An interdisciplinary approach to treatment of juvenile OCD: a case report

Yamini Kannappan*, Tinu Thambi, Aishwariya Ramesh

Department of Psychiatry, Kauvery Hospital, Chennai

*Correspondence: Email: [email protected]

Abstract

Background: Juvenile OCD is a rarity in India with an estimated prevalence of 0.6%. It is most often present in male children with onset prior to the age of 14 years for juvenile OCD. It is associated with male preponderance, genetic predisposition, and comorbid neurodevelopmental disorders. Treatment can be provided through pharmacotherapy, psychotherapy, family therapy, or a combination of all.

Case presentation: Master C, an 8-year-old male patient studying third grade in Chennai had come for a psychiatric consultation with history of significant aggressive obsessions, sexual obsessions, and need to ask compulsions. Following diagnosis of juvenile OCD using assessment tools, he was initiated on an eclectic treatment approach involving medication, cognitive behavior therapy and other interventions involving the family. The severity of symptoms had markedly reduced within a period of eight months.

Conclusion: Identification and diagnosis of OCD for children can be arduous as they may not be forthcoming with their problem. Using a combination of pharmacotherapy and psychotherapy is insisted over just one treatment method

Keywords: Juvenile, Obsessive-compulsive disorder, Psychotherapy, Pharmacotherapy, Cognitive behavior therapy

Background

Obsessive-compulsive disorder (OCD) is a thought disorder concerning recurrent intrusive thoughts, images, and/or feelings [1]. Juvenile OCD has a mean age of onset of 10 years, often following male preponderance, with a lifetime prevalence of 1–3% which may be lower in India [2,3]. Diagnosis and subsequent treatment of juvenile OCD may be delayed due to secrecy and lack of insight. An interdisciplinary approach is suggested for treatment entailing serotonin reuptake inhibitor and cognitive behavior therapy [4].

Case Presentation

Master C, an 8-year-old male studying in third grade, Chennai native residing in Australia, was brought for psychiatric consultation by mother with complaints of recurrent, uncontrollable, distressing thoughts and seeing images of other’s sexual parts and engaging in sexual activity with them, repetitive, intrusive, violent images of harming others, obscene images of religious idols, excessive fear of acting upon violent impulses, and constant reassurance seeking behaviour from mother. The symptoms had been present for three months with gradual onset, continuous and progressive in nature. It had begun when Master C’s best friend began to speak about matters with sexual content.

Gradually the child started to have repeated, uncontrollable, disturbing thoughts of sexual content. He also started to have repetitive thoughts of harming others. Gradually the frequency of thoughts increased, and distractibility decreased. The child had developed immense guilt and contended to fostering covert death wishes. Avoidance behaviors in the form of refusing to see triggers such as a man and a woman standing together, or advertisements with women in short clothes, were also observed. Head shaking was another behavior that the child engaged in to remove distressing thoughts. There was significant interference with the child’s functioning at school or home. No history suggestive of epilepsy or brain injury. Psychological assessment was performed with Child Yale-Brown Obsessive-Compulsive Scale (CY-BOCS) and he was diagnosed with juvenile obsessive-compulsive disorder (predominantly obsessive type).

Treatment

He was initiated on cognitive behaviour therapy (CBT) and fluoxetine 10 mg which was titrated to 20 mg after a period of three weeks. Exposure response prevention (ERP), a type of CBT, was employed using the ‘RIDE Up and Down the Worry Hill’, a 4-step method easy to comprehend keeping in mind the age of the patient and cultural differences. RIDE involved renaming negative thoughts as ‘villain thoughts’; insisting they are in charge; defying OCD; and enjoying success by getting the family to reward alternate behaviours. Patient was given psychoeducation with specific focus on how exposure results in habituation. The child had his favourite bike race taken as anecdote in which he was explained of being in race where the villain thought was his opponent in the game. The game had a path with lot of “worry hills” and he has to ride the bike up and down these hills.

An exposure hierarchy, referred as a fear ladder for his understanding, was created after symptom monitoring. Table 1 is the fear ladder created by the patient with the subjective unit of distress (SUDS) explained using a fear thermometer (Fig. 1). Imagined exposure was planned initially, habituation was further encouraged by asking Master C to view triggering cartoon clip arts. Once habituation had occurred, gradual shift to real-world exposures were scheduled and performed. Interventions such as thought stopping utilising positive coping statements were also efficient. He got to play video game for an extra 10 min based on their daily performance (as he always asked for extra time to play video games). Weekly he was taken out for their favourite outing based on consistent results in the past few days. The reward for performing well the whole month was getting his favourite toy, hot wheels car. If an increase in reassurance seeking behaviour was observed the response cost was 5 min reduction from his video game time (this was implemented once there was significant decrease in reassurance seeking behaviour over a period of time with rewards). The child had moved to Australia while treatment was going on, and had to continue therapy virtually. The intervals between sessions became irregular and thus the family was involved for monitoring tasks at home. The severity of symptoms markedly reduced within a period of eight months.

Table 1: Fear ladder

SITUATION SUDS (0–10)
Thought of doing yucky things to private parts 10
Thought of touching others private parts 8
Thought of hugging mom/grandma 8
Not asking/telling mom about it 8
When watching man and women hugging/kissing in television 7
When seeing a boy and girl talking 6
Thoughts of me hitting others 6
Thoughts of me shooting others 6
Thoughts of me putting things on fire in public place 5
Thoughts of me saying bad words to others 4

ocd-1

Fig. 1. Fear Thermometer

Discussion

Obsessive compulsive disorder involving sexual and aggressive obsessions can be particularly distressing for children which may engender strong feelings of shame and guilt. They may also not be forthcoming with such thoughts due to the associated feelings. Identification of the recurrent thoughts as an abnormal phenomenon is required to decrease negative cognitions. It may be arduous to involve the patient in ERP but using the RIDE method to explain and deciding on simple tasks to work on may yield better results [5]. Involvement of the family in therapy is highly beneficial in implementing such interventions and rewarding efforts to decrease overall distress [6]. Non-judgmental attitude of the family is requited for the child and psychoeducation plays a pertinent role.

Conclusion

Identification and diagnosis of OCD for children can be arduous as they may not be forthcoming with their problem [4]. Involving the family for treatment also assists in improvement of symptoms and reduced distress. Adherence to treatment may be difficult to sustain for which constant motivation is needed. Using a combination of pharmacotherapy and psychotherapy is insisted over just one treatment method [7].

Acknowledgements

None.

Competing interests

The authors have no competing interest to declare.

Consent

Written consent was obtained from the mother for the report.

References

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  5. Wagner AP. Cognitive-behavioral therapy for children and adolescents with obsessive-compulsive disorder. In: Dougherty DD, Hudak R, editors. Clinical Obsessive-Compulsive Disorders in Adults and Children. Cambridge Core: Cambridge University Press; 2011. p. 138–151.
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  7. Fineberg NA, Dell’Osso B, Albert U, et al. Early intervention for obsessive compulsive disorder: an expert consensus statement. Eur Neuropsychopharmacol. 2019;29(4):549–565.

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