Diagnosing Childhood OCD

Careful diagnosis and case conceptualization are central to effective treatment planning. However, diagnosis can be complicated when working with children and families. In addition to knowledge about diagnostic criteria, diagnosis relies heavily on clinicians’ ability to identify, conceptualize, and differentiate a range of symptoms in order to generate a successful treatment plan. There are a number of important considerations when diagnosing and differentiating obsessive-compulsive disorder (OCD) in children and youth. This chapter will discuss four key areas and skills that are central to a developmentally sensitive assessment of OCD. This chapter will (1) outline how to apply the diagnostic criteria for OCD to youth, including how to differentiate age-normative and pathological rituals; (2) review common OCD symptom presentations in youth; (3) provide clinical guidance on how to conceptualize and differentiate OCD symptoms from symptoms of anxiety and other psychopathology, particularly in the context of overlapping symptoms; and (4) highlight complicating factors to consider when assessing and diagnosing OCD in children and adolescents

One session treatment for specific phobias : an adaptation for paediatric blood–injection–injury phobia in youth

Blood–injection–injury (BII) phobia is a chronic and debilitating disorder, which has largely been neglected in the child literature. The present paper briefly reviews the aetiology of specific phobias with particular attention to BII and provides an integrated developmental model of this disorder in youth. Evidence-based treatments for child-specific phobias are discussed, and the development of a modified one session treatment (OST) approach to enhance treatment outcomes for BII phobia in children and adolescents is described. This approach is illustrated in two children with a primary diagnosis of BII phobia. The cases illustrate the unique challenges associated with treating BII in youth and the need for a modified intervention. Modifications included addressing the role of pain (e.g., psychoeducation, more graduated exposure steps) and disgust (e.g., disgust eliciting exposure tasks) in the expression of the phobia and fainting in the maintenance of this phobia. Moreover, it is recommended that parents be more actively involved throughout treatment (e.g., education session prior to OST, contingency management training, guidance regarding planning exposure tasks following treatment) and for families to participate in a structured e-therapy maintenance programme post-treatment.25 page(s

Treatment of aggressive obsessions in childhood obsessive-compulsive disorder

In this chapter, we discuss aggressive obsessions, which are obsessions related to violence or harm towards the self or others. Aggressive obsessions are highly distressing and prevalent, with reports of 30 to 70 % of youth obsessive-compulsive disorder (OCD) sufferers experiencing these symptoms. We outline the phenomenology and background literature on aggressive obsessions and then describe the case of a 16-year-old male experiencing aggressive obsessions. Case conceptualization, assessment, and treatment using cognitive behavioural therapy with exposure and response prevention are presented, followed by a discussion of complicating factors, conclusions, and key practice points.21 page(s

One session treatment for specific phobias in children : comorbid anxiety disorders and treatment outcome

Background and objectives: One-Session Treatment (OST) for specific phobias has been shown to be effective in reducing phobia severity; however, the effect of different types of co-occurring anxiety disorders on OST outcomes is unknown. The present study examined (1) the effects of co-occurring generalized anxiety disorder (GAD), social anxiety disorder (SAD), or another non-targeted specific phobia (OSP) on the efficacy of OST for specific phobias, and (2) the effects of OST on these co-occurring disorders following treatment. Methods: Three groups of 18 youth (7–15 years) with a specific phobia and comorbid GAD, SAD, or OSP were matched on age, gender, and phobia type. Outcome measures included diagnostic status and severity, and clinician rated improvement. Results: All groups demonstrated an improvement in their specific phobia following treatment. Treatment was equally effective regardless of co-occurring anxiety disorder. In addition, comorbid anxiety disorders improved following OST; however, this effect was not equal across groups. The SAD group showed poorer improvement in their comorbid disorder than the GAD group post-treatment. However, the SAD group continued to improve and this differential effect was not evident six-months following treatment. Limitations: The current study sample was small, with insufficient power to detect small and medium effect sizes. Further, the sample only included a portion of individuals with primary GAD or SAD, which may have attenuated the findings. Conclusions: The current study demonstrated that co-occurring anxiety disorders did not interfere with phobia treatment. OST, despite targeting a single specific phobia type, significantly reduced comorbid symptomatology across multiple anxiety disorders.7 page(s

Blood-Injection-Injury phobia and dog phobia in youth : psychological characteristics and associated features in a clinical sample

Blood-Injection-Injury (BII) phobia is a particularly debilitating condition that has been largely ignored in the child literature. The present study examined the clinical phenomenology of BII phobia in 27 youths, relative to 25 youths with dog phobia-one of the most common and well-studied phobia subtypes in youth. Children were compared on measures of phobia severity, functional impairment, comorbidity, threat appraisals (danger expectancies and coping), focus of fear, and physiological responding, as well as vulnerability factors including disgust sensitivity and family history. Children and adolescents with BII phobia had greater diagnostic severity. In addition, they were more likely to have a comorbid diagnosis of a physical health condition, to report more exaggerated danger expectancies, and to report fears that focused more on physical symptoms (e.g., faintness and nausea) in comparison to youth with dog phobia. The present study advances knowledge relating to this poorly understood condition in youth.13 page(s

Parents' perceptions of novel treatments for child and adolescent specific phobia and anxiety disorders

This study aimed to examine parents' perceptions of established treatments, including cognitive behaviour therapy (CBT) and selective serotonin reuptake inhibitors (SSRIs), relative to novel treatments of D-cycloserine (DCS) and attention bias modification (ABM) augmented CBT to determine if novel treatments are perceived as more or less favorable than established treatments. Participants included parents of children with a specific phobia, enrolled in one of two randomized controlled trials of either one-session augmented DCS (n = 38, Gold Coast) or ABM augmented one-session treatment (n = 34, Brisbane), as well as parents from a community sample (n = 38). Parents of children with a specific phobia perceived CBT most favorably. There was no difference between the sites on perceptions of ABM. However, parents of children enrolled in the DCS trial perceived DCS more favorably than parents of children enrolled in the ABM trial and the community sample. These results demonstrate parents' greater acceptance of psychological treatments over pharmacological treatments for the treatment of childhood phobias, highlighting the importance of educating parents to novel treatments.13 page(s

Patterns of response and remission following a One-Session Treatment for Blood-Injection-Injury Phobia in youth

Blood-Injection-Injury (BII) Phobia is a severe and impairing disorder that has been understudied in youth. The present study aimed to define patterns of response and remission following a modified One-Session Treatment (OST) including an e-therapy maintenance program for children and adolescents with BII Phobia. Moreover, characteristics of different responder groups were examined in order to determine correlates of a poorer response. Youth (n = 20; 8–18 years) were categorized into four responder groups (e.g., immediate remitter, delayed remitter, partial responder, and nonresponder) based upon defined criteria for remission. Immediate remitters to treatment were more likely to have a primary diagnosis of injection phobia, rather than a combined blood and injection phobia. Nonresponders reported significantly greater disgust sensitivity at pretreatment and were more likely to have a comorbid diagnosis of Social Phobia. In regards to within session change, youth who achieved the exposure goal of having a blood test during treatment had a significantly stronger treatment response. These preliminary findings may assist clinicians in the planning and delivering of intensive Cognitive Behavioral Treatment (CBT) approaches for BII Phobia in youth.21 page(s

One session treatment for pediatric blood-injection-injury phobia : a controlled multiple baseline trial

The present study evaluated the effectiveness of a modified One Session Treatment (OST), which included an e-therapy homework maintenance program over 4 weeks for Blood-Injection-Injury (BII) phobia in children and adolescents. Using a single case, non-concurrent multiple-baseline design, 24 children and adolescents (8-18 years; 7 males, 17 females) with a primary diagnosis of BII phobia were randomly assigned to a one, two or three week baseline prior to receiving OST. Primary outcome measures included diagnostic severity, diagnostic status, and child and parent fear ratings. Secondary outcome measures included avoidance during behavioural avoidance tasks (BAT), global functioning and self and parent reported anxiety, fear and depression. Efficacy was assessed at post-treatment, 1-month, and 3-month follow-up. BII symptoms and diagnostic severity remained relatively stable during the baseline periods and then significantly improved following implementation of the intervention. Treatment response was supported by changes across multiple measures, including child, parent and independent clinician ratings. At post-treatment 8 of the 24 (33.33%) children were BII diagnosis free. Treatment gains improved at follow-ups with 14 (58.33%) children diagnosis free at 1-month follow-up and 15 (62.5%) diagnosis free at 3-month follow-up. Preliminary findings support the effectiveness of a modified OST approach for BII phobic youth with treatment outcomes improving over follow-up intervals.12 page(s

Brief intensive CBT for pediatric OCD with E-therapy maintenance

Cognitive behaviour therapy (CBT), incorporating exposure and response prevention (ERP), has received strong empirical support for the treatment of paediatric OCD, and moreover, is considered the first line treatment of choice (Geller & March, 2012). However, despite the availability of effective treatments for this chronic and debilitating disorder, only a small proportion of youth receive these evidence-based approaches. The present study aimed to examine the effectiveness of an intensive ERP-based treatment for youth OCD, using a multiple baseline controlled design. Children and youth (N = 10; aged 11–16 years) with a primary diagnosis of OCD were randomly assigned to a 1- or 2-week baseline monitoring condition followed by the intervention. The efficacy of the intensive treatment, involving 1 session psychoeducation, 2-sessions ERP plus e-therapy maintenance was examined across parent- child- and clinician-rated measures at post-treatment and 6-month follow-up. Overall, there were significant reductions across time on almost all measures (except self-report anxiety), and moreover, the majority of the sample (80%) were considered reliably improved, and meeting clinically significant change. At post-treatment, 60% were in remission of symptoms, and at 6-month follow-up this increased to 70%. These findings provide strong support for intensive, time-limited approaches to ERP-based CBT for children and youth with OCD.10 page(s