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Obsessions and compulsions in youths

JAN 2012

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Cognitive behavioral therapy alone or combined with medication may help.

It is normal for many children, at various stages of development, to be concerned about symmetry and having things perfect, to insist on certain bedtime routines, or to develop superstitions and rituals like avoiding cracks in the sidewalk. But when such beliefs or behaviors become all-consuming and start interfering with school, home life, or recreational activities, the problem may be obsessive-compulsive disorder (OCD).

OCD afflicts 1% to 2% of American adults. The disorder usually originates in childhood or adolescence, with symptoms appearing as early as age 3. Childhood OCD is more common in boys than in girls, although the adult form occurs equally in both sexes.

Obsessions are irrational thoughts, images, and impulses that are felt as unrealistic, intrusive, and unwanted. In children, obsessions may govern how toys or other personal belongings are arranged in the playroom. In teenagers, thoughts and impulses may give rise to fears of contamination or excessive concern with religious rituals, such as praying constantly. To relieve the anxiety caused by these obsessions, youths of all ages may engage in compulsive rituals such as buttoning and unbuttoning a shirt dozens of times before wearing it.

Even young children often know that their obsessions are senseless, but they may be helpless to stop themselves. If youths try to avoid the situations that provoke the behavior, their lives may become increasingly restricted. As a result, they may become demoralized, and their development may be interrupted.

Much of the risk for developing OCD is genetic. Brain imaging studies show unusual activity in patients with OCD, chiefly in a circuit that runs between the cerebral cortex, the area of the brain associated with screening thoughts and sensations for significance, and the basal ganglia, a region involved in the control of body movements. As a result, patients with OCD may become overly focused on "unimportant" things and engage in repetitive behavior.

Initial treatment options

Since 2001, several randomized controlled trials and literature reviews have concluded that both cognitive behavioral therapy (CBT) and medication can help youths better manage OCD — but that the combination of both is best. In head-to-head trials, CBT is consistently more effective than medication, however, so many experienced clinicians recommend trying this form of psychotherapy before turning to medication.

CBT. A version of CBT known as exposure and response prevention is typically used in treating OCD in patients of any age. During therapy, a clinician gradually exposes patients — either physically or mentally (through the imagination) — to the things, places, and circumstances that provoke obsessions. Eventually, if all goes well, through habituation the patient learns to tolerate the anxiety. In a sense, this detoxifies the stimuli and makes the compulsive behaviors unnecessary.

Behavior therapy is usually conducted in weekly sessions for several months. Daily homework is also important, because the circumstances that provoke obsessions and rituals are different for each person and cannot be easily reproduced in a therapist's office. Sometimes the best place for therapy is the place where the most serious symptoms occur. Family members are usually enlisted to supervise and encourage young patients. After symptoms become less serious, later sessions may be needed to prevent relapse and to help the child cope with new obsessions and rituals if they develop.

Medication. Although CBT remains the first recommendation for OCD treatment, it may be difficult to find a clinician experienced at working with children and adolescents — or to find an insurance plan that covers the full cost of therapy. Such real-world circumstances help explain why medication tends to be the most common treatment for youths with OCD.

Selective serotonin reuptake inhibitors (SSRIs) such as fluoxetine (Prozac) and sertraline (Zoloft) are the drugs most often used and studied in youths with OCD. These drugs enhance the activity of the neurotransmitter serotonin by preventing its reabsorption at the nerve endings that release it.

It is not clear how serotonin-enhancing drugs yield helpful changes in brain function. Scientists have not confirmed any irregularity in the production, activity, or breakdown of serotonin in children or adults with OCD.

SSRIs require two months or more to have an effect on OCD symptoms — a longer time than they usually take to relieve depression. When used for OCD, these drugs are prescribed at doses generally higher than those needed for depression. Young people may need to keep taking an SSRI for at least a year and sometimes indefinitely. When the drug is the only treatment, youths usually relapse in a few months if they stop taking it.

Enhancing response

Although SSRIs are now a mainstay of treatment for OCD, many youths obtain only partial relief from the drugs. The Pediatric OCD Treatment Study II, a randomized controlled study involving youths ages 7 to 17, examined what might help young people who continue to struggle with symptoms in spite of treatment with an SSRI. The investigators tested two interventions — traditional CBT delivered by a therapist and a briefer, more do-it-yourself version termed "instructions in CBT." In this model — which is probably closer to what happens in actual clinical practice — the same person who prescribed the SSRI also spent time going over principles of CBT and provided homework for practice.

The study found that the briefer version of CBT wasn't much help, but that traditional CBT could indeed enhance patients' recovery. At the end of 12 weeks, only a third of patients assigned to medication combined with instruction in CBT were responding to treatment — about the same as those receiving medication alone — and in both groups, symptoms were still pronounced. In contrast, 70% of the group assigned to traditional CBT combined with medication had responded to treatment, and their symptoms had become significantly more manageable.

One problem with this study is that the researchers did not control for the fact that participants in the traditional CBT group spent 14 extra hours with a therapist. Even so, the evidence remains strong that CBT is the best treatment to add when a young person does not respond adequately to medications.

Future research may point the way to better medication options or effective shorter-duration psychotherapy. Until then, the evidence suggests that relief for youngsters with OCD will depend on increasing their access to experienced CBT therapists.

Franklin ME, et al. "Cognitive Behavior Therapy Augmentation of Pharmacotherapy in Pediatric Obsessive-Compulsive Disorder: The Pediatric OCD Treatment Study II (POTS II) Randomized Controlled Trial." Journal of the American Medical Association (Sept. 21, 2011): Vol. 306, No. 11, pp. 1224–32.

O'Kearney RT, et al. "Behavioural and Cognitive Behavioural Therapy for Obsessive Compulsive Disorder in Children and Adolescents," Cochrane Database of Systematic Reviews (Oct. 18, 2006): Doc. No. CD004856.

Ruscio AM, et al. "The Epidemiology of Obsessive-Compulsive Disorder in the National Comorbidity Survey Replication," Molecular Psychiatry (Jan. 2010): Vol. 15, No. 1, pp. 53–63.

Watson HJ, et al. "Meta-Analysis of Randomized, Controlled Treatment Trials for Pediatric Obsessive-Compulsive Disorder," Journal of Child Psychology and Psychiatry and Allied Disciplines (May 2008): Vol. 49, No. 5, pp. 489–98.

For more references, please see www.health.harvard.edu/mentalextra.