**7. Assessment practice guidelines**

**6.1. Pediatric OCD and family accommodation**

74 Anxiety Disorders - From Childhood to Adulthood

A child, age 8, becomes tearful after accidentally touching something in a public area due to worries of becoming severely ill. She cries and asks her mother repeatedly "Am I going to be sick and die?" The child's mother answers the question, "No, that's not possible, you aren't going to become sick from that"; however, the girl appears unsatisfied and continues to ask similar questions. When her mother eventually tells her she already answered the question and attempts to end the conversation, the daughter throws herself onto the floor and begs her mother to answer again. The mother knows from past experience that when she answers her daughter, she is likely to calm down sooner and experience relief. However, she has also observed that her daughter seems to ask more frequently for reassurance and seems to want her mother to repeat the answer more times. What is this mother's best choice in this situation? It is common for pediatric and adult individuals with OCD to involve close family members in OCD-related behaviors in some capacity [51, 52]. Accommodation refers to family members' modification of their own behavior in order to assist in their child's OCD-related rituals [53–55]. This may occur in a variety of forms including participating in rituals themselves (e.g., washing their hands excessively at their child's request or listening to repeated confessions of their child), facilitating avoidance of situations (e.g., picking child up early from school or removing knives in home if child has aggressive obsessions), and providing reassurance (e.g., saying nothing bad

Research suggests that the majority of families engage in accommodation on a regular basis. An analysis of the Pediatric OCD Treatment Study (POTS) explored the prevalence of family accommodation as well as whether there are child or parent factors that are related to a tendency toward accommodation. The POTS is a randomized controlled trial that investigated the effectiveness of cognitive behavioral therapy alone, medication alone, and the combination of therapy and medication, compared to a placebo control condition in children (ages 7–17) with OCD and their families [56]. In a subset of 96 individuals who completed the Family Accommodation Scale Parent Report (FAS-PR), 99% of parents reported engaging in at least one accommodating behavior to some extent and 77.1% reported engaging in at least one accommodating behavior daily [53]. More than half of parents reassured their child (63.5%), while about a third participated in their child's OCD rituals (32.33%) and assisted in avoiding triggering situations (33.3%) on a daily basis [53]. These results are comparable to other stud-

ies that have explored the prevalence of accommodation in pediatric OCD [46, 57].

Parents typically accommodate with their child's best interests at heart in hopes of alleviating distress, assisting with management of OCD symptoms, and/or improving family functioning. Accommodation often does result in short-term relief and can appear helpful when, for example, a child ceases tantruming after receiving reassurance. In reality, OCD symptoms are actually maintained as rituals are negatively reinforced and the child learns they cannot handle their fears without compulsions. Family accommodation has been shown to be associated with symptom severity pretreatment for children and adolescents with OCD, further evidence that this practice actually worsens rather than solves the problem [46, 57, 58]. Yet, children eventually come to expect family participation in rituals and become agitated when

is going to happen in response to child asking about a harm-related fear).

The 2012 evidence-based practice parameters published by the American Academy of Child Adolescent Psychiatry detail assessment recommendations for pediatric OCD symptoms [17]. Routine screening of obsessions and compulsions is recommended during all psychiatric evaluations of children and adolescents, regardless of whether OCD is part of the presenting complaint. Screening can be conducted via several brief questions such as "Do you have worries that just won't go away or get stuck" and "Do you do things over and over or have habits you can't stop?" [17]. For individuals who exhibit OCD symptoms and meet DSM criteria for the disorder, a comprehensive evaluation of possible comorbid psychiatric disorders is recommended as well as a thorough medical, developmental, family, and school history [17]. As discussed in comorbidity section above, children are likely to present with multiple diagnoses, which may impact their treatment needs and ability to participate effectively in OCD treatment. With regard to family history, inquiries should focus on family mental health history, activities of daily living, general family dynamics, and lifestyle factors. Medical history questions may also provide helpful information regarding differential diagnosis of PANDAS/ PANS. Additionally, gathering information about a child's academic performance over time also allows for an understanding of functional impairment and symptom severity outside of the child's home [17].

to decline naturally. For example, a child who worries about contracting a serious illness and engages in excessive handwashing and avoidance of germs would not only touch objects that

Manifestation and Treatment of OCD and Spectrum Disorders within a Pediatric Population

http://dx.doi.org/10.5772/intechopen.79344

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Family-based CBT programs have been recommended for early childhood OCD (approximately ages 5–8) and have demonstrated success in randomized control trials [45, 61]. Parent participation is particularly important for younger children who have unique developmental needs and rely heavily on their caretakers. The Pediatric Obsessive-Compulsive Disorder Treatment Study for Young Children (POTS JR) evaluated the efficacy of a family-based CBT protocol (FB-CBT) for young children who addressed cognitive, socioemotional, and family factors compared to a family-based relaxation training protocol [45]. This 14-week randomized clinical trial involved 127 pediatric outpatients with OCD aged 5–8 years at three academic medical centers. Results revealed that the FB-CBT led to significant reductions in OCD symptoms and functional impairment; young children with OCD were able to benefit from

Family-based CBT incorporates parent tools such as behavior management skills training; parents are trained in behavioral strategies such as implementing reward systems, modeling, and ignoring behaviors that are reinforced by attention [45]. As children may lack insight into their symptoms and/or resist voluntary contact with triggers, they may be more likely to participate in treatment with the addition of external reinforcers. Additionally, parents can be actively involved during in-session and home-based exposure exercises and provide helpful support to their child. Therapists teach parents how to act as a coach between sessions, which ensures increased likelihood of children practicing and adhering to CBT principles between sessions [45]. Parents who are included in the treatment process are less likely to accommo-

While outpatient therapy often involves a weekly schedule, the possibility of more intensive treatment can be considered depending on the child's clinical presentation and circumstances. Studies have demonstrated that daily sessions offer comparable results to weekly sessions and even provide slight advantages immediately posttreatment though there appear to be no group differences at later follow-ups [48, 49]. While weekly treatment allows for children to maintain their routines and remain in school and other activities, intensive treatment can also be considered as an option when children have a limited time frame and/or require a faster response rate. Many of our children receive intensive treatment during holidays or during the summer months. In addition, children who are unable to attend school may be

Children are encouraged to externalize the OCD as separate from themselves [64, 65]. Therapists often describe OCD as a "bully" or "worry monster" that puts "silly worries" or "scary thoughts"

are associated with germs but also refrain from handwashing for the exposure exercise.

**9.1. Family involvement in treatment**

**9.2. Treatment intensity**

considered for intensive outpatient programs.

**9.3. Additional consideration for ERP in child populations**

exposure and response prevention with parental support [45].

date their child's OCD, which can greatly enhance treatment outcomes [14].
