Obsessive Compulsive Disorder (9 page)

Approximately 30 per cent of young people with OCD also have Tourette’s syndrome (TS), where the young person experiences multiple motor or vocal tics (Wagner, 2006). Tics can be defined as sudden, rapid involuntary movements or sounds that occur randomly in a wide variety of situations and are not performed to reduce anxiety or neutralise obsessions.

In contrast, compulsions are purposeful, deliberate actions that are performed to reduce anxiety or prevent some undesired outcome. Despite these clear differences, TS and OCD can be difficult to distinguish as some young people with TS report a sense of compulsion with regard to their tics and compulsions are sometimes viewed as sudden and uncontrollable in OCD.

Advice from specialists should be sought if difficulties with differential diagnosis of TS and OCD occur and if queries about the impact of TS on the treatment of OCD arise.

Autism and Asperger’s syndrome (AS) share clear similarities to obsessive compulsive symptomatology. Young people with autism and AS often have obsessive interests and display stereotypical behaviour, but on the whole these are not associated with anxiety or the prevention of harm.

Autism and AS are also manifested by the development of restricted, repetitive patterns of behaviour and interests and sustained impairment in social interactions, whereas young people with OCD tend to display normal social development. Despite these differences, it is of course possible for a young person with AS also to have a diagnosis of OCD and prevalence rates for this dual diagnosis have been estimated at 2 per cent (Lehmkuhl
et al.
, 2007). Although there is extensive research demonstrating the effectiveness of cognitive behavioural interventions for young people with OCD, little is known about how effective these treatments are for children who have a dual diagnosis of OCD and ASD. However, several recent single case studies have shown promising results for the effective use of CBT with 42

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young people who have this dual diagnosis (e.g. Lehmkuhl
et al.
, 2007; Reaven and Hepburn, 2003). Furthermore there is increasing evidence that young people with ASD who have anxiety disorders can benefit from both individual and family-based CBT with appropriate developmental adaptations (Chalfant
et al.
, 2007; Sofronoff
et al.
, 2005; Sze and Wood, 2007). If the assessment highlights the presence of both AS and OCD, the therapist should consider the young person’s suitability for CBT

and seek to adapt the intervention appropriately in line with current findings. Specific guidance may be required from professionals working with this population.

Although differential diagnosis of depression and OCD is not normally problematic, it can be difficult to ascertain which constitutes the primary disorder. In many cases depression is secondary to OCD, although it may warrant being the initial focus of intervention if it is likely to limit the young person’s ability to actively engage in treatment for their OCD. The therapist should therefore note that depressive symptomatology can have implications for the successful treatment of OCD and should be reviewed regularly with the young person so that treatment can be adapted appropriately if necessary. If depression is identified the therapist should complete a full risk assessment which should include assessing for the presence and level of self-harming behaviours and suicidal ideation and behaviours (NICE, 2005) and monitor appropriately.

Due to high levels of comorbidity in childhood OCD, the therapist should use diagnostic interviews and questionnaire-based measures to try to identify whether OCD is the primary diagnosis and in order to make accurate differential diagnosis.

Assessing motivation and suitability for CBT

CBT is a collaborative treatment that involves the young person taking an active part in sessions and also completing tasks between sessions in the form of monitoring and behavioural experiments. For this reason it is important that the therapist is explicit about the nature of CBT early on in the assessment process and they should ask whether or not the young person feels that it is the right time for them to enter into treatment, for example: ‘Sessions will involve you and me sitting down together and trying to work out what is going on with your OCD. In particular, we will look at what might be behind the problem getting so upsetting and why the problem has been around for so long. Once we have tried to understand it a little bit more, you will start to try out new ways of dealing with the
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problem between sessions and come back and let me know how they have gone. How do you feel about trying to work on your OCD in this way? Does it feel like this is the right time for you to start trying to make things better? Can you see any problems with us working on your OCD

in this way right now?’

If the young person has had any previous treatment for their OCD or other difficulties it is important to ask about how they found this experience and to explore whether their previous treatment has any implications for the way you work with them. It can also be helpful at this point to review the pros and cons of staying the same versus changing if motivation appears problematic. If this ‘cost-benefit analysis’ is undertaken, the therapist should be mindful of exploring and acknowledging their reasons for staying the same before moving on to the pros of change which inevitably involves challenging the continuation of their obsessive compulsive symptoms.

Another issue that is central to the suitability of CBT is the young person’s ability to engage in the cognitive components of treatment. This necessarily involves the ability to distinguish thoughts, feelings and behaviours and to identify and evaluate thoughts and cognitive processes (Greenberger and Padesky, 1995). Research from developmental psychology suggests that children from the age of six years can engage in meta-cognition (i.e. thinking about thinking), recognise inner speech and link thoughts to feelings (Quakley
et al.
, 2003). However, if the therapist has concerns about the young person’s ability to engage in these cognitive aspects of CBT it may warrant further assessment. This could involve asking the young person directly if they can tell you how they would describe what thoughts and feelings are and how they relate to each other. Alternatively, the therapist could present the young person with a list of thoughts, feelings and behaviours and ask them to sort them into these categories. Presenting the young person with both ambiguous and potentially anxiety-provoking situations and asking them to identify possible thoughts and the impact of these thoughts (and their interpretations) on feelings and behaviour can also be helpful. If difficulties with the cognitive aspects of CBT or motivation are identified, this does not necessarily pre-clude the young person from entering into treatment. Preliminary work on motivational issues and understanding thoughts and feelings can be beneficial.

Motivation and suitability for CBT should be assessed. The pros and cons of change and the young person’s ability to engage in the cognitive aspects of treatment should also be considered.

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Assessment tools

Diagnostic interviews

Diagnostic interviews have been found to increase the reliability and validity of symptom assessment and diagnosis and aid differential diagnosis (Merlo
et al.
, 2005). Consequently, a diagnostic interview is useful in establishing the diagnosis of OCD, clarifying other diagnoses and deciding which of these is the primary problem for the young person and needs treating first. Therefore, although the use of structured diagnostic interviews for the assessment of OCD and other disorders is most common in research studies, where possible therapists should utilise them in general clinical practice. However, it is worth noting that they can be time-consuming to administer and it may therefore be appropriate to screen for OCD first before administering whole diagnostic interviews. Careful consideration needs to be given to the integration of child and parent report. Greatest reliability will be achieved by combining parent/

child data and it is generally regarded as appropriate to favour parent report on observable behaviour and child report for internal subjective experiences (Herjanic and Reich, 1982) if discrepancies occur. Clinicians will require training in the administration of diagnostic interviews. Commonly used diagnostic interviews are outlined below.

The Anxiety Disorders Interview Schedule
(ADIS; Silverman and Albano, 1996) is a clinician-administered structured interview, based on
DSM-IV
(APA, 1994) diagnostic criteria and developed specifically for anxiety disorders and their associated conditions. The interview takes approximately an hour and a half to administer with parents and children being interviewed separately. Each section of the ADIS corresponds to a different disorder and complete sections are only administered if initial criteria are reported. A diagnosis is given if appropriate symptoms are present and cause significant interference/clinical distress as indicated by a clinical interference rating of 4 or more (based on a scale of 0 to 8). The clinician then gives the diagnosis a clinical severity rating (0 to 8 point scale) based on the number of symptoms endorsed and the level of interference indicated by the parents and the child. The ADIS has been found to have sound inter-rater and test-retest reliability (Silverman and Albano, 1996).

The Schedule for Affective Disorders and Schizophrenia for School-Age
Children
(K-SADS-PL; Kaufman
et al.
, 1997) is a clinician-administered diagnostic interview based on
DSM-IV
criteria and adapted from the K-SADS-Present Episode Version (Chambers
et al.
, 1985). Children and parents are interviewed separately and diagnoses are given using clinical judgement and the amalgamation of both reports. The K-SADS-PL begins with an introductory interview that aims to build rapport and acts as the basis for further questioning. Full sections are only completed after initial screening for each disorder is completed. Unlike the ADIS, the K-SADS-PL

contains full diagnostic sections on affective, psychotic, substance and
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45

eating disorders. Symptoms and impairment are rated on a four-point scale and diagnoses are scored as ‘Definite’, ‘Probable’ or ‘Not present’. The interview takes approximately 75 minutes to complete. The K-SADS-PL has been found to have good inter-rater and test-retest reliability and sound concurrent validity has also been demonstrated for several diagnoses (Kaufman
et al.
, 1997).

Structured diagnostic interviews can be used to confirm diagnosis and identify comorbid conditions.

Clinician-administered measures

Once a diagnosis of OCD has been established, clinician-rated semi-structured interviews can be a helpful way of gaining further information.

They allow the clinician to rate the severity of reported OCD symptoms and levels of distress/interference based on clinical judgement and experience as well as concrete prompts.

The Children’s Yale-Brown Obsessive Compulsive Scale
(CY-BOCS; Scahill
et al.
, 1997) is the most widely used clinician-administered interview for paediatric OCD. This semi-structured interview is adapted from the adult measure (Y-BOCS; Goodman
et al.
, 1989) and is conducted with parents and the young person simultaneously or separately, taking approximately 30 minutes to complete. It asks about the presence of obsessions and compulsion separately over the previous week. Ratings are then given with regard to time occupied, distress and interference caused and levels of control and resistance, using a five-point Likert scale. The overall score (range is between 0 and 40) combines the obsession and compulsion severity subscales and gives an overall severity of OCD ranging from mild to extreme.

The CY-BOCS has been found to have excellent reliability for obsessions, adequate reliability for compulsions and sound convergent and divergent validity (Scahill
et al.
, 1997). However, the use of the CY-BOCS total score is not strongly supported for clinical or research purposes when it could underestimate symptom severity in a primarily obsessive or primarily compulsive young person (Merlo
et al.
, 2005).

The Leyton Obsessional Inventory – Child Version
(LOI-CV) is a 44-item card-sorting task based on the original
Leyton Obsessional Inventory
(LOI-CV; Berg
et al.
, 1988) which contains questions on persistent thoughts, checking, fear of dirt and/or dangerous items, cleanliness, order, repetition and indecision. The LOI-CV yields three distinct scores: ‘yes’ score (number of questions answered in the affirmative) and ‘resistance’ and ‘interference’

scores (where items rated as ‘yes’ are ranked for levels of resistance and interference in daily life). The LOI-CV has been found to have excellent test-retest reliability and concurrent validity has also been demonstrated (Berg
et al.
, 1988).

The Development and Well-Being Assessment
(DAWBA; Goodman 46

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et al.
, 2000) is a well-validated measure developed for the Survey of British Child Mental Health. It consists of a package of questionnaires, interviews and rating techniques designed to generate
ICD-10
and
DSM-IV

psychiatric diagnoses on young people aged 5 to 16 years old. The structured interviews are administered to both the young person (for 11-to 16-year-olds) and to parents separately. Once definite symptoms have been identified, open-ended questions and prompts are used to get parents and the young person to describe the problem in their own words. Information is brought together by a computer program that predicts possible diagnoses that can then be confirmed or disregarded by an experienced clinical rater.