When nervous habits become a problem

Researcher talks about the importance of early diagnosis and treatment of Obsessive-Compulsive Disorder in children.

By Karina Toledo

Agência FAPESP – Rituals are part of the routine of any small child. Many children have to hear their favorite bedtime story or to say goodnight to all their stuffed animals and dolls before going to sleep. Others like to count trees when riding in cars or avoid stepping on the cracks in sidewalks while walking.

However, when these typical childhood behaviors become very frequent and begin to interfere with routines or cause suffering, they may be the symptoms of Obsessive-Compulsive Disorder (OCD).

Specialists classify cases in which the disease manifests before age 10 as early-onset OCD. It has been believed that the earlier the symptoms appear, the worse the prognosis is. However, recent studies have shown that the starting age is not the determining factor; rather, the crucial factor is the time the patient remains without treatment.

Maria Conceição do Rosário, professor at Universidade Federal de São Paulo’s Child and Adolescent Psychiatry Unit (UPIA-Unifesp), addressed this subject during the World Congress on Brain, Behavior and Emotions, held in São Paulo in late June.

Rosário holds a doctorate in psychiatry from the Universidade de São Paulo’s School of Medicine and was a FAPESP fellow. After the completion of her doctorate, she held a post-doctorate at Yale University in the United States as a fellow of the Obsessive Compulsive Foundation and the Tourette Syndrome Association.

In partnership with Professor Marcos Mercadante, Rosário founded UPIA, which today serves approximately 500 children per month. She was the coordinator of the unit from 2009-2010 and currently heads the Obsessive Compulsive and Attention Deficit Hyperactivity Disorder units.

She is also a member of the Brazilian Research Consortium on the Obsessive Compulsive Spectrum (CTOC), which brings together nearly 70 researchers from seven institutions in five Brazilian states: São Paulo, Rio de Janeiro, Bahia, Rio Grande do Sul, and Pernambuco – as well as the International Genetics Consortium on OCD.

She collaborates in studies linked to the National Institute of Developmental Psychiatry (INPD), one of the National Science and Technology Institutes funded by FAPESP.

In an interview with Agência FAPESP, Rosário spoke about the importance of early diagnosis and treatment of OCD in children.

Agência FAPESP – Small children tend to like repetition and rituals. When is this no longer normal?
Maria Conceição do Rosário – There are phases of development in which rituals tend to be more intense and frequent, like between the ages of two and five, during adolescence, and in the pre-natal period – one month before giving birth – and the three months following delivery for men and women who become parents. These are periods of transition, and rituals help to organize the routine and leave the individuals more at ease. In the case of small children, rituals tend to emerge around eating, sleeping, and bathing. Some people can see symptoms of obsessive-compulsive disorder manifest, but they later disappear. This could mean that there is a predisposition. These are periods of greater vulnerability, and if the individual undergoes a traumatic or stressful situation, she could develop the disease. However, there is a difference between having obsessive-compulsive symptoms and having OCD. This is determined by three factors: the time the person spends on rituals and obsessive thoughts, the interference they cause to one’s routine, and the discomfort they cause. If the child begins to be late to activities, no longer plays for fear of getting dirty, believes that something will cause bad luck, or cannot sleep if their parent does not read the same story several times in the same way and is upset by the situation, this could be a red flag. However, when these occurrences are not very frequent or intense, the OCD symptoms can aid in development.

Agência FAPESP – Up to how many times a day would the manifestation of the symptoms be considered normal?
Rosário – In general, up to one hour a day, adding all the rituals and obsessive thoughts. This, however, could vary. In some cases, for example, it could last just 40 minutes and cause a major uproar or dramatically interfere with the routine. This would be enough for a diagnosis. It is important to consider the times of the day that they [the symptoms] are appearing, if there is a trigger, and what happens when the person has these thoughts. Is she calmer after doing the ritual or more anxious? Is she bothered? These are parameters that are often very difficult to evaluate. When in doubt, the parents can take their child for an evaluation. There are cases in which just orientation and re-adaptation to the routine resolves the matter. Delays in diagnosis and treatment, on the other hand, can worsen the development of the case.

Agência FAPESP – Why?
Rosário – Previous studies indicated that early onset OCD – before age 10 – was more serious and was worse in terms of progression than cases where symptoms appeared in adulthood. We are discovering that it is not the age that the disease manifests that makes the difference, but rather the time the person goes without treatment. This is more of a determining factor. There are neuroimaging studies that show changes in neurotransmission after treatment, both with medication and behavioral therapy. One of the hypotheses is that the sooner neurotransmission is normalized in the brain, the less development will be compromised. The second hypothesis proposes that the longer a child spends with obsessive-compulsive symptoms without adequate treatment, the greater the risks to school performance, self-esteem, and the ways she will relate to parents, the world, and herself. The more time she spends with all these experiences, the more difficult it will be to have a normal life. The third hypothesis for the progression of the disease in early onset cases is the occurrence of comorbidities. The longer it goes untreated, the greater the patient’s risk of developing associated disorders, such as social phobia, depression, and addiction, among other things. This is one of the main factors concerning response to treatment.

Agência FAPESP – What are the most frequently associated disorders?
Rosário – The younger the child, the greater the risk of also suffering attention deficit hyperactivity disorder, nervous tics, and other anxiety disorders. In the adult age, depression is more frequent, reaching up to 80% of patients, according to some studies.

Agência FAPESP – Is there a minimum age to confirm an OCD diagnosis?
Rosário – No. In the event of autism spectrum disorders, for example, we normally wait until three years of age for diagnosis. For ADHD, the symptoms must appear by age 12. In the case of OCD, there are no age parameters. The disease could manifest in any age range. What must be clear is that OCD covers very heterogeneous medical conditions. In an attempt to reduce this heterogeneity and ease research and clinical consultation, we tried to determine possible subgroups. One of these subgroups is early-onset OCD. It is a very different condition from the disorder that emerges in adulthood. The progression of the condition depends on the type of symptom, the family profile, the type of treatment that the child has access to. But if it is not treated, it will certainly turn into a more serious condition. Another predictive factor of a poor prognosis is a worsening of symptoms soon after they appear. The more intense they are as the condition appears, the worse the prognosis.

Agência FAPESP – What causes the disease?
Rosário – There is an interaction of genetic, environmental, and neurobiological factors. However, regardless of the etiology, the consequence is a functional alteration in the brain. Currently, the most widely accepted hypothesis is that there are changes in the neurotransmission of the cortical striatal thalamic circuit. All studies indicate that these circuits are compromised to a certain degree. However, it is not a lesion, such as a tumor or cyst. It is a change in their functioning.

Agência FAPESP – What are the risk factors for the development of OCD?
Rosário – One of the parents having obsessive-compulsive behavior or nervous tics is a risk factor because we know there is a genetic predisposition and there is an association between OCD and Tourette syndrome (a neuropsychiatric disorder characterized by nervous tics, spasms, or vocalizations that occur repeatedly in the same manner with considerable frequency). Stressful situations experienced by the child are also risk factors. A traumatic situation could trigger the disease, but it does not necessarily have to be tragic. It could be, for example, someone to whom the child is attached moving far away. In adolescents and adults, there are some studies that discuss drug use. Exposure to toxins such as lead, cigarettes, and alcohol during lactation is a risk factor for any psychiatric pathology.

Agência FAPESP – How is it diagnosed?
Rosário – Diagnosis is fundamentally clinical. For now, there are no exams that detect OCD. There are some scales and evaluation instruments to monitor the presence and severity of symptoms. However, they serve to monitor its evolution and are not for diagnosis.