Did You Know?

Observed annually on March 21, the International Day for the Elimination of Racial Discrimination commemorates the Sharpeville Massacre of 1960, when police in Sharpeville, South Africa, killed 69 people at a peaceful demonstration against apartheid “pass laws.” The United Nations General Assembly designated the day in 1966. It calls on all of us — individuals, organizations and governments — to work to end racial discrimination in all areas of life.

As a determinant of health, racism has a profound impact on child well-being. To learn more about this and about our evaluation of childhood antiracism interventions, see Volume 15, No. 3 of the Children’s Mental Health Research Quarterly.

Findings from a recent systematic review by the Children’s Health Policy Centre offer hope for children with obsessive compulsive disorder (OCD). These results suggest five implications for practice and policy:

• Start with Cognitive Behavioural Therapy (CBT) for childhood OCD. A strong body of evidence supports CBT — showing that it produces clinically meaningful reductions in both symptoms and diagnoses. It is also effective for children ranging from ages three to 18. CBT should therefore be the starting point for treatment.
• Build CBT capacity. Despite the strong evidence for CBT’s effectiveness in treating OCD, many young people have difficulties finding a practitioner to provide this intervention. In fact, in most countries, young people with OCD have limited access to CBT. Canadian policy-makers therefore may need to invest in training so that more practitioners can provide this highly effective treatment in public settings — and so that all children with OCD can receive timely treatment, with no out-of-pocket costs.
• Support family involvement. CBT for OCD often incorporates families into the treatment. The roles for families can be extensive, ranging from helping to develop treatment goals to encouraging children to practise CBT techniques. For younger children, family involvement is critical, as Family CBT is the form of CBT that has shown efficacy with children younger than age eight. For older children, family involvement should also be encouraged where feasible. As well, when family issues impede CBT’s effectiveness, Positive Family Interaction Therapy may be a helpful addition.
• Reach more children in need by expanding delivery options. Many children can benefit from CBT without ever entering a practitioner’s office. Studies show the effectiveness of telephone- and internet-based CBT equals that of in-person delivery for many children. These delivery modalities also make it possible to reach more children, including those in more remote communities. Internet delivery may also help reduce costs because it requires less practitioner time.
• Consider medications when CBT does not succeed. Some children continue to experience impairing symptoms, even after an adequate course of CBT. For these children, medications should be considered — particularly fluoxetine and sertraline, given their efficacy and more favourable adverse event profile. Still, children taking either medication need to be carefully monitored to assess both its effectiveness and potential adverse events.

All children diagnosed with OCD need rapid access to CBT. By providing this treatment early in the disorder’s course, associated distress and impairment for children and their families can be greatly contained. For more information, see Vol. 16, No. 1 of the Children’s Mental Health Research Quarterly.

Watching a child struggle with OCD symptoms can be both agonizing and frustrating. As a result, many family members try to help by assisting with their child’s OCD rituals. This can range from a mother repeatedly answering her son’s questions about his well-being to reduce his distress to a father changing his work schedule to allow more time for his daughter to repeatedly check the locks when leaving home. The frequency of family members participating in children’s OCD symptoms is so common that the term “family accommodation” was coined to describe it.

In fact, one study found that 99% of parents reported participating in at least one type of accommodating behaviour and 77% reported doing so daily. Despite parents having the best of intentions, accommodating OCD symptoms comes with risks, including maintaining or worsening the severity of the child’s symptoms and impairment. But the good news is that parents can learn strategies that help them disengage from these behaviours. For more information, see Vol. 16, No. 1  of the Children’s Mental Health Research Quarterly.

Pink Shirt Day, also known as antibullying day, encourages people across Canada to stand against all forms of bullying. Since its inception in 2007, Pink Shirt Day has helped raise millions of dollars for antibullying initiatives. This year, on February 28, participants in schools and workplaces nationwide will come together to raise awareness, promote inclusion and celebrate acts of kindness.

Bullying remains a significant problem in schools — a 2019 report by Smith et al. and the McCreary Centre Society found that 53% of BC students aged 12 to 19 years reported experiencing at least one form of bullying in the past year. But the right interventions can make a difference. In fact, the Children’s Health Policy Centre’s recent systematic review of antibullying programs found five interventions that reduced at least one form of bullying. To learn more, see Vol. 15, No. 4 of the Children’s Mental Health Research Quarterly.

A strong body of evidence supports cognitive behaviour therapy (CBT) for obsessive-compulsive disorder (OCD).  Beyond showing that CBT is effective, studies have also demonstrated that this treatment produces clinically meaningful reductions in both symptoms and diagnoses. When using CBT, practitioners typically begin by presenting children and parents with information about the disorder, including explaining what the treatment will involve. As part of this process, children are often encouraged to give the disorder a “nasty nickname” — to help them resist their symptoms and not blame themselves for having OCD. Children also identify their specific obsessions, compulsions, triggers and avoidance behaviours as part of developing the treatment plan.

To address physical OCD symptoms, children learn specific behavioural strategies such as relaxation and breathing techniques. Children also learn cognitive strategies such as challenging their beliefs about the likelihood of feared outcomes coming true. Children then practise exposure and response prevention, the core component of CBT. This involves children confronting their obsessions while resisting the urge to engage in compulsions. For more information, see Vol. 16, No. 1  of the Children’s Mental Health Research Quarterly.

Studies examining potential risk factors for obsessive-compulsive disorder (OCD) have identified both biological and environmental variables. Yet, the unique contribution of each identified variables was relatively small. This suggests that more research is needed to understand how OCD develops. In particular, studies identifying additional modifiable risk factors will be particularly helpful in informing and guiding the development of preventive interventions.

Still, research on protective factors for OCD is also beginning to emerge. For example, a prospective study in a representative sample of 515 adolescents identified one modifiable protective factor. Specifically, having higher emotional stability was associated with having fewer OCD symptoms in adolescence. (Emotional stability was defined as the ability to regulate emotions, or maintain a balanced affect over time.) For more information, see Vol. 16, No. 1 of the Children’s Mental Health Research Quarterly.

A recent meta-analysis estimated that 0.3% of children meet diagnostic criteria for obsessive-compulsive disorder (OCD) at any given time. This equates to about 18,500 children in Canada and 2,300 children in BC. OCD also starts early, with nearly 25% of boys who develop it doing so  before age 10 and with 25% of overall cases emerging by age 14. This early onset makes it crucial to identify these young people and provide effective treatments quickly, so children can thrive and so OCD does not persist into adulthood. For more information, see Vol. 16, No. 1  of the Children’s Mental Health Research Quarterly.

Many children experience repetitive thoughts and behaviours. A preschooler may insist on having the same book read to her every night for several months. A middle-schooler may frequently express his displeasure about attending a new after-school program. But these kinds of typical behaviours differ from the more intense, enduring and impairing obsessions and compulsions that are the hallmarks of obsessive-compulsive disorder (OCD).

Obsessions involve recurrent and persistent thoughts or images that are intrusive, unwanted and time-consuming, taking more than an hour per day. Compulsions, meanwhile, are repetitive behaviours or mental acts that a child feels obliged to do, typically to relieve distress associated with an obsession. Young people with OCD usually experience both obsessions and compulsions. These may include fear of contamination, fear of being aggressive, wanting to make things “just right,” as well as distressing sexual or religious thoughts. For more information, see Vol. 16, No. 1 of the Children’s Mental Health Research Quarterly.

A systematic review by the Children’s Health Policy Centre found five interventions that reduced at least one form of bullying, albeit with only modest effects for some interventions. Four of these programs were delivered in classrooms and showed success from the early years to adolescence: Youth Matters (elementary schools); Roots of Empathy (elementary and middle schools); Bullies and Dolls (secondary but not middle schools); and Media Heroes (middle and secondary schools). One clinical intervention — Integrative Family Therapy — was also effective at reducing bullying by teenage boys.

These findings suggest several implications for practice and policy.

• Reach children across a range of ages. The effective antibullying interventions we identified can be delivered in elementary, middle and secondary schools. So, programs can start early and be offered across a range of ages, which means they will reach more children to prevent the harms that come with bullying.
• Invest in reducing all forms of bullying. Most of the programs we reviewed aimed to reduce face-to-face bullying. But one program — the 10-session version of Media Heroes — effectively reduced cyberbullying. Efforts to reduce cyberbullying could be modelled on this successful program and evaluated for effectiveness in BC.
• Ensure adequate program duration. Two unsuccessful programs stood out for being particularly brief. Both Incremental Theory of Personality Intervention and the four-session version of Media Heroes were delivered over one day. In contrast, the five successful programs ranged in length from three weeks to two school years. So, interventions should mirror these longer durations.
• Watch for unintended consequences. Bullies and Dolls led to very different outcomes based on the grades students were in. While the program reduced victimization for students in Grades 8 and 9, it increased both victimization and perpetration for students in Grades 6 and 7. So this program caused harm for younger students and should not be used with them. As well, these findings illustrate the importance of always monitoring outcomes to ensure that program benefits outweigh harms. Evaluating programs in BC is particularly important when programs have been developed and tested elsewhere, and when there are no replication randomized controlled trials.
• Recognize that some children and families can benefit from the help of a mental health practitioner. Schools are excellent venues for reaching large numbers of children with antibullying programs. But some young people may need the support of a practitioner to address bullying and other aggressive behaviours. The clinic-based Integrative Family Therapy may be a helpful option for teenage boys who bully others.

Adults play crucial roles in creating and sustaining the environments that help children flourish and keep them safe. These roles include striving to ensure that homes, schools and communities are free of bullying in all its forms, for all children. For more information, see Vol. 15, No. 4 of the Children’s Mental Health Research Quarterly.

Roots of Empathy is a Canadian-developed program that aims to reduce bullying, aggression and violence in general. Certified instructors deliver the 27-session program over one school year to students in kindergarten and Grades 4 and 8. More than 165,000 BC students have participated in Roots of Empathy. And the program’s reach continues to grow. Many First Nations, Inuit and Métis communities in BC and throughout Canada have been delivering the program. It has also garnered noteworthy support from the Assembly of First Nations. In 2008, this organization endorsed a resolution supporting the program, citing its compatibility with traditional First Nations teachings and world views. For more information, see Vol. 15, No. 4 of the Children’s Mental Health Research Quarterly.