Katherine K. Dahlsgaard, PhD, and Laurel Weaver, MD, PhD
The parents of a 9-year-old shy, socially awkward but historically healthy girl are concerned about recent changes in behavior. For the past 3 months, the child has become increasingly distressed regarding school. She is an excellent student, but now worries about her homework being “perfect” and spends hours erasing and rewriting assignments, often until midnight. Her teachers have noticed that she is having difficulty completing classroom assignments, and cries when there are slight changes in classroom schedules or activities. The parents also report that their daughter has increased concerns about cleanliness, which include showering up to 6 times per day and washing her hands so often that they are cracked and bleeding. When they interrupt these activities, she cries and tantrums for up to an hour, and she is unresponsive to their reassurance.
Her parents brought her to the Emergency Department because she had been crying for hours and saying that she was afraid that she might die if she could not rewrite her homework before falling asleep.
Discussion: S. presents with obsessive-compulsive disorder (OCD), a neuropsychiatric illness affecting about 1% to 2% of children and adolescents. Typical onset of OCD for pediatric patients occurs pre-puberty, with mean onset ranging from 7.5 to 12.5 years. Symptoms emerge gradually over the course of months, as in S.’s case. (By contrast, symptoms are said to have a sudden, dramatic onset in pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections [PANDAS/PANS]).
OCD consists of both obsessions (thoughts, images, urges, or doubts that are experienced as aversive and distressing) and compulsions (repeated behavioral efforts to neutralize, avoid, or escape that distress). Classic examples of obsessions are contamination or causing catastrophic events, with compulsions involving overwashing or repetitive checking (locks, the stove). Sometimes an individual will present with what at first appears as purely obsessional OCD without obvious behavioral compulsions. However, careful assessment will reveal the presence of covert compulsions, such as avoidance of distressing stimuli, mental checking, replacing a “bad thought” with a “good thought,” or seeking reassurance (“Are you sure I won’t get sick?”).
The American Academy of Child and Adolescent Psychiatry (AACAP) practice parameters recommend routine screening for OCD and suggest the process is “straightforward and that simple probes will reveal the great majority of cases.”
OCD can sometimes be difficult to recognize because there are so many variations in symptom presentation. S. presents with two very common forms of OCD, contamination/washing and perfectionism/ scrupulosity, but the following table details some other, less well-known, presentations.
"How do I know I'm not gay?" (in children who are not)
|Avoid looking at pictures of same-gender children, repeatedly seeking reassurance from parents that one is not gay|
|"My body (or a part of my body, such as breath, underarms, genitals) smells really bad." (when it doesn't)||Over-washing, excessive use of perfumes or deodorants, avoidance of getting physically close to others|
|"How do I know I won't deliberately harm my parent/harm my siblings/harm myself?"||Refuse to handle knives or sharp objects, refusal to be alone with someone, refusal to watch movies depicting murder or suicide (lest that "drives" the child to commit the same act)|
|"How do I know I didn't accidentally harm someone else (by bumping into them, running over them in the car)?"||Physical avoidance of others, repeated requests to "drive back around the block" to check for downed pedestrians|
|"If I came in contact with a (usually undesirable) person, I will begin to take on characteristics of that person." (Not a delusion, but a form of OCD known as loss of essence)||Avoiding the person, not breathing in around the person, purging after contact with the person (spitting, etc.)|
Well-controlled, randomized studies with pediatric samples have consistently shown the efficacy of cognitive-behavioral therapy (CBT), specifically exposure and response prevention (ERP). ERP involves helping the child to expose herself repeatedly to the distressing thoughts or situations without engaging in neutralizing compulsions (response prevention). This practice will, over time, result in a decrease of distress via habituation. Reviews have shown ERP to benefit 60% to 90% of individuals with OCD, with 50% to 80% reduction in symptoms commonly cited.
Based on reviews of randomized, well-controlled studies, AACAP deemed CBT the first-line treatment for mild to moderate cases of pediatric OCD in their practice parameters published first in 1998 and updated in 2012. AACAP continues to recommend medication plus CBT for moderate to severe presentations of OCD, or when CBT fails to achieve clinical response after several months. Selective serotonin reuptake inhibitors (SSRIs) are the recommended first-line medication intervention. Fluoxetine, sertraline, and fluvoxamine have all been approved by the FDA for OCD in children and adolescents. Clomipramine, a tricyclic antidepressant, may have superior efficacy to the SSRIs, but is generally reserved as second-line treatment because of the increased risk of side effects.
In S.’s case, we would assess for the severity of OCD using the children’s Yale-Brown obsessive-compulsive scale (CY-BOCS) and begin a course of ERP, perhaps with an SSRI. Her history of shyness and social awkwardness should also be assessed during the initial evaluation and then again during treatment. We would recommend the excellent www.ocfoundation.org as a general resource for the family. A highly recommended book for all family members is “What to Do When Your Brain Gets Stuck: A Kid’s Guide to Overcoming OCD” by Dawn Huebner (Imagination Press, 2007).
American Academy of Child and Adolescent Psychiatry. Practice parameter for the assessment and treatment of children and adolescents with obsessive-compulsive disorder. J Am Acad Child Adolesc Psychiatry. 2012;51(1):98-113.
Himle M, Franklin, M. The more you do it, the easier it gets: Exposure and response prevention for OCD. Cognitive and Behavioral Practice. 2009;16:29-39.
Storch E, Abramowitz J, Goodman W. Where does obsessive-compulsive disorder (OCD) belong in DSM-V? Depression and Anxiety. 2008;25;336-347.
Susan F. Epstein, PhD, and Ambreen Naeem, MD
Autism spectrum disorders (ASD) have become a significant part of any pediatric practitioner’s caseload over the past several years. A broader characterization of the spectrum has led to expanding prevalence rates and an increasingly complex and difficult-to-treat population of children. Despite the great need for effective interventions, however, no single stand-alone therapy has proved beneficial for all children with ASD. This is likely due to several factors including complex pathophysiology, neurodevelopmental atypicalities, and clinical heterogeneity.
Applied behavior analysis (ABA) principles continue to form the basis of the most highly researched non-pharmacologic interventions and can be adapted for different settings and abilities. Other interventions, including speech-language therapy, occupational therapy, and social skills training, are also frequently appropriate in combination with ABA treatment. For some high-functioning children, cognitive behavior therapy (CBT) may be helpful for addressing comorbid conditions, such as anxiety. However, the need for symptom alleviation often becomes a focus of clinical intervention via the use of psychopharmacologic agents.
At present, no medications treat the underlying causes of ASD. It has been challenging to find medications that can effectively target the core socialization and communication impairments that are hallmarks of these disorders. While reducing target symptoms often results in improved social behavior, research shows that children with ASD do not always react to medications similarly to other patients. Extra care must be taken to monitor side effects and evaluate the costs/benefits of any pharmaceutical treatment. Clinicians should carefully review each child’s medical history and past experience with medications to select the most appropriate, effective, and safest treatments. In all cases, treatment options should be tailored to the child’s unique needs and should be fully discussed with parents.
Atypical antipsychotics, especially risperidone, have been shown to be useful in the treatment of serious behavioral symptoms in autism such as aggression and irritability. Recent trials with selective serotonin reuptake inhibitors (SSRIs) have not shown very robust results. ADHD medications can sometimes be useful for counteracting hyperactivity and short attention span. Antiepileptics have shown promising results, but indications for them are nonspecific at this time. No definitive studies have shown fenfluramine, naltrexone, or secretin to be effective for core ASD symptoms. Glutamatergic drugs and oxytocin have shown promising results in improving the core symptoms of autism. However, additional placebo-controlled trials are needed before widely recommending these drugs.
Evidence-based treatments are developed through research. The Center for Autism Research (CAR) at The Children’s Hospital of Philadelphia has a wide variety of research efforts aimed both directly and indirectly at improving clinical and educational interventions. Some of CAR’s projects include pharmaceutical treatment trials (including arbaclofen and oxytocin), a computer game intervention for improving social skills, and a study of the effects of hyperarousal on anxiety and sleep. It also conducts brain imaging and genetics research with the ultimate goal of finding biological markers to clarify variations within the autism phenotype that will determine the most appropriate interventions to benefit specific individuals. The Autism Instructional Methods Study (AIMS), in partnership with the School District of Philadelphia, is the largest randomized controlled trial of a behavioral intervention to determine the best strategies to move evidence-based autism interventions into real-world public school settings. Research studies at CAR include participants of all ages, from infants to adults. Interested participants (who receive free evaluations) can visit the CAR Web site for more information.
While early identification facilitates earlier treatment and better outcomes, early intervention is too frequently an aspirational goal rather than something easily achieved. CHOP’s EASI (Early Autism Screening and Identification) Clinic is helping families obtain timely, simple-to-access diagnostic evaluations. The EASI Clinic sees toddlers up to 3 years of age and is comprised of a pediatric nurse practitioner, a developmental-behavioral pediatrician, a speech/language pathologist, and a social worker. The evaluation is arena style, with disciplines working together while the attending observes through a one-way mirror. Several evaluations can occur simultaneously to increase the capacity of the clinic. Evaluations include taking a comprehensive medical and developmental history, conducting a physical examination, administering standardized general and autism-specific screening questionnaires, and carrying out a comprehensive language evaluation. In another development, availability of comprehensive assessments for children of all ages has recently been initiated through CHOP’s Department of Child and Adolescent Psychiatry and Behavioral Sciences and the Autism Integrated Care initiative. These are particularly relevant for children with complex presentations. Referrals to both of these programs can be made through Child Development at 215-590-7500.
Posey DJ, Erickson CA, McDougle CJ. Developing drugs for core social and communication impairment in autism. Child Adolesc Psychiatric Clin N Am. 2008;17(4):787-801, viii-ix.
What is Autism page. Autism Speaks Web site. www.autismspeaks.org/what-autism. Accessed May 22, 2012.
Diagnosing attention deficit hyperactivity disorder (ADHD) for the first time in adolescents necessitates ruling out comorbid conditions and choosing the most effective first-line treatment. While DSMIV criteria for ADHD require the presence of impairing inattentive and/or impulsive/hyperactive symptoms prior to the age of 7 years, it’s likely DSM-5 will amend this to require that “several inattentive or hyperactive-impulsive symptoms were present prior to age 12.” The American Academy of Pediatrics (AAP) has recently published a supplement to the 2011 Clinical Practice Guidelines for the Diagnosis, Evaluation, and Treatment of ADHD. It includes a thorough “ADHD process-of-care algorithm” that details the basics of the ADHD evaluation.
(parents, guardians, other frequent caregivers)
|History of symptoms (eg, age of onset and course over time)|
|Past medical history|
|Review of symptoms|
|Validated ADHD instrument|
|Evaluation of coexisting conditions|
|Report of function, both strengths and weaknesses|
(and important community informants)
|Validated ADHD instrument|
|Evaluation of coexisting conditions|
|Report on how well patients function in academic, work, and social interactions|
|Academic records (eg, report cards, standardized testing, psychoeducational evaluations)|
|Administrative reports (eg, disciplinary actions)|
(as appropriate for child's age/developmental status)
|Interview, including concerns regarding behavior, family relationships, peers, school|
|For adolescents, validated self-report instruments of ADHD and coexisting conditions|
|Report of child's self-identified impression of function, both strengths and weaknesses|
|Clinician's observations of child's behavior|
|Physical and neurological examination|
When evaluating adolescents for ADHD, the AAP recommends obtaining information from at least 2 of a child’s teachers and from parents using standardized rating scales. Among many instruments, the Vanderbilt Rating Scale, which can be downloaded for free, effectively assesses for symptoms of ADHD and also screens for coexisting conditions including anxiety, depression, oppositional defiant disorder, and conduct disorder.
Teens without a prior ADHD diagnosis must be screened for substance use, depression, anxiety, and other reasons for school refusal. PCPs should also screen for learning disorders, language disorders, sleep disorders, seizures, and tic disorders, taking note of conditions that may mimic ADHD or predispose a child to ADHD.
Psychostimulants are first-line treatment for adolescents with ADHD. Methylphenidate- and amphetamine-based stimulants both have effect sizes equal to 1.0, while nonstimulants such as atomoxetine, extended-release guanfacine, and extended-release clonidine have effect sizes of 0.7. Atomexetine should be considered when stimulants are not tolerated due to increasing tics, excessive weight loss, or insomnia. Clonidine and guanfacine are generally used as adjuncts to stimulants and have effect sizes up to 0.45 as adjuncts.
Proper dosing involves starting at the short-acting stimulant medication’s lowest dose and titrating up every 3 to 7 days to minimize side effects. AAP guidelines recommend titrating to “maximum" doses that control symptoms without adverse effects” rather than titrating on a milligram-per-kilogram basis. Therefore, as the shortacting stimulant dose is increased, obtain feedback from the patient’s morning teachers and titrate to effect. If these same benefits are not noted in afternoon classes, it’s likely the patient requires a long-acting stimulant formulation of comparable dose. If substance abuse is a concern, consider the nonstimulants or stimulants with limited abuse potential such as lisdexamfetamine (Vyvanse), dermal methylphenidate (Daytrana), or OROS methylphenidate (Concerta).
The most common side effects of stimulants include appetite suppression, abdominal pain, headaches, and sleep disturbances. In youths who experience appetite suppression, we recommend delaying the application of the stimulant until a full breakfast can be consumed. When possible, we supplement lunch, snacks, and dinner with Boost Plus or other high-calorie snacks, particularly in the evening when the stimulant is out of their system. If ADHD symptoms are not impairing the teenager during weekends, employing brief “stimulant vacations” to increase food consumption may be helpful. If these and other behavioral modifications fail, practitioners can lower the dose of the stimulant, try another stimulant (an amphetamine instead of methylphenidate), or, as a last resort, consider switching to the nonstimulants. Other less common side effects include the emergence or exacerbation of tics, increased mood lability, and dysphoria, and the emergence of hallucinations and other psychotic symptoms. Sudden cardiac death is extremely rare in patients taking stimulant medication, and there is conflicting evidence if the medication increases the sudden death risk.
In addition to medication, adolescents with ADHD can benefit from behavioral interventions and family-systems oriented therapy. These approaches can help patients improve their ability to self regulate, organize, and problem solve. Combining treatments often allows for lower dose of medications, possibly reducing risks of adverse events. Referral to child psychiatrists should be considered whenever there is uncertainty about the diagnosis, side effects interfere with multiple stimulant trials, doses on various stimulants have been maximized and symptoms are not controlled, or there are concerns for comorbid serious psychopathology.
American Academy of Pediatrics Supplemental Information. American Academy of Pediatrics Web site. http://pediatrics.aappublications.org/content/suppl/2011/10/11/peds.2011-2654.DC1/zpe611117822p.pdf. Updated October 11, 2011. Accessed June 1, 2012.
Langberg JM, Froehlich TE, Loren RE, Martin JE, Epstein JN. Assessing children with ADHD in primary care settings. Expert Review Neurotherapeutics. 2008;8(4);627-641.
Proposed Revisions in the DSM-V for Attention Deficit/Hyperactivity Disorder. American Psychiatric Association Web site. http://www.dsm5.org/ProposedRevision/Pages/proposedrevision.aspx?rid=383. Updated September 30, 2011. Accessed June 1, 2012.
Wolraich M, Brown L, Brown RT, et al. ADHD: Clinical practice guideline for the diagnosis, evaluation, and treatment of attention deficit/hyperactivity disorder in children and adolescents. Pediatrics. 2011;128(5);1007-1022.
Department of Child and Adolescent Psychiatry and Behavioral Sciences (DCAPBS) and for ADHD referrals, call 215-590-7555.Information for ADHD also can be found at www.chop.edu/adhd.
CHOP’s EASI (Early Autism Screening and Identification) and Autism Services can be reached at 215-590-7500 (physicians press # 3).
For obsessive-compulsive disorder referrals to the Anxiety Behaviors Clinic (ABC) in the DCAPBS, call 215-590-7555.
Information on the Center for Autism Research (CAR) can be found at www.centerforautismresearch.com.
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