The Interplay of Risk and Resilience Factors in Childhood Obsessive Compulsive Disorder
Introduction
The emotional disorders are termed the ‘internalising disorders’ and comprise depression and the anxiety disorders. Although the emotional disorders of childhood are discussed as separate entities, in reality it is not that easy to separate them because there is a lot of common ground. The reason they are seen as separate entities is due to the clinical approach of DSM IV. Often, in any given case, depression and anxiety are both present to some degree and there is also often overlap with the conduct disorders. Obsessive Compulsive Disorder (OCD) is categorised as one of the anxiety disorders.
In most individuals with OCD, the picture is frequently mixed to a lesser or greater extent. OCD is highly co-morbid, with most studies finding up to 70% of children with OCD having at least one other disorder. Most common are other anxiety disorders, ADHD, developmental disabilities, conduct problems, substance abuse, depression and bipolar disorder (Swedo, Rapoport et al 1989). Any treatment programs for the OCD child must therefore take this into account and tailor the approach accordingly.
The nature of childhood OCD and special problems faced
Obsessions are unwanted, repetitive, intrusive thoughts, while compulsions involve repetitive, stereotyped behaviours that the child or adolescent feels compelled to perform. In the majority of youngsters with the disorder, both obsessions and compulsions are a feature (Wicks-Nelson & Israel, 2000).
The implication is that the obsessions are covert, involuntary thoughts which increase anxiety and the compulsions are overt, voluntary behaviours which decrease the anxiety (Edelman 1992).
According to the DSM IV, the obsessions must cause anxiety or distress and must not be simply excessive real life worries. The person must attempt to ignore, suppress or neutralise the thoughts and he (or she) must recognise that the obsessions are products of his own mind. With compulsions, the acts must be an unrealistic attempt to prevent or reduce distress or a dreaded situation and the person must feel driven to perform them.
In children, the most common obsessions involve concerns with dirt or germs; a terrible event happening to the self or a loved one and neatness, orderliness and symmetry. Compulsions most commonly involve excessive hand-washing or other grooming rituals; repeating rituals (for example performing an action a certain way and a certain number of times); and checking behaviours (Swedo, Rapoport et al., 1989).
With adults there is the requirement that the person realises the thoughts and behaviours are unreasonable. This is not required in children although with older children and adolescents it may well be part of the picture. In fact, even in younger children, the child may view the repetitive actions as strange and may certainly be aware that other people find it odd. Like Julie in the case study (see Appendix), children may worry that they are "crazy" because they are aware their thinking is different to that of their friends and family. A child's self-esteem can be negatively affected because the OCD has led to embarrassment and shame.
Another diagnostic element is that the thoughts and behaviours must take up a disproportionate amount of the child’s time, interfering with normal functioning. OCD can make daily life very difficult and stressful for children and their parents. OCD symptoms often take up a great deal of a child's time and energy, making it difficult to complete tasks such as homework or household activities.
In the morning, children often feel they must do their rituals exactly right, or the rest of the day will not go well. Meanwhile, they feel rushed to be on time for school. This combination leads to feeling pressured, stressed, and irritable. In the evenings, they may feel compelled to finish all of their compulsive rituals before they can go to bed. At the same time, they know they must get their homework done and take care of any household chores and responsibilities. Some children stay up late into the night because of their OCD, and are then exhausted the following day.
The concept of risk and resilience
The issue of risk and resilience centres on the question of what makes one child develop a disorder whilst another does not. Risk factors are variables that increase the likelihood of behavioural impairments or problems. However, in the presence of similar risks it is well known that some individuals develop problems, in other words they are vulnerable, whilst others do not because they are resilient. Resilience implies protection from risk and is the ability to ‘bounce back’ from life’s adversities. (Wicks-Nelson & Israel, 2000).
When speaking of risk and resilience, there are two key concepts namely:- ❑ Multifinality – which means having similar beginnings (for example low socio economic status) but very different possible outcomes. ❑ Equifinality – having very different beginnings (for example one poor and the other privileged) but with the same outcome.
Developmental Risk Factors
Some risk factors can be seen as coming from the disposition to respond to life challenges maladaptively. A person’s disposition can arise from biological factors or through life experiences and is usually a combination of both. A difficult temperament is an example of a dispositional risk factor.
Risk is also inherent in life events and situations that cause stress and strain. Stress factors can be acute and occur suddenly such as the unexpected death of a parent or they can be chronic and continuous such as poverty. Some events such as parental divorce may appear to be acute and limited to a certain time frame, but in fact they hold the potential for chronic long-term demands and strain. This can be seen in the long term effects of parental divorce on Julie in the case study (see Appendix).
Of particular importance is the number of risk factors present. A single factor may certainly have an impact but multiple factors are especially deleterious. As the number increases so does the potential for negative outcome. Risks also accumulate over time – that is, the impact of one risk may increase the likelihood that the individual will succumb to future risks.
Resilience
Why do some people, physically and psychologically, survive just about any negative outcome that life presents? There is a tendency to think of resilience as existing within the individual – for example, people say ‘he or she is just a very strong or positive person’. Certainly a child’s inherent characteristics are important but crucial protective factors also reside within the environment.
Sources of Resilience
|Within the person |Family |Extrafamilial |
|Temperament |Stability |Other interested adults |
|Self esteem |Parenting style:- |School & teachers |
|Locus of control |authoritative as |Peer relationships |
|Emotional regulation |opposed to either authoritarian or |Organisations |
| |indulgent | |
There is a constant interaction between risk and resilience factors which changes all the time. This interaction occurs within the child, between the child and the environment and between different risk and resilience factors. Depending on the context, a particular factor may even constitute either a risk or resilience. For example, the peer group may constitute a risk – as in the case of gangs – or may provide protection – for example a group of supportive friends.
How common is OCD in childhood?
OCD was once considered to be a rare phenomenon in children but this is no longer thought to be the case. For example in a study of adolescents who had not been specifically referred for treatment for any psychological problems, Flament and colleagues established that the prevalence rate amongst adolescents was of the order of 1% (Flament et al., 1988).
According to a recent study by Judith Rapoport and Gale Inoff-Germain, OCD in children is often under reported. Although 50% of cases actually have their onset by age 15, pediatric OCD is usually only recognised if very severe and typically years after onset. Children often keep the behaviour a secret and parents frequently underestimate its frequency and severity. This highlights the need for sensitive and direct interviewing of the child. (Rapoport and Inoff-Germain 2000).
Differentiating between clinical and normal obsessive compulsive type behaviour in children
Ritualistic and compulsive-like behaviour can be readily observed in children’s games. Playing tag or hopscotch and reciting rhymes like ‘step on a crack, break your mother’s back’ are common activities that resemble the ritualism and magical thinking that occur in OCD. In these childhood rituals, as in OCD, certain behaviours are performed for the specific purpose of warding off harm to the self or others, notably often the parents (Evans et al 1999).
Working with children less than 12 months old through to 72 months old, the goal of a study by David Evans was to develop a method for measuring and assessing ritualistic and compulsive behaviour in normal children and secondly to discover just how common these behaviours really are. For the purposes of the study, the researchers divided behaviours into two groups, what they called ‘repetitive’ and ‘just right’ behaviours, the second category being behaviours performed in such a way as to satisfy some kind of sensory perceptual criteria (e.g. arranging objects in a very specific way). The study concluded that this type of behaviour is common in early childhood, with different aspects peaking between certain ages, and thus appears to be part of a normal sequence of early development. However, ritualistic behaviour becomes less common after a certain point and its persistence may indicate an overly rigid style at a time when greater flexibility is in fact needed to meet the developmental tasks of older childhood.
This study highlights the importance of distinguishing between OCD and the milder rituals of childhood which are a normal part of development. Obviously the main criteria for differentiating would be the extent to which these behaviours dominate the child’s life and interfere with normal functioning.
An interesting issue from a cultural viewpoint is that the ‘topics’ or ‘subjects’ of obsessions and compulsions are very similar across different cultures. This may indicate that these issues have (or once had) some sort of fundamental biological or survival significance for human beings (Frude 1998).
Specific Risk factors and vulnerabilities in childhood OCD
Like most psychiatric conditions OCD is likely the result of a number of inter-relating factors specific to the individual and his or her circumstances. In a significant number of cases, however, the main underlying vulnerability appears to be genetic or biological in nature.
Several studies have confirmed the familial aggregation of OCD and other related syndromes and it is often observed that a child diagnosed with OCD has family members with OCD, OCD type behaviour of some kind or other anxiety problems. Tourette’s syndrome (TS) is a chronic disorder first appearing in childhood in which sufferers often experience obsessions and compulsions. A number of twin and family aggregation studies as well as linkage analyses support the hypotheses that TS, chronic tic disorder and OCD are passed vertically across generations via a single autosomal dominant gene. (Paul J. Lombroso et al 1994). This study, as well as several others, indicates that the underlying tendency to react to the environment in the particular maladaptive way characteristic of OCD may have a substantial genetic basis. However, it is important to realise that this is not the full story as far as vulnerability goes. If it was, then monozygotic twin studies would show a correlation of incidence of 100%. Since they do not, other factors must also be involved.
Further indicating that a strong genetic predisposition to clinical obsessive and compulsive behaviour is likely is the finding that behaviour similar to that found in OCD is a feature of other known genetic conditions. Prader-Willi syndrome (PWS) is a genetic condition (an abnormality on chromosome 15) featuring mild retardation plus very characteristic behaviours – many of these very similar to those found in OCD. A study of the prevalence of these behaviours amongst a sample of 91 PWS individuals, ranging from 5 years to 47 years, indicated that prominent OCD type symptoms such as hoarding, ordering and arranging, concerns with symmetry and exactness, rewriting and needs to tell, know or ask were seen in 37-58% of the sample (Dykens et al 1996). The study also compared the PWS individuals to age and sex matched non-retarded persons with OCD. Both groups showed similarity with regards severity of symptoms and the number of compulsions.
There is also evidence that, at least in a proportion of OCD sufferers, infection could be either a direct trigger or a significant ‘exacerbating’ agent.
A periodic and gradual waxing and waning of symptoms is typical in many cases of OCD. In paediatric patients with OCD, there is a sub-group whose onset, or the waxing and waning of their usual symptoms, is marked by a sudden dramatic onset of clinically significant symptoms. This is strikingly reminiscent of the course of Sydenham’s Chorea (a variant of rheumatic fever) (Allen et al 1995).
After a resurgence of rheumatic fever in parts of the United States, Rapoport (1989) conducted a survey of 37 patients with rheumatic fever, a strep infection. About 20% of rheumatic fever patients develop Sydenham's Chorea, probably as the result of an autoimmune response in the basal ganglia, leading to potential damage in that area (Rapoport, 1989). In her survey, 23 of the rheumatic fever patients developed Sydenham's chorea and 14 did not. In blind evaluations in which the interviewer did not know the medical diagnosis, scores for obsessional symptoms were significantly higher among those with Sydenham's chorea. In addition, three chorea patients, but no rheumatic fever patients without chorea, met diagnostic criteria for full-fledged OCD. This has been considered as evidence that, at least in some patients, dysfunction of the basal ganglia may be involved in OCD. However, since strep infections are extremely common in children, and a relatively small proportion of such children develop OCD, other mechanisms must also be involved.
In one study which compared the obsessional thoughts of both normal people and those of a clinical sample with OCD it was found that various elements had a bearing on the duration and nature of the obsessions. In both groups the phenomena was related to mood, with both groups reporting greater frequency during periods of stress, anxiety and depression (Barlow 1988). The main difference between the clinical and non clinical groups was that the clinical obsessions lasted longer, were judged to be more intense, more frequent and provoking more discomfort. From this it would appear that environmental stressors are a trigger but that only some persons (presumably those with vulnerabilities in addition to the environmental stressors) react with the characteristic thinking and behaviour of the OCD sufferer.
Stressful events are often found to precede the onset of OCD symptoms. This might be a discrete event such as a death or a longer term stressful life situation such as chronic dysfunction in the family (Frude 1998).
Conclusion
From the foregoing one can conclude that the occurrence of OCD is the result of a number of vulnerabilities or risk factors mitigated by certain resiliencies.
However, It would appear that, compared to other disorders, there is an especially large body of evidence indicating a biological basis or predisposition for the disorder. OCD could be thus seen within the framework of the diasthesis stress model in which the individual has an inherent tendency to react to the environment in a particular way and that this tendency is actualised by stressful events or triggers in that person’s life.
An etiological account of OCD which brings together biological, behavioural and cognitive elements was developed by Barlow (1988). He theorised that some people are biologically predisposed to respond to intrusive thoughts and images in an exaggerated fashion. They experience extremely high levels of arousal as a result of these cognitions which then results in high levels of anxiety. However, these responses will be mediated by the person’s appraisal of the environment and the cognitive intrusions themselves. A further risk factor is that some people tend to judge a very wide range of situations as being highly threatening and many of their judgements reflect irrational beliefs and unwarranted assumptions. As such people become increasingly preoccupied by their intrusive thoughts they are likely to increase their anxiety which in turn increases the intrusive thoughts. Efforts to stop the intrusive thoughts may actually increase their frequency and the person may then engage in certain other cognitions or behaviours to reduce the distress. This usually brings some relief but the nature of it is short lived thus necessitating repetition.
Case Study
The interaction of risk factors can be clearly seen in the case study of Julie. It would appear that Julie has a familial background of anxiety with her mother reporting that she herself is a worrier with a tendency to ruminate over possible negative outcomes. In Julie’s father we see a more direct link to obsessive compulsive behaviour since he reports that he has suffered similar problems himself which are generally precipitated by stress. However, the father indicates that he has had the insight to recognise a problem in himself and appears to have had the resilience to combat the impulses.
In terms of Julie’s temperament it is apparent that even before the onset of OCD symptoms Julie exhibited a sensitive and anxiety prone nature as evidenced by her sleep difficulties, worries over war and unrest and need for reassurance.
Prior to the onset of her OCD symptoms, Julie experiences an extremely traumatic event – marital discord and the subsequent divorce of her parents. Initially, Julie seems able to function relatively normally by assuring herself that the situation regarding her parents is reversible and that the family will be reunited. The fact of the father meeting and then marrying another woman seems to spell the death of this dream and precipitates the start of Julie’s OCD.
Appendix
Case study of Julie
Julie, currently 12 years old, first started to cause concern to her mother when she was 9 years old as a result of compulsive behaviour that was becoming increasingly disruptive to family life.
When Julie was 8 her parents were divorced. The divorce was not an acrimonious one but Julie was considerably upset because her father left the family home. She missed her father and was quite open about her desire for her parents to get back together. She seemed, according to her mother, to believe that this might happen in the future even though the mother was patient in explaining that this would not occur. Julie maintained active contact with her father and did not appear to give up hope that he would eventually move back home.
About a year after the divorce when Julie was 9, her father established a serious romantic attachment with another woman whom he has subsequently married. Julie did not really discuss this in any detail with her mother and on the surface did not appear to be too distressed, she even appeared to quite like her father’s new partner. However, Julie stopped talking about her father moving back home and stopped being enthusiastic about his visits, often finding excuses why they should not take place. As a result the visits gradually decreased in frequency and a coolness descended over her attitude to her father.
Around this time Julie started to exhibit increasingly strange ritualised behaviours which worried her mother a great deal. To start with the behaviours focussed on the neatness and order in Julie’s room. For example, she had a collection of many china cats which had to be arranged in a specific order and in a specific way in their various positions around the room. It took Julie about half an hour at night to check their positions and satisfy herself that everything was in order. Her mother reported that it was almost impossible for her to dust because any re-arrangement of the cats, even minor changes in position, caused tremendous upset and an extended period of checking.
Julie also had rituals involving bathing and dressing and undressing which took increasingly long periods of time and which interfered with getting ready for school and other outings. In the same way, it took a very long time to get changed at night and prepare for bed. Any interference with the rituals caused great distress and resulted in even more time being taken. She developed an itinerary of clothing that was to be worn in specific combinations on the various days of the week and was extremely upset and angry if the clothing was not available on the specific day. This often involved the mother in impromptu washing and ironing sessions which she found tiring and exasperating especially since she worked full time. Julie realised her behaviour was odd and felt embarrassed about it but admitted to her mother that she could not stop herself since she was overwhelmed by the feeling that something terrible would happen either to herself or her mother unless she performed sequences just so. Julie’s mother sought treatment for her daughter when the rituals were taking up between 2 and 3 hours a day and were severely impacting on homework and other aspects of family life.
In terms of temperament, Julie’s mother described her daughter as a rather quiet, shy and nervous child who was always very disturbed by frightening images on the television. For example, on seeing reports of trouble or war on the TV Julie would often express fear that the trouble was nearby and would need to be reassured that it was not. Often she would ask about the item again the following day just to make sure that all was in fact alright. She was also very prone to sleep problems including nightmares and often wanted to sleep in her parent’s bed for comfort.
Julie’s mother reported that she herself, whilst never suffering from obsessions or compulsions, had always been a very anxious person who she said ‘had to fight the tendency to always imagine the worst’ and who always ruminated a great deal on negative issues.
Julie’s father admitted that in the past, particularly in his work as an accountant, he had had compulsive tendencies himself with regard neatness and the correctness of his work. He reported that at the time he recognised that his thinking was a ‘little odd’ and it worried him – in particular the insight that if he was not careful it could ‘get out of control’. He made diligent efforts to control the urges and not act on them. He said that this problem always came about at times of stress such as financial year end and that at more relaxed times he did not experience a problem.
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