Did you know that Obsessive Compulsive Disorder (OCD) affects 2-4% of adolescents and that 80% of people who have OCD experience symptoms before age 18?
It is important to point out that most mental health challenges start in childhood.
I value science and the need for a uniform way of discussing mental health, yet feel the term “disorder” (when discussing mental health) really puts a distance to someone embracing their “neurostyle”. We need to identify children who need extra mental health support and integrate wellness thinking and acceptance of neurodiversity in our society. Let’s discuss OCD now.
Did you know that the World Health Organization (WHO) ranks OCD as one of the ten most disabling diseases?
The OCD cycle usually starts with an environmental trigger that leads to an obsession described as intrusive, repetitive, negative images, thoughts or impulses. This causes distress as manifested by anxiety, fear, disgust or shame, followed by compulsive behavior as represented by repetitive thoughts, images, or actions.
The OCD cycle
(Trigger >>Obsession >>Distress>>Compulsions >>Negative Reinforcement)
It is a myth that OCD is an Adult disorder.
The two common onset peaks for OCD include earlier for boys that have the triad of OCD, ADHD and Tic disorder, and early puberty for girls.
In child psychiatry it is common for children to present with more than one behavioral disorder. OCD exists in combination with one other behavioral problem ¾ of the time and with multiple problems 1/3 of the time.
How do we identify and begin to treat OCD?
A diagnostic interview is done which includes parent and child interviews, a review of rating scales, report cards and if OCD is present a clinician scores the severity of OCD with the Yale-Brown Obsessive Compulsive Scale (YBOCS). The 10-item (each item rated from 0 (no symptoms) to 4 (extreme symptoms) Y-BOCS scale evaluates the severity of obsessions and compulsions separately and is the standard scale used in treatment outcome studies of obsessive compulsive disorder (OCD). The severity of OCD is based on total core: 0-7,is subclinical; 8-15 is mild; 16-23 is moderate;24-31 is severe; 32-40 is extreme.
Do you want to know the good news? Pediatric OCD is usually responsive to treatment with the goal of a score of <8 on YBOCS .
“Exposure therapy is the secret sauce in treating OCD,” UCLA Scientist and Professor James McCracken M.D. would say during our child psychiatry clinic. Exposure therapy is a behavior therapy that involves the exposure of the patient to the feared object or context without any danger in order to overcome their anxiety. An example would be an individual with fear of contamination. The exposure would be putting their hands in dirt and not allowing them to wash their hands for a period of time. The patient ranks their fear level before and after the exposure and realizes that the fear reduces over time after exposure.
The first line treatment for OCD is Cognitive Behavioral Therapy with Exposure and Response Prevention (ERP).Children who lack insight, have ADHD or depression, have a family history of OCD, or high family conflict tend to have challenges with response to behavioral therapy alone. From a medication standpoint the Selective Serotonin Reuptake Inhibitors are the first line of treatment, the four FDA approved SSRI”s are Clomipramine, Fluoxetine, Sertraline and Fluvoxomine.
The well known POTS study (Pediatric OCD TREATMENT STUDY JAMA 2004:292(16) reveals that combination treatment was consistent with a 53.6% remission rate and CBT alone 39.3%, Zoloft alone 21.4%. It was also noted that those with family history of OCD had more than a 6 fold decrease in response to CBT alone.
Combination therapy yields the best results for moderate to severe OCD.
Let me give you a clinical example of a sixteen-year-old girl, Christina (pseudonym) who I worked with whose trigger to her obsessions was watching television and witnessing motor vehicle accidents, or driving over speed bumps. Her obsession was that she had fatally harmed someone as her obsessive image and thought. Her compulsive behavior was getting in the car and retracing her route to make sure she had not actually injured someone. She would call hospitals to make sure no one had been hurt. She came to see me for help with her OCD.
Her YBOCS score was in the extreme range (>32). She did not respond initially to CBT-ERP alone. A combination of Prozac and exposure therapy yielded great success for Christina! Her YBOCS was less than 8 within a year of treatment. She and I drove in her car and we would ride over bumps and not go back to the site to see if anyone was ok or call hospitals to make sure no one was in the emergency room. Christina is now in her mid twenties successfully working and is not on any medication for OCD! She utilizes her tools from therapy, exercises regularly, eats healthy and meditates routinely. This is a great thrive story-right? This is why I love what I do.
As a Child Psychiatrist I see a lot of children struggling with different types of anxiety: Separation Anxiety, Generalized Anxiety, Social Anxiety. The symptoms of each above often “travel together” and are persistent into the adult years which can lead to other more serious challenges such as substance abuse and other mood disorders.
Here’s the good news:
We have great treatment options and can provide early intervention so that your child can thrive!
Here is the data to back this up:
The Child/Adolescent Anxiety MultiModel Study (CAMS) (Dr. JT Walkup in 2008) revealed greater than 2/3 of the children with anxiety had two or more types of anxiety listed above. *This is the largest existing anxiety study to date.
The data revealed combination therapy (Cognitive Behavioral Therapy [CBT] and sertraline combined) which showed an 81% response! Therapy alone revealed a 60% response and medication alone a 55% response rate.
Source:Walkup JT,et al, NEJM 359:2753-2766,2008
This is amazing, right?
The bottom line is that you should always start with cognitive behavioral therapy as the first line of treatment for childhood anxiety symptoms. For complex and severe situations medication and cognitive behavior therapy together capture a great response.
What is CBT?
Cognitive behavior therapy is one of the few forms of psychotherapy that has been scientifically tested and found to be effective in hundreds of clinical trials for many different disorders. In contrast to other forms of psychotherapy, cognitive therapy is usually more focused on the present, more time-limited, and more problem solving oriented. In addition, patients learn specific skills that they can use for the rest of their lives. These skills involve identifying distorted thinking, modifying beliefs, relating to others in different ways, and changing behaviors.
How can we as a society have less suffering and more “mental wellness”?
I believe parents, teachers, and pediatricians are on the “front line” to be able to recognize anxiety. If you are a parent reading this ask yourself: “Is there anyone in my family who was a “worrier”? Any relatives with difficulty in social situations?” “Did I have troubles separating from my Mom as a kid?” Many families have a history of anxiety. Usually you see a child psychologist, or a child psychiatrist if there is moderate to severe impairment at school, home, or socially.
If you are a teacher you can give information to the parents at parent-teacher conferences with examples of the ways a student might be shy, socially challenged or perfectionistic. I know that a lot of teachers share their observations, which can prompt a parent to be aware of any need for further help.
I have been very impressed with the pediatricians I work with that are providing early screening for anxiety. I am so happy to see routine questionnaires being given to detect any outlier anxiety or other behavioral issues.
When treating these disorders, I include the importance of nutrition, daily exercise, and daily meditation. It is common sense to limit sugar and teach kids to listen to their bodies to know when they are full or hungry. Kids thrive when they move! A sport, PE, or good old fashioned hide and seek can burn calories and reduce stress.
I am a strong believer in teaching our kids meditation.
I recommend starting with ten minutes a day with the goal of twenty minutes as a lifetime daily habit. I like simple solutions. What if every school in the World included a ten-minute “quiet time” for meditation right after lunch? This is possible and I am committed to implementing these types of important programs into our schools, not only because of the proven research but also the results I’ve seen are life changing.
In summary, childhood anxiety is common and can be treated effectively. Cognitive behavioral therapy is first line treatment. Combined treatment yields 81% response. Prevention of substance abuse and mood disorders can happen if early intervention happens!
I have a confession to make. The word disorder is like nails on a chalkboard to me when discussing the way someone processes or perceives the world. We are all neurodiverse. I value an organized and scientific way about talking about human behavior, I just do not view my patients as “disordered.”
I am not alone in feeling this way. The movement in Western medicine is shifting from illness to patient centered care defined by the Institute of Medicine as “care that is respectful of and responsive to individual patient preferences, needs, and values and ensuring that patient values guide all clinical decisions.”
I could not start discussing ADHD without making this point. I do not view you or anyone as disordered. We all have our own unique “neurostyle.”
Ok. Let’s discuss ADHD.
The first thought that comes to my mind when I am on the phone with a parent who is making a first appointment about “focus issues” for their child is: “It is going to be ok. No problem. Your kid is going to learn about the way he/she processes information and deals with frustration. School and life in general are about to get a whole lot better.” Before a family walks through the door I have spoken to them on the phone to set the stage for wellness. I let them know that my goal for their child is to spend the least amount of time in my office while gaining the tools to thrive. Kids should be at soccer or out playing with their friends.
The same mindset holds true for the adults I assess. If medications are needed, I prescribe the least amount possible for improved focus and impulse control while preserving an individual’s creativity and spirit. Adults want to thrive too!
The evaluation of a child for ADHD includes a psychiatric interview and collecting and reviewing data from multiple sources. Data gathering includes rating scales from parents, teachers and the child, report cards (from preschool to current age of the child), standardized testing results, and any other psychological or other type of evaluations that have been done. A recent physical exam with a full medical workup is essential to rule out or understand any medical issues that can contribute to focus issues. The clinical interview is approximately two hours as the child and the parents are interviewed separately. Input from any tutors, grandparents, and childcare providers are all taken into account.
An evaluation of an Adult for ADHD includes a clinical interview, a review of rating scales and input from someone close to them about their behavior as well as any other evaluations and a medical workup. If adults have access to their childhood report cards they are reviewed as well. All forms of data are important.
The initial connection to the patient and their family is the most important step. If someone trusts you they will be able to give you “the bottom line” as to why they are there and leave the shame at the door.
In making the diagnosis of ADHD you need six or more symptoms for children and five or more for age 17 or over:
ADHD – Predominantly Inattentive Presentation
- Fails to give close attention to details or makes careless mistakes.
- Has difficulty sustaining attention.
- Does not appear to listen.
- Struggles to follow through on instructions.
- Has difficulty with organization.
- Avoids or dislikes tasks requiring sustained mental effort.
- Loses things.
- Is easily distracted.
- Is forgetful in daily activities.
ADHD – Predominantly Hyperactive/Impulsive Presentation
- Fidgets with hands or feet or squirms in chair.
- Has difficulty remaining seated.
- Runs about or climbs excessively in children; extreme restlessness in adults. Difficulty engaging in activities quietly.
- Acts as if driven by a motor; adults will often feel internally as if they were driven by a motor.
- Talks excessively.
- Blurts out answers before questions have been completed.
- Difficulty waiting or taking turns.
- Interrupts or intrudes upon others.
ADHD – Combined Presentation
- Individual meets both sets of inattention and hyperactive/impulsive criteria.
As an Integrative Psychiatrist I embrace Western Medicine coupled with all paths to wellness. The biopsychosocial treatment plan is coupled with a Spirit/Mind/Body approach that focuses on mental wellness, not mental illness. The severity of symptoms and a multidimensional understanding of the patient determine whether or not medication will be recommended in adjunct to behavioral therapy and other modalities of treatment.
Did you know? It is speculated that some of the most creative, intuitive and brilliant entrepreneurs and scientists had ADHD. Just google it. I am not saying that everyone with ADHD is brilliant. I am saying that the ability to access “non-linear” information is essential for creativity and invention. This is why it is important to be properly assessed and not overmedicated. We all want to be the best version of ourselves!
Be empowered. Be educated. Know all of your options for thriving with any focus or behavioral challenges. Find someone who will embrace your neurostyle – no matter what!
You know what I love? Kids and Adults who reach their fullest potential. Do you know how cool it is when I get a card around the holidays with someone’s report card with high marks due to high effort? Or a top realtor has tripled their sales due to improved focus?
That is the reward and honor of helping to facilitate your “A” game!
Child Psychiatry Crisis’ come in many flavors. I am going to list some of the most common chief complaints I experience from the parents of my patients:
“My son’s grades went from B’s to D’s & F’s. We have done everything. Tutors. Therapy. Help!”
“My daughter is complaining of stomach aches. She has missed almost a month of school. The pediatrician has ruled everything out. I tend to have some anxiety and it is heartbreaking to see her suffer like this.”
“My son is just not able to keep up in school or socially. He also is having trouble making friends. Therapy is helping a bit yet we need to figure this out.”
“My daughter was always a good eater until she took this nutrition class. She always likes to be perfect and she followed the nutrition tips to the point now where she is counting calories, has lost 15 lbs, and will not eat at the dinner table with us.”
“My kid was bullied last year. We were hoping a break from that group would help. It started again. He is sad. He wants to change schools now.”
Do you know how hard it is for someone to call a Child Psychiatrist for his or her child? Really, really hard. Parents often tell me that they waited three to six months to make the call. They report: “I was just hoping it would be a phase.” They also mention that they think calling me means: “I have to put my child on meds.”
I make it very clear that is always done based on clinical presentation (severity and true indication) and that I would choose all other modalities of wellness before going the medicine route.
By the time someone calls me they have already tried therapy, tutors, nutrition changes. You name it. Parents want their child to thrive. So do I. You can see that a Child Psychiatrist is usually the last line of defense.
When the call comes in a child is usually in crisis. I educate parents about the process of the evaluation and clearly state: “My goal is to prescribe the least amount of doctors appointments and the least amount of medications. The end point is for your child to move out of crisis, feel empowered and thrive.”
My patients thrive. Bottom line. It does happen.
I spend time on the phone before a family comes into my practice so patient education and therapeutic intention is known. My patient, their parents and myself are going to all be working towards thriving and mental wellness. I set that expectation and hold them accountable for engaging in their life and treatment. I am a Doctor and a Facilitator of Wellness. I believe that everyone needs to realize how powerful and important their thoughts, actions and behavior are.
I validate the “illness” part of suffering yet explain that our thoughts and word choice are an essential part of the “fast track to wellness.” I use language that is appropriate for each age group. I embrace Western medicine coupled with all paths to wellness. I practice with an open mind and heart and this leads to the best outcome for my patients.
If you are seeking a doctor for you or your child it is important to know if they are well trained, compassionate and empathic.
How do you figure this out? You get to spend time with them. You listen carefully to not only the facts they educate you with but how they deliver the information. Do you feel like they want you to be well? Are they treating you like a person and not like you are a “walking target symptom”? Do they make eye contact when they are talking to you? Do they listen to your viewpoint?
The key to going from crisis to thriving is the belief in your ability to get well, the belief in your doctor’s expertise and empathy, and your determination to follow the outlined path to wellness and “engage” in your health.
We as Child Psychiatrists have the data to utilize medication, cognitive behavior therapy and other indicated treatment modalities thanks to our “Academic Mental Health Warriors.” I want to express gratitude to my colleagues at UCLA and Emory University and all of the “Pioneers of Child Mental Health” that have been doing the clinical trials to gain the knowledge and data we have at this point in history.
When you or your loved one is going through a crisis, remind yourself or them that on the other side of that is stabilization and that everyone has the ability to maintain a place of thriving.
We all want what is best for our children. I want to take it a step further and push the envelope of wellness. As a society we need to embrace mental health and wellness in every environment. We need to be proactive not reactive. We all thrive when individuals thrive.
Focus on the end point of THRIVING – not just the current crisis. Take that first step and look at the areas in your life that make you feel energized. Ask yourself, how can I create my best life? Make a list and begin to focus on those things. With the right support, the right plan, you will begin to turn your life around and thrive.