HELP FOR PARENTS WITH STRONG-WILLED, OUT-OF-CONTROL CHILDREN AND ADOLESCENTS

Education and Counseling for Individuals Affected by Oppositional Defiant Disorder and ADHD

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Teens and OCD

At least 1 in 200 kids and adolescents in the United States have Obsessive Compulsive Disorder (OCD). Understanding the special impact that the disorder has on their lives is important in helping them get the right treatment. Some common issues with OCD in kids and adolescents are as follows:

1. Anger Management Problems: This is because the moms and dads have become unwilling (or are unable!) to comply with the youngster's OCD-related demands. Even when moms and dads set reasonable limits, children and adolescents with OCD can become anxious and angry.

2. Disrupted Routines: OCD can make daily life very difficult and stressful for children and adolescents. In the morning, they feel they must do their rituals right, or the rest of the day will not go well. In the evenings, they must finish all of their compulsive rituals before they go to bed. Some children and adolescents even stay up late because of their OCD, and are often exhausted the following day.

3. Other Mental Health Problems: Children and adolescents with OCD are more likely to have additional mental health problems than those who do not have the disorder. Sometimes these other disorders can be treated with the same medicine prescribed to treat the OCD. Depression, anxiety disorders and trichotillomania (compulsive hair or skin picking) may improve when a youngster takes anti-OCD medicine. On the other hand, Attention-Deficit Hyperactivity Disorder (ADHD), tic disorders, and disruptive behavior disorders usually require additional treatments, including medicines that are not specific to OCD.

4. Physical Complaints: Stress, poor nutrition, and/or the loss of sleep can make kids physically ill.

5. Problems at School: OCD can affect homework, attention in class, and school attendance. If this happens, you need to be an advocate for your youngster. It is your right under the Disabilities Education Act (IDEA) to ask for changes from the school that will help your youngster succeed.

6. Problems with Self-Esteem: Children and adolescents worry that they are "crazy" because their thinking is different than their friends and family. Their self-esteem can be negatively affected because the OCD has led to embarrassment or has made them feel "bizarre" or "out of control."

7. Social Relationships: The stress of hiding their rituals from peers, times spent with obsessions and compulsions, and how their friends react to their OCD-related behaviors can all affect friendships.

Experts agree that cognitive behavior therapy (CBT) is the treatment of choice for children with OCD. Working with a trained CBT therapist, kids and adolescents with OCD learn that they are in charge, not OCD.

Using a CBT strategy called exposure and response prevention (ERP), youth can learn to do the opposite of what OCD tells them to do, by facing their fears gradually in small steps (exposure), without giving in to the rituals (response prevention). ERP helps them find out that their fears don't come true and that they can get used to the scary feeling, just like they might get used to cold water in the swimming pool.

Here is an example:

Imagine a teen that repeatedly touches things in his room to prevent bad luck. Using ERP, the teen would learn to leave his room without touching anything. He might feel very scared at first, but after some time, the anxiety goes away as he gets used to it. He also finds out that nothing bad happens.

At first, ERP may sound scary to many kids and teens. They may not be ready to try it. It is important to find a CBT therapist who is experienced in working with kids with OCD. An experienced therapist will be able to get your youngster ready for ERP by making it kid-friendly.

When youth understand how the therapy works, they may be more willing to deal with the initial anxiety experienced during ERP because they know the anxiety will increase and then go down over time. Moms and dads need to be involved in their youngster's treatment as well, under the therapist's guidance.

Medicines should only be considered when there are moderate to severe OCD symptoms. Both cognitive behavioral therapy (CBT) and medicine effectively treat OCD in kids and adolescents. Their use is supported by the treatment guidelines of the American Psychiatric Association (APA) and the American Academy of Child and Adolescent Psychiatry (AACAP).

Antidepressants are usually the first kind of medicine that a doctor will try. Your doctor might refer to these medicines as SSRI's, which stands for "Selective Serotonin-Reuptake Inhibitors", or TCA's, which stands for "Tricyclics." Here are some names of each of these kinds of medicines:

SSRI's-
• citalopram (Celexa®)
• escitalopram (Lexapro®)
• fluoxetine (Prozac®)
• fluvoxamine (Luvox®)
• paroxetine (Paxil®)
• sertaline (Zoloft®)

TCA's-
• clomipramine (Anafranil®)

OCD medicines control and decrease symptoms, but do not "cure" the disorder. OCD is usually well controlled when the right treatment is in place, but symptoms can often return when the youngster stops taking the medicine.

All OCD medicines work slowly. It is important to not give up on a medicine until it has been taken at the right dose for 10 to 12 weeks. Studies have also shown that improvement of childhood OCD can continue for at least a year after starting medicine.

Only four OCD medicines have been approved by the FDA for use in kids:
  • clomipramine (Anafranil®)
  • fluoxetine (Prozac®)
  • fluvoxamine (Luvox®)
  • sertaline (Zoloft®)
But, doctors can prescribe any OCD medicines to kids if they feel it is needed.

The best dose of OCD medicine should be determined on an individual basis. Kids should start at a lower dose than adolescents, but OCD symptoms often need to be treated with higher, adult-sized doses. If a youngster has difficulty swallowing pills, a liquid or other version may be available. The following dose ranges may be necessary:

• fluvoxamine (Luvox®): 50-300 mg/day
• sertaline (Zoloft®): 50-200 mg/day
• clomipramine (Anafranil®): 50-200 mg/day
• citalopram (Celexa®): 10-60 mg/day
• paroxetine (Paxil®): 10-60 mg/day
• fluoxetine (Prozac®): 10-80 mg/day
• escitalopram (Lexapro®): 10-20 mg/day

No two kids respond to OCD medicines in the same way. In general, clomipramine (Anafranil®) is usually not given first because of its side effects.

Factors that may guide the medicine choice can include:

• a good response to a certain drug by other family members
• cost or availability
• potential for side effects
• presence of other disorders

In the largest youngster OCD treatment study to date (POTS)1, remission (the absence of any major symptoms) occurred in about 1 in 5 kids on medicine and in more than half of those with medicine and CBT. In addition, many more kids had improvement (but not full remission). Some kids will have no response at all to some medicines, but it does not mean that other medicines will not help.

Every kind of drug has potential side effects. These side effects must always be weighed against the benefit. Some common side effects of OCD medicines include:

• a heightened sense of energy
• inability to sit still
• nausea
• sleepiness or insomnia

In general, the other drugs are safer than clomipramine (Anafranil®) which has its own side effects, including:

• concentration problems
• drowsiness
• dry mouth
• problems with urination
• racing heart
• weight gain

For all antidepressants in kids and adolescents, the FDA has issued "black box warnings" about suicidal thoughts and urges. The highest risk period for this is when starting or increasing the dose of the medicine. However, a recent study found no increase in suicidal thoughts in groups of kids with OCD who were studied.

These drugs appear very safe with long-term use and side effects reverse when they are stopped. There is no current evidence that they do permanent damage to the body.

It is important to know that if the first medicine does not improve OCD, another one should be tried. Trying several OCD medicines may be needed. Many people have better results if CBT is added to drug treatment. If the combination of one drug and CBT don't work, adding a second or third medicine can also be tried.

Many doctors suggest that OCD treatment should continue for at least one year, even after the symptoms have stopped. Unfortunately, OCD drugs do not "cure" the illness. When medicine is stopped, symptoms often return within a few weeks to months. If they return, most patients will respond well after starting to take the medicine again.

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