Obsessive-Compulsive Disorder

Epidemiological studies indicate lifetime prevalence rates of OCD from 2% to 3% by late adolescence (Zohar, 1999). The average age of onset among children is approximately 10 years, but OCD has been reported to occur in children from 5 to 18 years (Flament et al., 1988; Geller et al., 1998; Leonard et al., 1993; Masi et al., 2005). As indicated in DSM-5, obsessions and compulsions are core features of OCD. Obsessions are characterized by intrusive, unwanted thoughts or feelings that create significant distress, while compulsions are ritualistic behaviors performed in an effort to relieve distress. More specifically, patients with OCD feel compelled to engage in rituals that counteract their obsessions and thus temporarily alleviate their anxiety. According to DSM-5 diagnostic criteria, individuals with OCD may have either obsessions or compulsions. When only one component is present, children, in comparison to adolescents, are much more likely to present with compulsions rather than obsessions (Geller et al., 1998; Last & Strauss, 1989). When obsessions are present, most children with OCD report one predominant type of obsession (Masi et al., 2005).

With respect to content, the most common obsessions include contamination fears and concerns about illness and disease. Also common but somewhat less frequently reported by children with OCD are thoughts of aggression (e.g., inflicting harm on oneself or others), symmetry/exactness, religion, sex, and somatization. The most prevalent compulsions include checking, hand-washing, and cleaning. Other common rituals include repeating, ordering/arranging, touching, counting, and hoarding/saving (Barrett & Healy-Farrell, 2003; Flament et al., 1988; Hanna, 1995; Last & Strauss, 1989; Riddle et al., 1990; Swedo, Rapoport, Leonard, Lenane, & Cheslow, 1989).

Trichotillomania

As discussed in DSM-5, recurrent pulling out of one’s hair is the core feature of TTM. Although data focused on children with TTM are more limited, a lifetime prevalence rate of approximately 0.6% has been found in two separate studies primarily including adults (Christenson, Pyle, & Mitchell, 1991; Duke, Bodzin, Tavares, Geffken, & Storch, 2009). The hair-pulling often occurs in conjunction with: (1) negative emotions such as stress, irritation, or doubt; (2) when the individual is sitting alone, perhaps doing homework, watching television, or reading; and/or (3) after significant life events (e.g., starting school, moving to a new city, automobile accident) (Chang, Lee, Chiang, & Lü, 1991; Christenson, Ristvedt, & Mackenzie, 1993; Hanna, 1995; Reeve, Bernstein, & Christenson, 1992). Two primary subtypes of hair pulling have been identified: (1) a “focused” subtype in which pulling occurs under conscious awareness, and (2) an “autonomic” subtype in which pulling occurs outside of awareness, usually during sedentary or mindless activities like watching television (Flessner, Berman, Garcia, Freeman, & Leonard, 2009). Hair may be pulled from the head, eyebrows, eyelashes, or pubic area. A survey study among 133 youth with TTM ages 10 to 17 years found the most common sites of hair-pulling are the scalp (86%), eyelashes (52%), eyebrows (38%), pubic region (27%), legs (18%), and arms (9%) (Franklin et al., 2008). Hair selected to be pulled is described as feeling different in some way (too kinky or straight, too short or long, or just odd). In some instances, hairs are pulled only from areas where it is easy to cover bald spots; in other cases, the baldness may be so extensive that concealment is not possible. Some children eat the hair, and in certain instances hair-pulling co-occurs with thumb-sucking (Walsh & McDougle, 2001).

Mean age of onset in some TTM samples is reported during early to mid-adolescence (Duke et al., 2009; King et al., 1995; Swedo & Leonard, 1992). However, in other samples, approximately one third of children had an onset prior to age 10, and 14% had an onset prior to age 7 (Muller, 1987; Walsh & McDougle, 2001). According to Flessner et al. (2009), TTM often co-occurs with OCD, and children presenting with both disorders report more obsessions and compulsions than those with OCD alone. Further, children with comorbid OCD and TTM more commonly report contamination, aggressive, sexual, somatic, and religious obsessions and washing/cleaning, checking, repeating, and counting compulsions. Parents of children with both disorders more commonly report the presence of tactile/sensory sensitivities than do parents of children with OCD alone (Flessner et al., 2009).

Psychosocial Treatment for Obsessive-Compulsive Disorder

Cognitive behavioral therapy (CBT) consisting of exposure and response prevention (ERP) is the treatment of choice for children and adolescents with OCD, according to Expert Consensus Guidelines (March, Frances, Carpenter, & Kahn, 1997) and the American Academy of Child and Adolescent Psychiatry practice parameters (Geller & March, 2012). The goal of ERP is to weaken associations between obsessions and anxiety and between compulsions and experiencing anxiety relief. The child or adolescent confronts the stimuli that evoke obsessional anxiety (e.g., touching a “dirty” bathroom doorknob) while simultaneously refraining from compulsive behaviors (e.g., washing hands). An exposure hierarchy is developed so that exposure tasks begin with less anxiety-provoking stimuli and gradually move toward tasks of increased difficulty. Exposures that elicit moderate levels of anxiety are thought to be optimal for promoting within-session habituation and to decrease the likelihood of treatment dropout (Norton, Hayes-Skelton, & Klenck, 2011).

During exposure sessions, therapists provide support and encourage the child to confront the feared stimuli via modeling, instruction (e.g., “Try a little bit at a time”), and verbal praise (e.g., “You’re doing great!”). Subjective units of distress (SUD) ratings (i.e., a Likert-type scale) are recorded at brief intervals throughout the exposure to help the therapist gauge the child’s level of habituation. Ideally, exposures should not be discontinued until the child’s SUD ratings have decreased by at least 50% from the peak anxiety rating. SUD ratings can be tracked visually on a graph during exposures to promote learning that anxiety eventually will decrease on its own in the absence of compulsions and/or avoidance. Tracking progress in treatment both within and across sessions may also build motivation for more difficult exposures. Also, since most treatment gains are made outside of treatment sessions (Piacentini & Bergman, 2000), homework assignments in which children practice ERP between sessions is critically important.

ERP can be delivered in either an in vivo or an imaginal format, depending on the nature of the child’s obsessions and/or compulsions as well as the age of the child. Compared to adolescents, children may experience difficulty holding the feared stimulus in their mind for long periods of time, making in vivo exposures more ideal for younger patients. During in vivo exposures, the child actually confronts the feared stimulus (i.e., touching an item believed to be contaminated). In order to facilitate generalization, exposures may also be conducted outside of sessions in other anxiety-provoking settings, such as at school, at home, or in a hospital. Imaginal exposures may be necessary when obsessions include inappropriate content or are not easily reproduced in the treatment setting. As an example, a child who fears s/he will physically harm a loved one might be encouraged to imagine carrying out this act. Generally, exposures that are more vivid and realistic are more effective (Piacentini, Gitow, Jaffer, Graae, & Whitaker, 1994). In vivo and imaginal exposures can also be used in combination. In an evaluation of the efficacy of a CBT treatment package in which ERP was conducted utilizing both in vivo and imaginal exposures, Piacentini, Bergman, Jacobs, McCracken, and Kretchman (2002) found a response rate of 79%.

Research examining the efficacy of ERP alone (Bolton & Perrin, 2008) or as part of a treatment package (see Barrett, Farrell, Piña, Peris, & Piacentini, 2008; Freeman et al., 2013) suggests that exposure is the most critical component in the treatment of pediatric OCD. An initial open trial of ERP-focused CBT conducted by Franklin and colleagues (1998) revealed that 12 out of 14 youth experienced a 50% reduction in scores on a measure of symptom severity (i.e., Children’s Yale-Brown Obsessive Compulsive Scale [CY-BOCS]). In comparing ERP alone to a wait-list control condition, Bolton and Perrin (2008) found statistically significant improvement in OCD symptoms (46%) from pre- to posttreatment in 20 youth (8–17 years). Several other randomized control trials have demonstrated the efficacy of CBT protocols utilizing ERP (see Watson & Rees, 2008), and a meta-analysis by Abramowitz, Whiteside, and Deacon (2006) found that CBT incorporating ERP produces larger effect sizes than selective serotonin reuptake inhibitors (SSRIs) alone.

Cognitive restructuring techniques are also helpful in the treatment of pediatric OCD (Bolton et al., 2011; Williams et al., 2010). Based on the principles outlined by Salkovskis (1998), cognitive restructuring consists of identifying and relabeling obsessive thoughts in order to achieve some “distancing” from OCD symptoms (e.g., “I’m not really going to make my mom die if I don’t say good-bye to her. It’s just my OCD talking”). Cognitions that are commonly identified for relabeling include exaggerated responsibility appraisals (e.g., “It’s my responsibility to tap three times to keep my mother healthy”) or thought-action fusions (i.e., the belief that thinking about something is as bad as doing it). Strategies aimed at normalizing these intrusive thoughts, such as surveying friends and family or conducting Internet-based research, can help the child reappraise the situation in a less threatening way. Behavioral experiments may also be used to directly test the veracity of thoughts (i.e., testing the power of a thought to make something happen). Unlike ERP, these experiments are designed to challenge maladaptive cognitions instead of promoting habituation to anxiety-provoking stimuli. Cognitive restructuring may also help some children cope with extreme anxiety during difficult exposures (Piacentini et al., 1994). In a sample of 21 youth ages 9 to 18 years, Williams and colleagues (2010) compared cognitive-focused CBT with a wait-list control group and found a large treatment effect (Cohen’s d = 1.07) and a significant reduction in CY-BOCS scores. Another study by Bolton and colleagues (2011) revealed that both brief (an average of five sessions) and longer (an average of 12 sessions) treatment with CBT emphasizing cognitive restructuring significantly improved OCD symptoms (i.e., CY-BOCS scores) among 96 youth ages 10 to 18 years as compared with a wait-list condition.

CBT protocols for OCD may sometimes incorporate other components as well, including psychoeducation (Bjorgvinsson et al., 2008; March & Mulle, 1995), anxiety management techniques (March et al., 2004), contingency management (Piacentini et al., 1994), and relapse prevention (Barrett, Healy-Farrell, & March, 2004). During psychoeducation, OCD is described as a neurobiological disorder using a medical model. Consequently, symptoms are viewed as external from the child, and the child and family work together against OCD. The principles of behavioral theory and the process of ERP are also explained. Anxiety management training may include diaphragmatic breathing, progressive muscle relaxation (PMR), constructive self-talk (i.e., “If I can just wait a little while longer, my anxiety will go down”), and humorous visualizations (i.e., picturing OCD as a funny cartoon character). Contingency management consists of rewarding a child for attempting or completing in-session exposures or homework. The nature of rewards depends on the developmental level and preferences of the child. During relapse prevention, any unrealistic expectations (e.g., the belief that symptoms will disappear completely) are addressed. The child is asked to identify stressors or situations that may increase risk for a relapse or exacerbate symptoms and to establish a plan for ongoing support.

Combining Psychosocial With Pharmacological Treatments for OCD

SSRIs, including fluoxetine, fluvoxamine, paroxetine, sertraline, and a tricyclic antidepressant, clomipramine, are also commonly used to treat pediatric OCD (Geller et al., 2003). Until recently, these medications were presumed to have a good safety profile, as few changes in blood pressure, pulse, weight, or electrocardiogram were reported (e.g., Liebowitz et al., 2002; Riddle et al., 1990). However, many of the SSRIs now carry a “black box warning” due to an association with increased suicidal ideation. Meta-analytic results (Abramowitz et al., 2006) also indicate that while children treated with SSRIs report reduced symptoms, obsessions and compulsions often remain severe enough to meet entrance criteria for most clinical trials (March et al., 2004). Overall, about 33% of pediatric patients fail to benefit from pharmacotherapy alone, and medication is less likely to be associated with long-term improvements than CBT (O’Leary, Barrett, & Fjermestad, 2009; Shalev et al., 2009).

In a randomized, placebo-controlled comparison trial (Pediatric OCD Treatment Study [POTS]) (March et al., 2004), CBT, sertraline, their combination, and pill placebo were compared among 112 youth with OCD ages 7 to 17 years. At posttreatment, scores on a measure of symptom severity (i.e., CY-BOCS) indicated significant improvement in all three active treatment conditions, but children in the combination condition showed significantly greater symptom reductions on the CY-BOCS compared to those treated with sertraline or CBT. However, when clinical remission rates were examined (defined as posttreatment CY-BOCS score ≤10), 53.6% of the combination group, 39% of the CBT group, 21% of the sertraline group, and 3% taking placebo reached remission status. Statistically, combination treatment was superior to sertraline alone based on remission rates, and sertraline did not differ from placebo. Effect sizes for combined treatment, CBT alone, and sertraline were 1.4, 0.97, and 0.67, respectively. Other more recent studies have provided further support for the increased efficacy of combination therapy as opposed to pharmacological monotherapies (Franklin, Edson, Ledley, & Cahill, 2011; Storch et al., 2010). Psychosocial interventions are therefore considered the first line of treatment for pediatric OCD, with pharmacological interventions recommended in combination with CBT for more severe cases of the illness (Geller & March, 2012).

Treatment for Trichotillomania

The efficacy of behavior therapy (BT) with habit reversal training (HRT) (Azrin & Nunn, 1973) for treating adults with TTM is well established (Stemberger, McCombs-Thomas, MacGlashan, & Mansueto, 2000; Wetterneck, Woods, Norberg, & Begotka, 2006). Studies evaluating the efficacy of behavioral treatment in children and adolescents with TTM are limited, however. When pulling behavior occurs in conjunction with thumb-sucking, elimination of thumb-sucking may eliminate TTM (Watson & Allen, 1993). In a review of available case studies, Bruce, Barwick, and Wright (2005) concluded that behavioral treatments have the greatest support in young patients. For example, Blum, Barone, and Friman (1993) and Vitulano, King, Scahill, and Cohen (1992) reported some success with a range of traditional behavioral interventions, such as overcorrection, annoyance review, and differential reinforcement of other behaviors. Overcorrection usually has aversive connotations (Foxx & Bechtel, 1982), but in the case of children with TTM, it has been used in the form of positive practice by having the children comb or brush their hair (Vitulano et al., 1992). Annoyance review simply refers to having the children acknowledge the problematic nature of hair-pulling and their reasons for wanting to stop. This approach is probably most effective for preadolescents and adolescents rather than younger children. Differential reinforcement of other behavior means giving the child attention only when pulling behavior is absent. Positive touches (in young children) and compliments (in older children and adolescents) are also commonly used (Blum et al., 1993).

Only one randomized controlled trial to date has demonstrated the efficacy of BT in the treatment of children and adolescents with TTM (Franklin et al., 2011). In this study, 24 youth ages 7 to 17 years were treated with the primary components of HRT: awareness training, stimulus control, and competing response training. Given that children often report “automatic” as opposed to “focused” hair-pulling (Flessner et al., 2009), awareness training is implemented to increase awareness of pulling behavior and urges by identifying situations (i.e., sleep onset or television watching) and/or triggers (i.e., bathroom mirror) that increase risk for pulling. Self-monitoring strategies, such as using a mirror or keeping a diary (in older children), may be helpful. Stimulus control strategies involve creating barriers to pulling during high-risk situations (i.e., wearing gloves or covering nails with bandages while falling asleep) or placing visual reminders near triggers (i.e., a sign placed by the bathroom mirror or television).

During competing response training, the child or adolescent is taught to engage in an alternative, opposite movement when becoming aware of an urge to pull. The competing response should be physically incompatible with pulling, such as playing with clay or holding a tight fist. Given the theoretical association between stress and pulling behavior, progressive muscle relaxation was also implemented to (indirectly) reduce pulling. Finally, cognitive restructuring was used to challenge negative autonomic thoughts associated with pulling. Compared with a minimal attention control condition, this combined treatment package resulted in a significant reduction in scores on the National Institute of Mental Health Trichotillomania Severity Scale (NIMH-TSS) at posttreatment and at an 8-week follow-up assessment (Franklin et al., 2011). These results are promising overall, but more controlled treatment research is needed to more definitively establish the efficacy of HRT and its individual components in treating youth with TTM.