Presented by: Martin E. Franklin, Ph.D.
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Dr. Franklin discussed the use of CBT techniques in clinical practice with children and adolescents with OCD, and will described adaptations of CBT for use with related conditions as well.
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2. What sort of criteria are you using to diagnose ocd in children? Are not the dsm-iv criteria geared more towards adults? What term do you use for obsessive children who do not fulfill dsm-iv criteria?
We do attempt to apply DSM criteria into diagnosing children, though it is important to recognize that developmental issues may preclude sufficient awareness of obsessional content. We use a formal structured interview to guide diagnosis (e.g., the Kid Mini-International Neuropsychiatric Interview, the Anxiety Disorders Interview Schedule). The DSM-IV criteria are more geared towards adults, although we have had success in applying them to children provided that the interviewer is knowledgeable and that parent data (e.g., parent observations at home) are also taken into account. Most kids with obsessions usually have some either over (e.g., behavioral) or covert (e.g., mental) rituals. In the absence of any rituals, avoidance behavior or passive avoidance behavior, we would need to return to the conceptualization of the thoughts as obsessions.
3. Do you recommend meds while using cog behavior ?
It appears that specific medications (e.g., Selective Serotonin Reuptake Inhibitors) are compatible with CBT and might afford an advantage over CBT alone for some children (e.g., Pediatric OCD Treatment Study Team, 2004). However, there is a wealth of evidence indicating that CBT alone is an effective therapy for pediatric OCD. Clinical factors such as the presence of comorbid depression may dictate the use of combined treatment in some circumstances.
4. Please describe how you apply CBT treatment to trichotillomania. Also, have you observed stimulant medication for ADHD to trigger trichotillomania.
I have seen rare cases in which trichotillomania followed the initiation of stimulant medications for ADHD but the empirical evidence for a causal relationship is weak. CBT can be applied for trichotillomania with greater emphasis on the use of competing responses ro combat strong urges to pull and with a de-emphasis on the role of exposure to pulling cues persay. For a detailed account of the application of CBT for trichotillomania, please see Franklin and Tolin’s 2007 book, “Treating Trichotillomania: Cognitive Behavior Therapy For Hair Pulling and Related Problems.”
5. My son is 12 yrs old and has TS. We are concerned he has OCD as well. Is it common for kids to try and conceal there OCD. He has to sing a certain verse of a song 13 times as he climbs 13 steps on our staircase. I constantly hear him mumuring to himself and finally he admitted this behavior.
It is very common for children to try to disguise their symptoms, especially as they enter into developmental periods where independence is desired. The comorbidity between TS and OCD is quite high and the therapist with experience using CBT procedures with both disorders would be the optimal treatment provider, as there are similarities as well as differences in how these conditions would be approached.
6. My son has to re-trace his “e’s” when writing his sentences, paragraphs (in the 4th grade He has tourettes, OCD and Aspergers). Do I make him write his e’s over and over in a “messy” way to tackle this?”
Ideally, if you could engage your son in a discussion of these behaviors and solicit his opinion about whether he would like to work on reducing this behavior, that discussion may yield a direction to pursue. I am reluctant with all kids to move forward with implementing exposure-based practices without first establishing the child’s willingness to do so. This is especially important for children with Asperger’s since their tolerance for intense emotion may compromise the efficacy of such procedures.
7. My son has been hitting things in rhythmic patterns for years…is this a tic or a compulsion, does it really matter what it is and could CBT help?
CBT could help, and it could matter in that if there is a clear cognitive prompt to these behaviors (e.g. rhythmic tapping will prevent harm) then treatment procedures would differ. In the absence of information about the function of that behavior, it is difficult to distinguish these two possibilities or to rule out other explanations.
8. Do you know the efficacy with CBT with TS? How do the CBT techniques differ to target TS?
There are very similar modifications for TS with those typically made for Trichotillomania in that a competing response would be used in response to strong urges. With respect to efficacy, there is now a growing literature attesting to CBT’s helpfulness for TS (e.g., Cook and Blacher, 2007).
9. In your experience with adolescents what medication do you feel is been sucessful for ocd and tourettes
I am a psychologist, not a psychiatrist, and thus do not wish to make specific recommendations regarding pharmacotherapy. However, the treatment outcome literature supports the efficacy of the Selective Serotonin Reuptake Inhibitors (SSRI’s)for OCD and the efficacy of typical and atypical neuroleptics for TS. However, a child and adolescent psychiatrist who is knowledgeable about the use of these medications in children would important to consult.
10. If you have topics you get fixated on like seeing a particular peson or buying a particular item is that OCD? Not so much fear or repitive behavior as it is a one track mind. He is on guanafacine so his OCD may be under meds. Is being fixated on an idea or getting something OCD? not a fear more a want? from a young age. If things dont go as you picture it and you want people redo things to meet your needs. Who gives you a bottle, food or getting something you want?
Obsessions in OCD invariably involve an intrusive, unwanted component. Other conditions may better explain hyper-focus and cognitive inflexibility and thus a careful diagnostic screening by a well-trained mental health professional would be imperative to establish proper diagnosis and to recommend an appropriate treatment course.
11. How do you help an adolescent who sees their rituals as acceptable and only problematic to others who they think must learn to accept them?
Perhaps by providing examples to the contrary, highlighting the cost to the adolescent of engaging in such behaviors, and by reducing family accommodations that serve to support the OCD at the expense of the adolescent.
12. How can we explain OCD to the siblings without OCD? How can they help their sibling get better?
By providing developmentally appropriate psychoeducation about the nature of OCD, explaining how OCD tangles up families and by emphasizing that their sibling has a medical condition that is not of their own choosing. Siblings can be helpful by treating the affected child with kindness and by seeking advice and support from their parents regarding how best to interact with their brother and sister.
13. At what age and what level of impairment due to OCD would in-patient programs be considered?
Some OCD-specific inpatient programs in the U.S. will consider admissions as young as age eight or nine. Inpatient treatment is typically considered in the context of stepped care whereby less intensive treatments delivered by qualified providers has proven ineffective. Inpatient treatment is usually driven by the development of very substantial functional impairment (e.g., inability to attend school because of OCD).
This discussion has been closed. Thank you to everyone who participated!
What are your top 3 things when choosing a good CBT therapist?
Posted on January 28th, 2010 at 12:04pm by KelleyT