Name the topic
often underrecognized and underdiagnosed in youth, in part due to lack of patient lack of desire to seek help. First study in this topic ~20yrs ago
1-2% prevalence, genetic basis, PANDAS
Bimodal distribution in preadolescent children and young adults (mean age 21yo)
symptoms less pronounced later in life
Epidemiology
repeated exposure associated w decreased anxiety across graded exposure trials
Exposure/response prevention
Response prevention: provide adequate exposure and then blocking negative reinforcement effect of rituals or avoidance behavior, graded exposure
May cause difficulty treating patient
target OCD first → decrease anxiety contributing to symptoms
DMDD or other disruptive behavior disorders, ODD
especially in the setting of misuse or overdose, SSRIs safer and more well-tolerated than
TCAs
should come with an evaluation of the pediatric patient's medical condition and cardiac status, along with investigation of personal or family history of heart disease.
Preadolescent starting dose: 2.5-10mg
adolescent starting dose: 10-20mg
typical dose range (mean dose RCT): 10-80 (25mg)
Prozac
74% of youth w OCD meet criteria for at least one of these things; lower treatment response and remission w CBT
Those without have success rate over 70% w SSRI use
Comorbidities
May include DMDD, mood, eating, body dysmorphia, trichotillomania, nail biting, excoriation spectrum
Decrease in response with patients with comorbid ADHD (56%), tic disorder (53%), or oppositional defiant disorder (39%)
When possible, this the first line treatment for mild to moderate cases of OCD in children
Numerous studies have consistently shown its acceptability and efficacy
CBT
important to identify before the initiation of an SSRI
these pathologies may affect CBT treatment effectiveness and overall improvement for patients of all ages
Mood disorders
Increases of initial doses
every 3+ weeks
Takes 12 weeks for substantial benefits, yet may take 6 to 12 months for full effect
Preadolescent starting dose: 12.5-25mg
adolescent starting dose: 25-50mg
typical dose range (mean dose RCT): 50-200 (178mg)
Sertraline
Family studies shown OCD = genetic basis
Monozygotic twin studies show higher rates of OCD than dizygotic twin studies
Higher risk of OCD in 1st0 family members, especially those w OCD in childhood
Glutamate receptor/modulating gene associated w dev of OCD
Pediatric Autoimmune Neuropsychiatric Disorders (PANDAS): an immune response to group A β-hemolytic streptococcus (GABHS) infections, causing a cross reactivity with, and inflammation of basal ganglia, w distinct neurobehavioral syndrome
Includes Sydenham chorea, a consequence of rheumatic fever; includes OCD, tics, and hyperactivity
Etiology
Although Medications for OCD in child and adolescent patients began with clomipramine in 1989, Subsequent trials gained approval for this type of medication
SSRIs
less common in children w OCD, may become more frequent during adolescence
medical considerations must be stabilized prior to mental health interventions
eating disorders
medication can be gradually withdrawn over several months at this point, however
After 2-3 relapses of at least moderate severity, consider longer-term treatment
After stabilization for 6 to 12 months
Preadolescent starting dose: 12.5-25mg
adolescent starting dose: 25-50mg
typical dose range (mean dose RCT): 50-300 (165mg)
Fluvoxamine
Children's Yale-Brown Obsessive-Compulsive Scale (CY-BOCS) - use "worst-report algorithm" to be most accurate - combine positive findings from interview and scale
others - Leyton Obsessional Inventory; Ten Year Review of Rating Scales II for Internalizing Disorders; anxiety - Anxiety Disorders Interview Schedule for Children, Pediatric Anxiety Rating Scale, the Screen for Child Anxiety Related Disorders, and Multidimensional Anxiety Scale for Children
Symptom Rating Scale
2004 Study with Participants that were randomly assigned to receive CBT alone, sertraline alone, combined CBT and sertraline, or pill placebo for 12 weeks.
CBT alone did not differ statistically from sertraline alone initially, was superior for the remission rate
CBT and sertraline combination were better than placebo
Long-term studies on Sertraline suggested a cumulative benefit with gradually decreasing scalar scores and increasing remission rates for up to one year
Pediatric OCD Treatment Study (POTS) randomized controlled trial
Usually NOT preceded by specific cognitions (obsessions) - more like a sense of tension that is general or localized
Behavior is often a source of (temporary) gratification but may be followed by remorse and shame and mainstay of treatment is Behavioral therapy not SSRIs
“spectrum” of compulsive/impulsive habit disorders include trichotillomania, compulsive nail biting, skin picking, and other forms of self-injury
Increased risk of increased suicidal behavior remains a concern;
Should be noted that no suicides occurred in any of the pediatric randomized controlled trials of SSRIs.
Black Box Warning
Preadolescent starting dose: 2.5-10mg
adolescent starting dose: 10-20mg
typical dose range (mean dose RCT): 10-60
Citalopram
Symptoms can progress over childhood with developmental themes that may distinguish them from adults
In young children, often unable to verbalize symptoms and compulsions may be exhibited without clear obsessions and/or rituals other than typical washing, repeating ordering, counting or checking
Majority will have many obsessions and compulsions over lifetime
No consistency with nature, age, or gender, but often revolve around catastrophic family event like death of caretake
M>F ratio occurrence in younger ages; usual onset age 7-13
Clinical presentation/phenotype
do NOT seem to directly alter OCD symptoms, BUT rather help to encourage exposure and so produce an indirect, clinical benefit
Positive reinforcements, Rewards
Punishment is unhelpful
usually starts in adolescence, but possibly sooner, when developmental pressure increases regarding appearance
Body dysmorphic disorder
Whereas behavioral side effects are more common in younger children, such as behavioral activation, Peripubertal children exposed to antidepressants are at higher risk of ____?
Conversion to mania
Preadolescent starting dose: 6.25-25mg
adolescent starting dose: 25mg
typical dose range (mean dose RCT): 50-200mg
Clomipramine