Obsessive Compulsive Disorder in Children

He Obsessive compulsive disorder in children It differs in that compulsions are diagnosed more easily than obsessions because they are observable.

Most of the information we have about this disorder comes from adults. However, these patients report that in adolescence they presented the disorder and some in childhood presented some of the symptoms.

One of the possible causes of OCD being underdiagnosed is its secret nature, since children conceal that they suffer from this problem for fear of being judged by their environment, by the Feelings of guilt , Embarrassment and embarrassment that causes them to talk about these issues.

At times, children attribute their way of acting to something inherent to themselves that has no solution.

The search for psychological help occurs when adults discover that their children have a Very high anxiety , When the observable behaviors are too extravagant and / or there is a functional deterioration.

Unwanted thoughts and Intrusive Is something that is present in 90% of the population. The content and manner in which these thoughts appear are identical in general population and population with disorder.

On some occasion, any of us have thought"what if I cross the street while the cars pass?","And if I scream in the middle of the library?","Have I closed the door?"

In the majority of the population are present this type of thoughts, however, some perceive this mental event as unpleasant and uncontrollable.

This discomfort generated by these cognitions, produces the need for the subject who experiences them to do something to reduce or eliminate it. That is when it becomes problematic and we could talk about the Obsessive-compulsive disorder .

When a person experiences these intrusive mental events as something that causes him so much anxiety that interferes with his daily life, it is when we would be talking about OCD.

Until DSM-IV, obsessive-compulsive disorder was placed within the category of anxiety disorders. In the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), obsessive-compulsive disorder has been set up as an independent diagnostic category.

When this disorder is not treated, the course is usually chronic and episodic. Sometimes, the worsening coincides with a Decreased mood . The number of spontaneous remissions is lower than in the anxiety disorders .

The usual onset of this disorder is usually late adolescence and early adulthood. However, this disorder may also occur in children.

Characteristics of Obsessive Compulsive Disorder

The most frequent obsessions in children and adolescents are those of contamination and obsessive doubts. Although religious obsessions can also be found to a lesser extent.

The most frequent compulsions that are executed to neutralize the discomfort that the obsessions produce are the washing of hands, the symmetry, the repetition, the avoidance and the mental rituals.

The pollution obsession is more a sensation than the child describes an elaborate thought. The child feels uneasy when he touches certain objects that he considers contaminated and often say things like"he has bugs","I feel disgust".

If the child touches this object that he considers contaminated, or if he doubts if he has touched it, he would wash it until he"feels clean".

Sometimes the compulsion to wash does not arise from the fear of contamination, but from a thought that something bad is going to happen to him or someone in his family and that when washing is neutralized. This is more in the line of superstitious obsessions-compulsions.

The content of obsessive doubts is usually about whether it has caused harm to the other. In these cases, the compulsion may be to try to review all the steps you have taken to make sure that what you fear has not happened or, it could also be asking someone close if you convince them that nothing bad has happened.

Regarding religious obsessions, they are not as common as the previous ones. In these situations, the child tries to neutralize them through prayer or developing a mental image to eliminate obsession.

The characteristics of obsessive thoughts are:

1. They are Repetitive And disrupt mental activity, producing a high level of discomfort and functional deterioration.
2. Thoughts are usually Stereotyped , Simple, unstructured and often appear the same way.
3. They are Egodistonics (Unpleasant or repulsive) of obscene and / or violent content. Although they sometimes take the form of an obsessive doubt about issues that are not important to prevent decision making.
4. In many cases they are perceived as Absurd . It is necessary to determine the degree of introspection that has the subject, that is to say the degree of credibility that the subject gives to the beliefs. For this, we must identify whether the subject has a good or acceptable introspection, little introspection, or lack of introspection or delusional beliefs.

The hypotheses

There is a continuous flow of thoughts in our mind. This is a survival system that we humans have to keep the brain active in any event.

The thoughts that we have are of diverse content, and there are times that can be about violence, sex, death, etc. Most people who experience this type of thinking do not try to do anything to eliminate them or to lessen the discomfort that produces this mental content.

However, some people, faced with an intrusive thinking of these characteristics, experience high levels of anxiety. This somewhat discomfort leads them to do something to feel better.

This behavior they perform to alleviate the discomfort of intrusive thinking or to eliminate the likelihood that whatever they think happens we call it compulsion. When a person starts the compulsion, in the short term he experiences relief.

However, this seems to reduce the discomfort, is the factor that maintains the problem in the long term, since it does not allow the person to verify that what he fears does not happen.

In addition, whenever this mental content is experienced as disagreeable, the person will implement this strategy, and in this way the sequence is automated, consolidating the obsession-compulsion circuit.

It is possible that the ritual becomes more and more sophisticated and complex as the disorder is more consolidated and the history of the problem is longer.

Assessment of Obsessive Compulsive Disorder

In order to perform a treatment for OCD the essential thing is to carry out an exhaustive evaluation of the disorder.

For this, it is necessary to gather information through the different evaluation tools such as the interview, questionnaires and self-registers.

To know the operation of the disorder we must inquire about:

• Onset of disorder, premorbid characteristics, family history of psychological disorders (especially of father, mother and siblings), previous treatments.
• What situations, objects or people trigger obsession.
• What situations make it worse or lessen the discomfort.
• Level of discomfort or discomfort produced by thought.
• Degree of irrationality of thought.
• Intrusiveness of thought and attribution to one's own mind.
• Frequency and duration of thought.
• Duration of the obsession.
• Degree of control of obsession.
• What is the compulsion and to know topographically the conduct of exhaustive way.
• Description of impulsive behavior.
• Ritual nature of behavior.
• Neutralizing purpose of the action.
• Degree of discomfort or discomfort produced by the action or ritual.
• Frequency and duration of ritual.
• Degree of introspection.
• Resistance and degree of control of compulsion.
• Level of discomfort when avoiding compulsion
• How the disorder has affected family life. In some cases, the family adapts to the problem and alleviates the child's discomfort, at other times, the compulsions are annoying and generate family tensions.
• Degree of interference in the child's life and in the family.

The information can be obtained from the parents of the child, the teachers and the child. From the age of 8, children are able to provide accurate information about their emotions, thoughts and impulses.

Questionnaires and clinical scales

There are different useful scales that can provide us with information about obsessive compulsive problems:

CY-BOCS-SR (CHILEY-BROWN OBSESSIVE-COMPULSIVE SCALE-Self Report)

This scale comes from a semi-structured interview called CY-BOCS for adults.

The version for children, consists of two parts differentiated.

The first part of this scale consists of definitions of 66 obsessions of diverse content (pollution, aggression or damage, sexual, symmetry-order-accuracy and others) and compulsions (washing-cleaning, checking, repetition, counting, Magic, superstitious, rituals involving other people, etc.)

In the second part the person must answer based on his main obsession to five questions. Through these questions the severity, duration, frequency and degree of interference are evaluated.

OCI-CV (OBSESSIVE-COMPULSIVE INVENTORY-Child Version)

It is the obsessive-compulsive inventory for children and adolescents. This scale consists of 21 items that evaluate various types of obsessive-compulsive behaviors.

This test gives us a general index on obsessive-compulsive symptoms and scores on six scales:

• Doubts-checking
• Obsessions
• Accumulation
• Washed
• Order
• Neutralization

Psychological treatment

The treatment of choice for obsessive-compulsive disorder is Exposure with Response Prevention. In the case of children and adolescents it is necessary to adapt to the age of the patient and use means and resources to facilitate the treatment.

First Phase: Understanding the hypothesis

The first phase of treatment is for the family and the child to understand the OCD hypothesis.

For a child or adolescent to overcome OCD, it is necessary for the adults in their environment to support the intervention as it provides therapeutic help and helps the patient carry out the tasks.

Parents generally facilitate the intervention and help to implement the guidelines or therapeutic tasks that are proposed.

Understanding the hypothesis of the problem leads to greater adherence to treatment, since the child and his / her relatives understand how the problem works and why it is maintained in the present. This will understand how you will work from the therapy to act on the problem.

Phase 2: Exposure with Response Prevention

Treatment consists of Exposure with Response Prevention. This procedure consists in confronting the situation without initiating the neutralizing behaviors, that is, exposing ourselves to obsession without initiating rituals, distraction or reassessment.

For this reason, it is important to know what the compulsions that the child puts in order to eliminate them.

First of all a hierarchy will be elaborated according to the level of discomfort that the different situations generate to him.

This hierarchy of situations will be called"missions"that the child must fulfill, as if he were in a video game and should go to the next screen.

It is advisable to adapt to the games that the child knows to understand the simile. In this way, the child will gradually face the feared situations. These situations are ordered according to the degree of discomfort that they generate.

Each situation will be called missions that the child must meet. These missions will be to expose yourself to the situation without using the strategies you used in the past to alleviate the discomfort.

We can explain that sometimes the missions can be difficult and that can cost us, since we have become accustomed to that when we have been very nervous we have always tried to calm down.

But our mission is to wait until this discomfort disappears without carrying out the behaviors we have defined.

Both the professional working with the child and the parents should reinforce the attempts of coping and courage that the child manifests.

Parent collaboration in treatment

Although the main cause of OCD is the child, the family members also suffer from the disorder.

The main thing is that the child's environment understands what the problem is, how it works, why it is maintained and how they should act in the face of the difficulties they may face.

Parents become co-therapists and help children cope with the missions they are offered from psychotherapy.

It is essential for parents to understand how much effort each person, and especially a child, faces in facing the dreaded situation without implementing relief strategies, that is, doing the Exposure with Response Prevention.

It is usual for the infant to adapt to the problem of the child. For example, if the child is afraid of being contaminated by dirt on the cutlery, the family, before serving the food to him, performs a thorough cleaning of the cutlery so that his child feels safe and can Eat quietly.

In this way, we have unwittingly become complicit in the problem. Little by little we must eliminate these rituals that have been incorporated into the family as the psychologist says.

The role of parents in treatment is key, since they have to act as Motivational agents , Encouraging the child to confront these situations and praising any attempt at coping.

In addition, the parents will be the ones who inform the professionals of the progress, of the relapses, of the difficulties and if the missions are carried out or not.

In order for parents to be able to record progress, it is the job of the practitioner to instruct them not to focus only on the most striking behaviors, taking away from others that do not cause problems in family dynamics but are equally important to the problem.

The end of treatment: relapse prevention and achievement maintenance

When the missions have been overcome and the treatment comes to an end it is important to relapse prevention and maintenance of achievements.

For this, the psychologist together with the child and the family must raise a series of hypothetical situations that could generate a relapse. In this way, we advance them to future problems.

When we list a number of situations that could lead to relapses, we focus on how we are going to detect that the problem is starting again. For example, when the child is tempted to initiate ritualistic behavior.

Relapse prevention also aims to raise the strategies the child has learned to implement in the wide range of situations that could trigger the problem again.

At this time, parents are instructed to observe if all is well for very young children.

Clinical sessions are spaced out and follow-up sessions are conducted where the psychologist checks that the results are maintained and that the person is provided with preventive strategies to put them in gear for the future.

It is important to leave a line of communication open between the family and the therapist, since in this way you do not have the feeling that the relationship with the psychologist is over.

Symptoms of Obsessive Compulsive Disorder

Obsessions

Obsessions are thoughts, images, ideas, or recurrent thoughts that the person experiences as intrusive, undesirable, and egodistonic. Obsessions often appear and can not be controlled.

This feeling of lack of control generates unpleasant emotions such as anxiety, disgust and guilt. Obsessions can be verbally formatted as phrases, words, speeches, or in image format.

Obsessions often revolve around the possibility of danger, damage, or responsibility for causing danger or harm to others.

The content of obsessions usually includes aggressive actions, contamination, sex, religion, making mistakes, physical appearance, illness, need for symmetry or perfection, etc.

Compulsions

Compulsions are repetitive voluntary motor or cognitive behaviors or mental acts that the person performs as a response to their obsessions as a deliberate attempt to eliminate it, eliminate the probability of the feared event, and / or lessen the discomfort generated by the obsession .

Over time compulsions tend to become longer and more sophisticated and are carried out following very specific guidelines.

Sometimes rituals or compulsions have a logical connection to obsession, for example someone who is afraid to become contaminated, has a compulsion to wash his or her hands.

On the other hand, there are times when logic does not follow or at least there seems to be less connection. For example, in the face of an obsession with violent content, I have to hit the ground three times to prevent it from happening.

Rituals

Rituals can be overt behaviors but they can also be mental or covert. It is important to differentiate obsessions from covert rituals.

The difference between an obsession and an undercover ritual is:

• Concealed rituals are always voluntary: the person generates at will a compulsion to alleviate the discomfort he generates. They are not experienced as intrusive. Obsessions cause discomfort and are experienced as uncontrollable and intrusive.
• Obsessions generate discomfort and rituals reduce or eliminate discomfort.
• Obsessions seem to have no end while rituals have beginning and end.

The compulsions or rituals we encounter are:

• Visible Rituals : It is the motor rituals performed by the individual to alleviate the discomfort and prevent the misfortune he fears from happening, for example, washing his hands, checking the state of things, etc.
• Distraction : Try to think voluntarily in other things to neutralize the obsession, for example, to focus on listening to music.
• Undercover Rituals : It is the mental rituals that are done to try to restore the obsession, for example if a person thinks about drowning their child, the hidden ritual could be to remember a scene of his son having a good time.
• Avoidance : Avoid situations (places, objects or people) that can trigger obsessions.
• Reinsurance : People use others around them to confirm the doubt that causes them discomfort. For example,"Are you sure that I have saved it?".

And what experience do you have with OCD in children?

References

1. American Psychiatric Association (2014) DSM-5 Diagnostic and Statistical Manual of Mental Disorders. Pan American.
2. Gavino, A. and Nogueira, R. (2014) Treatment of OCD in children and adolescents. Pyramid.
3. Pastor, C. and Sevillá, J. (2011) Psychological treatment of hypochondria and generalized anxiety. Behavioral Therapy Center Publications.
4. Salcedo, M., Vásques, R and Calvo, M. (2011) Obsessive compulsive treatment in children and adolescents. Rev. Colombi. Psychiatry. 40, 1, 131-414.
5. Vargas, L.A., Palacios, L., González, G. and de la Peña, F. (2008). Obsessive-compulsive disorder in children and adolescents. An update. Second part. SciELO 31, 4.