3% of children and adolescents (e.g., Valleni-Basile et al., 1995). At any given moment, between 0.5 and 1% of the pediatric population suffers from OCD (Flament et al., 1988). However, these figures may underestimate the true magnitude of the problem in children under 9 years of age, because young children tend to be secretive about OCD symptoms and may experience developmentally-based difficulty articulating their concerns to others (Rapoport et al., 2000).

Symptoms of OCD may have a significant impact on academic performance. For example, spending time in the morning completing compulsions may contribute to a child's tardy arrival or absence from school. In addition, parents and children report that obsessions and compulsions can disrupt a child's ability to concentrate, complete homework, or achieve the level of academic success of which he/she is capable (Valderhaug & Ivarsson, 2005). Given that early childhood coincides with the beginning of formal schooling, OCD-related difficulties during this period may have a particularly devastating impact upon the establishment of strong academic functioning and peer relationships (Valderhaug & Ivarsson, 2005). Intervention at an early stage is designed to enable the child to master skills and reduce symptomatology before problematic patterns are well established. In this way, coping skills can be in place when developmental transitions (such as starting formal schooling) occur, thereby minimizing the chance that the child's anxiety will interfere with learning (Hirshfeld-Becker & Biederman, 2002).

In recent years, research on the effectiveness of cognitive behavior therapy (CBT), and in particular, exposure with response prevention, has been carefully reviewed and studied in children and adolescents with OCD (e.g., Abramowitz, Whiteside, & Deacon, 2005, for a review). While there are encouraging results for the efficacy of CBT, the samples have not included young children with OCD below the age of 7, and the treatment models have not directly addressed the unique characteristics of young children with OCD.

This paper describes a developmentally tailored, family-based treatment program for early childhood onset OCD that addresses the unique needs of young children (ages 5-8) with OCD. While the program is adapted from treatment manuals for OCD in children and adolescents (e.g., March & Mulle, 1998; Piacentini, Jacobs, & Maidment, 1997), there are particular differences between this family-based treatment program for young children and current CBT programs for OCD in children and adolescents (see Table 1). Specifically, the overall focus of this treatment program is to provide both child and parents with a set of "tools" to help them understand, manage, and reduce OCD symptoms. Most importantly, parents administer the practices of treatment at home and in session, which is an integral part of the intervention.

 
Table 1 ERP modifications for young children versus the ERP for older 
children/adolescents 
 
ERP for older children/              Modifications for ERP with young 
adolescents                                 children 
 
Primarily focuses on providing      The child is included in the 
individual treatment to the child.  treatment to the level of the 
                                    child's developmental capacity 
                                    but treatment may be primarily 
                                    focused on teaching the parents 
                                    tools to help their child fight 
                                    back against OCD. 
 
Provides the child with cognitive   Provides both child and parents 
tools for resisting OCD             with a set of "tools" to help them 
                                    understand, manage, and reduce 
                                    OCD symptoms. 
 
Provides psychoeducation            Provides two sessions of 
regarding the nature of OCD         psychoeducation regarding OCD 
to the parents and children         with the parents alone, prior to 
together.                           introducing the children to 
                                    treatment. 
 
Treatment focuses on repeated       Exposures may be modified to occur 
exposures without performing        within the context of 
compulsions.                        developmentally 
                                    appropriate play. 
 
Parents included at the             Incorporates a formal parent 
discretion of the clinician.        training component to help parents 
                                    learn tools to help their child 
                                    (e.g., attention, modeling, and 
                                    guiding the child's emotional 
                                    regulation in response to an 
                                    event). 

The family-based program consists of 3 principal components: psychoeducation about OCD in young children, parent education and tools to facilitate exposure, and child tools adapted to allow young children to participate in exposure with response prevention. Each of these components of treatment is considered to be important in observing treatment response. For young children (ages 7-8) who are cognitively and developmentally capable of utilizing the child tools, all three components of treatment are considered to be important in reducing symptoms of OCD (see Figure 1). However, for very young children (ages 5-6) who are cognitively or developmentally unprepared to participate actively in treatment, the parent tools are considered to be the primary mechanism by which symptom reduction occurs (see Figure 2). For example, young children who are unable to report their own emotional state and fear ratings in situations which provoke OCD require their parent's support to successfully face them.

[FIGURE 1 OMITTED]

[FIGURE 2 OMITTED]

Background for Treatment of Young Children with OCD

Current treatment approaches have typically excluded young children under 7 for a variety of reasons, including developmental differences in symptom presentation and the treatment modality. For example, OCD symptoms are somewhat different in children, as compulsions without articulated obsessions are common, and the compulsive behaviors themselves may be different than those observed in adolescents or adults (Rosario-Campos et al., 2001; Swedo, Rapoport, Leonard, Lenane, & Cheslow, 1989). This may be even more pronounced in children younger than 7, due to their cognitive and language development. Young children may have difficulty describing the feared consequence behind their compulsions, which makes it difficult to differentiate compulsions from tics or other repetitive behaviors in this age group. Increased sensory phenomena-related compulsions, such as the need to touch or tap things until they feel "just right," …