IN BRIEF

Addressing Childhood Obsessive-Compulsive Disorder in Primary Care

May 9, 2019
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Primary care providers play an important role in recognizing the disorder and in providing a bridge to mental health care providers.

While a child or adolescent with obsessive-compulsive disorder likely will need specialty cognitive behavioral therapy, a family may first seek help in primary care. A pediatrician’s ability to recognize the disorder, offer an initial assessment and refer patients to the correct mental health provider could lead to better outcomes more quickly.

As part of an ongoing Behavioral Health Webinar Series from Nationwide Children’s Hospital, Heather Yardley, PhD, a psychologist at Nationwide Children’s, recently gave guidance to providers who may see children with OCD in their practices.

“There are some differences in the way we approach children and adults with OCD, and some different questions we may need to ask,” says Dr. Yardley, who is also an associate professor of Pediatrics at The Ohio State University College of Medicine. “Primary care can often help begin the process.”

OCD is essentially a negative reinforcement loop. A person has thoughts, impulses or mental images that provoke anxiety, called “obsessions.” To relieve that anxiety, a person engages in behavior that is either obvious or covert (like mental counting), called “compulsions.”  Relief is temporary, so the person repeatedly engages in the compulsion, until it begins to impair regular living.

A significant difference between diagnosis in adults and children is that adults understand their obsessions and compulsions are excessive or unreasonable, but children may not, says Dr. Yardley.

Perhaps the most useful, validated assessment of children’s OCD is the Children’s Yale-Brown Obsessive Compulsive Scale, or CY-BOCS. It lists many options for obsessions and compulsions and helps with developing a “hierarchy,” or list of troublesome thoughts and behaviors in order of severity.

In the absences of the CY-BOCS, however, Dr. Yardley suggests some basic questions that can help a provider in assessment:

  • Are there things you feel like you have to do in a certain way?
  • Can you do it in a different way?
  • What happens if you get interrupted?
  • What happens if you can’t do it?

A clinical interview including family members is also important, and may include questions about length of symptoms, who else is involved in the rituals (a parent may need to perform an action as part of a child’s compulsion, for example) and the impact on the family. It may also become clear that another family member may have an anxiety-related condition; 80% of adults with OCD exhibited the disorder in childhood.

Once a provider has a suspicion of OCD, a referral to a pediatric cognitive behavioral therapist should be made, says Dr. Yardley. In locations where that is not possible, a pediatrician may seek to refer to a psychologist with experience treating anxiety disorders. Even when a pediatric therapist is an option, wait lists can be long, and primary care providers can make some recommendations to families and caregivers in the meantime:

For more information on this and other Nationwide Children’s Behavioral Health webinars for providers, including instructions on receiving CME credit for participating, click here.