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Furthermore, because adolescents hide their symptoms, it is difficult to determine the actual prevalence of the disorder, and when they seek professional help, they may be misdiagnosed as depression or anxiety disorder due to not mentioning their symptoms [ 31 ]. In the past few decades, knowledge of OCD has increased, but studies were mostly done in adult population and less studied in children.

Although the first study about the prevalence of OCD in children was reported in , there are few population-based studies presented about the prevalence of OCD in children and adolescents recently [ 32 ].

Structure–Function Correlates of Cognitive Decline in Aging | Cerebral Cortex | Oxford Academic

The prevalence of OCD in children and adolescents has been reported between 0. In a recent study, in 16 European countries, median prevalence of OCD was found 0. It is predicted that OCD is the fourth frequent psychiatric disorder after phobies, substance use disorder, and depression. Studies in different countries and cultures show that OCD prevalence is independent from cultures [ 27 ].

Previous epidemiological and clinical studies show that OCD is more frequent among males prior to adolescence and during childhood, the difference between the sexes diminishes to a similar rate as the age advances, and the prevalence rate does not differ between sexes during adolescence and adulthood, and the rates are equal in both sexes at this time [ 36 , 37 , 38 , 39 , 40 , 41 , 42 , 43 , 44 , 45 , 46 ].

OCD has adverse effects on family, school, and social lives of children and adolescents [ 49 , 50 ]. Several studies have detected that OCD often starts at late adolescence and early adulthood period [ 51 , 52 ]. Studies with adolescents showed that OCD development risk is higher at late adolescence than early adolescence [ 53 ]. It is generally considered that in children obsessive thoughts are less common compared to adults; solely compulsive behaviors in the absence of obsessive thoughts are more frequent, while solely obsessive thinking is less common [ 45 ].

However, there are studies in literature showing that all children with compulsive aspect of the disease also have accompanying obsessions [ 57 ]. Some studies have reported that unlike adults, children may add their families in their rituals, and they cannot describe triggering factors and stressors as well as adults [ 42 ]. A study including 44 adolescents, 43 early onset adults, and 45 late onset adult OCD patients reported that religious and sexual obsessions are more common in adolescents than in adult patients, obsessions about contamination are more common in adolescents, and grooming compulsions are more frequent in early onset adults than adolescent patients [ 60 ].

Childhood OCD in boys is 1. In boys disorder is more severe, and neurological symptoms and comorbidities are more common [ 27 ].


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Poor insight in children and adolescents with OCD is associated with severity of symptoms and loss of functionality and has a great influence on duration and success of treatment [ 62 , 63 ]. Poor insight in OCD causes patients not to recognize their symptoms as a problem and results in reduced treatment motivation and treatment success. Therefore OCD patients with poor insight may be misdiagnosed or may not seek treatment [ 62 , 64 ]. It involves two subscales for Obsessions Severity and Compulsions Severity, and total score is estimating with these two subscales [ 65 , 66 ].

The most commonly reported accompanying diagnoses include anxiety disorder and depression [ 71 , 72 , 74 ]. In addition to these accompanying disorders, eating disorders, especially anorexia nervosa, can be frequently observed concurrently with OCD in females [ 79 ].

Language development and literacy

Other studies have found association between early onset OCD and somatoform disorders, tic disorder, impulse control disorder, and high resistance to treatment [ 80 , 81 , 82 , 83 ]. There are many diagnoses that can be confused with OCD. For example, some anxiety disorders must be considered like generalized anxiety disorder, specific phobia, and social anxiety disorder.

In generalized anxiety disorder, recurrent thoughts are usually about real-life concerns as finances and family, but in OCD these thoughts are irrational. Anxiety of patients with specific phobia is more limited with specific objects or situations, and they do not have rituals or compulsions. In social anxiety disorder, fear is limited with social situations.

Some disorders that are under the category of OCD and related disorders like body dysmorphic disorder, trichotillomania, and hoarding disorder can interfere with OCD. In body dysmorphic disorder, obsessions and compulsions are only with physical appearance; in trichotillomania there are no obsessions, and compulsive behaviors are only hair pulling. Hoarding disorder patients have difficulty in discarding or parting with possessions. In consequence objects extremely accumulate, but in OCD obsessions are not typically related with dispose of objects.

Although obsessions and compulsions in anorexia nervosa are limited to body image or weight, this disorder can be confused with OCD. Tic disorders also can be misdiagnosed as OCD. Tics are not related with neutralizing obsessions, and tics are less complex than compulsions. Not only OCD but also psychotic disorder patients can have irrational thoughts or delusional beliefs. But OCD patients do not have other psychotic symptoms and recognize that the intrusive thoughts are a product of their own mind.

Obsessive-compulsive personality disorder does not have specific obsessions or compulsions but have a resistant perfectionist or controller personality structure. OCD can be confused with some medical conditions because of the results of compulsions like eczema, rashes, and constipation [ 8 , 9 , 84 ].

CBT is a kind of psychotherapy which is developed on the basis of learning theories in psychology and the principles of cognitive psychology. The purpose of this therapy is to change emotions and incompatible behaviors by using psychotherapeutic methods based on these principles [ 86 ]. Behavioral therapies began to be used in the treatment of emotional and behavioral problems of young people in the s. These behavioral approaches are based on the theories of Thorndike, Watson, and Bandura, and classical and operant conditioning have been used to treat behavioral disorders seen in infants and children.

Cognitive therapies were developed by Aaron Beck in the s and started to be used in the treatment of child and adolescent cases in the s [ 87 ].

Background

According to CBT, the mental condition of a person is the result of the mutual interaction of the environment, relationships, the biological structure, emotions, cognition, and behaviors. Psychotherapeutic methods can only be applied to cognition and behaviors of a person [ 86 ]. In the CBT, children and adolescents learn to confront with their fears step by step. By learning how to behave against what the OCD tells them, they would understand that their fears do not reflect reality [ 90 ]. According to cognitive theory, cognitive processes determine the feelings and behaviors of people.

Hence, problems that disturb the person are not due to the events and experiences themselves but due to perception and evaluation of the events and experiences [ 92 ]. Instead of these problematic forms of interpretation, cognitive therapy tries to reveal more compatible and appropriate perception and evaluation structures for a situation [ 93 ]. Additionally, cognitive therapy emphasizes that improper cognitive structures are an important factor in emerging and maintaining mental disorders.

The basic cognitive features of OCD are an overestimation of thoughts and feelings, exaggerated sense of responsibility, perfectionism about controls of thoughts and behaviors, and catastrophic interpretation of possible outcomes of thoughts and impulses, and these features lead to misinterpretations [ 21 ]. Cognitive therapy firstly tries to establish connections among emotion, behavior, and thought [ 94 ]. Cognitive therapy deals with automatic thoughts. These thoughts are spontaneous and located in the stream of mind. Also, they are cognitions that are mostly specific to environment and situation that accompanied to moments of emotional distress.

Contrary to emotions automatic thoughts are rarely noticed. These thoughts could be verbal or imaginary. Nonfunctional intermediate beliefs lead the therapist to core beliefs that are the deepest cognitive structures. These beliefs are reinforced by similar experiences and learnings by time [ 95 ].

According to Piaget, the child enters the concrete operational stage around the age of 7—8. Most of the children at the concrete operational stage have the logical processes to take advantage of the cognitive debate. There may be difficulties in cognitive therapy in children who have not reached the concrete operational stage [ 95 ]. So the first thing to do by the therapists is to introduce themselves and to explain to the child who they are, what they do, and how they can help [ 93 ].

Cognitive Behavior Theory

The most effective behavioral techniques are a combination of exposure and response prevention. It is always worth making an initial consultation visit to familiarize the child or adult with the professional and to see if this is a good match for your needs.


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Such an introductory visit is helpful as it enables the child or adult with Down syndrome also to feel comfortable with the place, provider, and it also enable you to get a timely appointment in a crisis situation in the future when a critical situation arises. It is often much more difficult to get an initial appointment and to be able to do so in an acute situation has become increasingly difficult, especially in well known centers.

Please remember that the ideal mental health provider skilled in Down syndrome is someone who has knowledge of developmental disorders and who also has had experience in working with children. It may be advisable to first seek a mental health provider who works in a pediatric medical center or who works in close proximity to a pediatric practice.

Many of these programs have been in existence for over 30 years and are located in tertiary care centers with interdisciplinary services that include mental health professionals child psychiatrists, psychologists, social workers , as well as developmental-behavioral pediatricians. The UCEDD programs can also provide advice regarding referral to adult service in the community and help locate mental health providers that have expertise in working with individuals with Down syndrome.

If it is very important to select a psychiatric provider with expertise in medication management with individuals with developmental disorders, it is critical that you find someone who has worked in close proximity to a medical practice, or agency serving the needs of individuals with developmental disorders. This is a common question that many medical as well as mental health providers are asked by concerned parents.

This manifests as an increased level of both baseline as well as situational anxiety with clear cut stressors for each. Situational anxiety is often manifest during transitions and anticipation of new situations, e. They also engage in repetitive, compulsive, as well as ritualistic behaviors that raise the question of obsessive-compulsive disorder.


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The child or adult under these circumstances tends often to be unhappy, fearful, and the two states — generalized anxiety and obsessive -compulsive behaviors — may often co-exist. The disruptive, oppositional and inattentive child with Down syndrome often does not tend to be unhappy, but rather quite silly, happy, and excited. Unlike in children with Down syndrome with impulsive, oppositional, and attention deficit profile, the restlessness, fidgeting, and compulsiveness associated with generalized anxiety state has an identifiable onset with a more intermittent course.

There is a need to take a detailed history in all these situations in order to identify the source or environmental triggers contributing to the anxiety in relation to change in immediate home, school or work environment. In such circumstances assessment of antecedents, behaviors, and consequences ABCs and development of a behavioral modification and management plan is essential.

The use of antidepressants or anti-anxiety medications may help and should be reserved for more persistent and serious level of symptoms. Disrupted sleep commonly co-occurs in both depression and anxiety states and do not necessarily help us to distinguish between them. These may include previously unrecognized medical illness or pain or psychosocial stressors, e.

We recommend that if any negative changes are to be anticipated that supportive counseling services and supports be put in place in anticipation of their impact. Attempt to treat persistent depression in the context of ongoing stress with pharmacological intervention is often futile without individual supports.

Combination treatment involving both psychosocial and pharmacological components is needed. In children with greater cognitive and receptive-expressive language deficits, especially for younger age groups, the difficulties in attention are often accompanied with impulsive and hyperactive behaviors. This pattern of inattention, impulsivity and motor hyperactivity is consistent with a diagnosis of Attention Deficit Hyperactivity Disorder.