Hoarding Symptoms in Children and Adolescents With Obsessive-Compulsive Disorder: Clinical Features and Response to Cognitive-Behavioral Therapy

Hoarding behavior and its association with mental health and functioning in a large youth sample

Hoarding behavior is prevalent in children and adolescents, yet clinicians do not routinely inquire about it and youth may not spontaneously report it due to stigma. It is unknown whether hoarding behavior, over and above obsessive-compulsive symptoms (OCS), is associated with major clinical factors in a general youth population. This observational study included N = 7054 youth who were not seeking help for mental health problems (ages 11-21, 54% female) and completed a structured interview that included evaluation of hoarding behavior and OCS, as a part of the Philadelphia Neurodevelopmental Cohort between November 2009 and December 2011. We employed regression models with hoarding behavior and OCS (any/none) as independent variables, and continuous (linear regression) or binary (logistic regression) mental health measures as dependent variables. All models covaried for age, sex, race, and socioeconomic status. A total of 374 participants endorsed HB (5.3%), most of which reported additional OCS (n = 317). When accounting for OCS presence, hoarding behavior was associated with greater dimensional psychopathology burden (i.e., higher P-factor) (β = 0.19, p < .001), and with poorer functioning (i.e., lower score on the child global assessment scale) (β = - 0.07, p < .001). The results were consistent when modeling psychopathology using binary variables. The results remained significant in sensitivity analyses accounting for count of endorsed OCS and excluding participants who met criteria for obsessive-compulsive disorder (n = 210). These results suggest that hoarding behavior among youth is associated with poorer mental health and functioning, independent of OCS. Brief hoarding-behavior assessments in clinical settings may prove useful given hoarding behavior's stigma and detrimental health associations.

Childhood Obsessive-Compulsive Disorder

Obsessive-compulsive disorder (OCD) frequently affects children and adolescents, with most cases beginning during this time. Symptoms of OCD in youth may present as exaggerated developmental concerns and excessive ritualistic behavior beyond what is part of normal development, yet low levels of insight may prevent recognition. Affected youth commonly have comorbid neurodevelopmental diagnoses, especially males. Early detection and intervention are critical to recovery and remission, as well as family involvement in treatment. Cognitive behavioral therapy and serotonin reuptake inhibitors are first-line treatments.

Hoarding Disorder: The Current Evidence in Conceptualization, Intervention, and Evaluation

Hoarding disorder is characterized by difficulty parting with possessions due to strong urges to save the items, leading to the excessive accumulation of items. High clutter levels result in varied personal, social, and legal consequences. Specialized treatments, including individual, virtual, and group cognitive and behavioral therapies, community-based interventions, and peer support approaches have shown preliminary effectiveness. Animal, attachment, and neurobiological models are expanding our understanding of the etiological bases of the disorder. Specialized populations such as children, older adults, and involuntary patients are highlighted as requiring special consideration for intervention and risk mitigation. Directions for future research are identified.

Co-occurring Obsessive-Compulsive Disorder and Hoarding Disorder: A Review of the Current Literature

Current research suggests obsessive-compulsive disorder (OCD) co-occurs in around 20% of people with hoarding disorder (HD). The article discusses the theoretical conceptualization of co-occurring HD and OCD (HD+OCD), highlighting similarities between the disorders that may contribute to comorbidity, such as potentially overlapping etiological factors, comorbidity profiles, and phenomenological aspects; and differences that are important to consider in differential diagnosis and conceptualization, such as belief patterns, ego-syntonicty/dystonicity, and trajectory. The combination of HD+OCD versus either disorder alone appears to be associated with a profile characterized by higher nonhoarding OCD symptoms, anxiety symptoms, depression, and tic disorders, and which may be more treatment-refractory. The authors discuss some commonly used measures to assess hoarding that may be relevant in the context of OCD, as differential diagnosis of hoarding behaviors is often difficult, and hoarding may be difficult to detect in patients with OCD, especially in children. The article ends with a discussion on considerations for the treatment of HD+OCD with cognitive-behavioral therapy, as hoarding symptoms are less likely to respond to gold-standard exposure and response prevention, and there are no established treatment protocols that are designed to treat co-occurring HD and OCD.

Hoarding Disorder: Development in Conceptualization, Intervention, and Evaluation

Hoarding disorder is characterized by difficulty parting with possessions because of strong urges to save the items. Difficulty discarding often includes items others consider to be of little value and results in accumulation of a large number of possessions that clutter the home. Cognitive-behavioral therapy (CBT) with exposure and response prevention and selective serotonin reuptake inhibitor medications traditionally used to treat obsessive-compulsive disorder are generally not efficacious for people with hoarding problems. A specialized CBT approach for hoarding has shown progress in reaching treatment goals and has been modified to be delivered in group, peer-facilitated, and virtual models. Research on hoarding remains in the early phases of development. Animal, attachment, and genetic models are expanding. Special populations, such as children, older adults, and people who do not voluntarily seek treatment need special consideration for intervention. Community-based efforts aimed at reducing public health and safety consequences of severe hoarding are needed.

Identifying adolescents with hoarding disorder

Hoarding disorder is a relatively new diagnosis in the DSM-5, only just included in the most recent edition. The disorder has piqued the interest of many in the community, in part because of the hit TV show called "Hoarders." Although there is interest, there continues to be relatively few research studies into the causes, treatment, and management of this disorder specifically in adolescences. Yet, in the research that has been published, it often sites the disorder first appearing in adolescents. This paper will discuss the following elements of adolescent hoarding disorder: The potential etiology and risk factors noted in the literature, the DSM-5 criteria for the diagnosis of hoarding disorder, and the characteristic signs and symptoms found in the adolescent presentation, as well as treatment. Finally, it will also include recommendations for healthcare professionals for early screening and treatment.

Clinician-reported barriers to using exposure with response prevention in the treatment of paediatric obsessive-compulsive disorder

Exposure techniques are underutilised in the treatment of anxiety disorders in routine practice, but little is known about the use of exposure with response prevention (ERP) for OCD, particularly in youth. The current study aimed to examine the utilisation of ERP for paediatric OCD via an anonymous online survey completed by clinicians (N = 107). Specifically, we explored the association of clinician characteristics and OCD symptom subtypes with ERP use, as well as clinician-reported barriers to ERP implementation. The majority of clinicians reported commonly using ERP when treating youth with OCD, and rates of ERP use were highest among clinical psychologists. Clinician-held negative beliefs about exposure were significantly associated with lower ERP use. Additionally, clinicians reported being less likely to use ERP to treat hoarding symptoms and taboo obsessions, compared to other OCD symptom subtypes. The most commonly endorsed barriers to successful ERP implementation were aspects of the phenomenology of OCD (e.g. covert compulsions, frequently changing rituals) as opposed to general barriers (e.g. insufficient time during sessions). Overall, our findings suggest that OCD presents unique challenges for clinicians delivering exposure-based therapy. Training should address these OCD-specific obstacles in order to promote dissemination of ERP for youth with OCD.

Editorial: Hoarding and Obsessive-Compulsive Disorder

Hoarding disorder is more than surplus clothes and belongings that could be remedied by a visit from Marie Kondo (https://konmari.com). It is officially recognized as a distinct condition in DSM-5 and placed under obsessive-compulsive conditions.1 Before the designation in DSM-5, hoarding was regarded as a diagnostic element in obsessive-compulsive personality disorder or a symptom nested within obsessive-compulsive disorder (OCD).2 In DSM-5, hoarding disorder is defined by great reluctance or outright refusal to discard belongings-including articles of limited value. Individuals with hoarding disorder commonly describe indecision, distress, or both when faced with discarding superfluous items. They may claim that the item could be useful in the future or that it has sentimental value. A direct consequence of refusing to discard items of limited value is accumulation of clutter that, over time, interferes with daily activities and functional use of living space. For example, a sink piled high with dishes and food containers may not be available for practical use. The accumulation of poorly organized possessions may restrict movement in the home to narrow winding pathways through the mounds of debris. Excessive accrual of debris may also extend to vehicles. A car stuffed with rags, take-out containers, old mail, cardboard, and rolls of paper towels may not accommodate passengers.