Thérapie basée sur les inférences ciblant les enfants ayant un trouble obsessionnel-compulsif : cas clinique

Abstract

Le trouble obsessionnel-compulsif (TOC) se caractérise par la présence d’obsessions et/ou de compulsions, altérant le fonctionnement et causant une détresse significative. Selon the Expert Consensus Guidelines, la thérapie cognitive-comportementale (TCC) combinée à la prise de médicaments est considérée comme le traitement le plus efficace (March, Frances & Carpenter, 1997). Toutefois, selon the Pediatric OCD Treatment Study (2004), 47 % des enfants ayant un TOC sont réfractaires à la TCC combinée à la prise de médicaments après 14 semaines de suivi. Fontaine, Berthiaume et O’Connor (2018), ont mis sur pied un manuel de traitement inspiré du modèle adulte de la thérapie basée sur les inférences (TBI). La TBI cible les composantes imaginaires des obsessions et des compulsions dans le récit de l’enfant et identifie le doute obsessionnel pour diminuer les symptômes du TOC plutôt que d’utiliser des techniques d’expositions avec prévention de la réponse (O’Connor & Aardema, 2011). L’objectif de cette étude est d’évaluer la faisabilité et l’effet de la TBI auprès d’un enfant. Cette étude présente l’étude de cas d’une enfant de 12 ans atteinte du TOC. Les résultats montrent une réduction complète des obsessions et des compulsions à la fin du traitement, alors que ces dernières étaient considérées comme sévère à l’évaluation prétraitement. L’amélioration clinique des symptômes du TOC s’est maintenue à l’évaluation de suivi huit mois. La présente étude de cas évalue la faisabilité et évalue l’effet de la TBI chez l’enfant montrant des résultats prometteurs. Ainsi, une étude de validation de l’efficacité de la TBI devra être conduite ultérieurement en tenant compte des limites méthodologiques et des pistes de réflexion suggérées.

Obsessive-compulsive disorder (OCD) is characterized by the presence of obsessions and/or compulsions that affect child functioning and causes significant distress. Cognitive behavioral therapy (CBT) combined with medication is considered the most effective treatment (Pediatric OCD Treatment Study [POTS], 2004). However, 40 % of children with OCD are refractory to treatment and obsessions or compulsion symptoms remains (Pediatric OCD Treatment Study [POTS]), 2004). In response to the large percentage of children who do not respond to traditional CBT, Fontaine Berthiaume and O’Connor (2018), have developed an inference-based therapy inspired by the adult model. This therapy focuses on imaginary components of the obsessions and the narrative of the child, rather than the irrational beliefs that maintain obsessions. The main aim of the study was to evaluate the feasibility and the effect of inference-based therapy on OCD symptoms in children (Fontaine Berthiaume & O’Connor, 2018). In order to test our hypothesis, we examined a case study of a twelve-year-old recruited at a pedopsychiatric hospital in Montreal. Her neuropsychologist had already diagnosed her with OCD, and she had motor and vocal tics as well as dyslexia. However, the obsessive-compulsive symptoms were the most disabling, more precisely compulsions with respect to counting everything in her environment. These obsessive-compulsive symptoms took more than 8 hours of her time per day. To assess the strength of obsessions and compulsions the child completed questionnaires measuring the severity of OCD, such as the Children's Yale-Brown Obsessive Compulsive Scale (Goodman, Price, Rasmussen, Riddle & Rapoport, 1991), the Child Obsessive-Compulsive Impact Scale-Revised (Piacentini, Peris, Bergman, Chang & Jaffer, 2007) and the Children Depression Inventory (Kovacs, 1992). Mean comparisons using the different questionnaires were made pre and post treatment. The results indicated complete remission of obsessions and compulsions at the end of treatment, whereas OCD symptoms were considered severe at the pretreatment evaluation. A comparison of the results using the Children's Yale-Brown Obsessive Compulsive Scale (Goodman et al., 1991) was made with the sample of Storch and colleagues (Storch, Murphy, Geffken, Soto, Sajid & Allen, 2004). The results show a z-score of 2.84 below the Storch et al. (2004) average, in post-treatment. Also, the results show a complete reduction of social functioning difficulties and an improvement in social and family spheres in post treatment. A comparison of Child Obsessive-Compulsive Impact Scale-Revised (Piacentini et al., 2007) results was made with the Skarphedinsson and colleagues sample (Skarphedinsson, Weidle, Thomsen, Dahl, Torp, Nissen et al., 2015). The results show a z-score of 1.32 below the Skarphedinsson and colleagues (2015) average in post-treatment. The improvement in obsessions and compulsions and with respect to social functioning was maintained at following up eight months after therapy. The evolution of obsessions and compulsions throughout the sessions identified key steps in the success of the therapy. Indeed, the theme of vulnerability was a central element in improving the symptoms of the participant. This case study not only demonstrated a positive effect of the program for reducing pediatric OCD symptoms, but also allowed the therapist to identify the most important section of the intervention program during the therapeutic process. This study was intended to be the first step in evaluating the feasibility and the effect of the inference based therapy for children with OCD. Overall, the case study of the young participant shows a promising avenue for the treatment of severe pediatric OCD. Changes in the inference based therapy program for children have subsequently been made to improve the integration of contents and the adherence of participants to therapy over sessions. Thus, a study measuring the efficacy of this treatment with a larger sample could be conducted in the future.