Obsessive-Compulsive Disorder (OCD) in youth: obsessive beliefs as vulnerability factors
Childhood and early adolescence are critical life periods for the development of obsessive-compulsive disorder (OCD), as this condition shows a bimodal incidence distribution with a peak in childhood and a second one during early adulthood [1-2]. OCD in youth is currently considered as an emerging severe condition, as demonstrated by its increasing prevalence rates [3]. According to a review, prevalence rates vary in Europe from 0.38% in Poland to 4.1% in Denmark, while the prevalence rate in USA is 2.9% [4]. If it is not properly recognized and timely managed, OCD in childhood and early adolescence can evolve into a chronic illness, while causing a strong impairment in different domains of functioning including family life, peer relations and school performance [5-9].
The development of strategies for early identification is drawing the attention of policy makers, as one of the peculiar characteristics of help-seeking behaviour in adult OCD patients is that they consult a physician after about 17 years from its onset [10]. The importance of early identification is also supported by the data showing that 30 to 50% of adult patients report the first onset of symptoms during the prepubertal period [11]. To develop tailored early approaches, a key element is the knowledge of vulnerability factors for OC symptoms or features amongst young individuals in the community [12].
To provide an explanation of the pathogenetic process leading to full-blown disorder, cognitive models of OCD proposed that symptoms might arise from dysfunctional beliefs, specific to this condition, which would act as vulnerability and maintenance factors of the disorder [13-15]. The Obsessive Compulsive Cognitions Working Group [14] identified distinct, albeit intercorrelated cognitive domains, i.e., the so-called “obsessive beliefs” including Perfectionism/Intolerance of Uncertainty (the inability to tolerate mistakes or imperfection associated with the difficulty tolerating uncertainty or ambiguity), Inflated Responsibility (the belief of being personally responsible for the content of one’s thoughts as well as any possible negative outcomes that might arise from such thoughts), Threat Overestimation (the exaggerated belief about the probability and cost of aversive events), Importance and Control of Thoughts (the belief that the mere presence of the thoughts makes those thoughts meaningful and that complete control over them is both possible and necessary).
A large amount of observational and experimental studies in clinical and non-clinical adult samples demonstrated the association between obsessive beliefs and OCD [16], but not all the studies supported this relationship [17]. Moreover, some of the so-called obsessive beliefs may not be specific of OCD, i.e., they are also associated with anxiety or depressive symptoms or disorders, and some beliefs may be more strongly related to OCD than other [18-19].
A relatively smaller body of research focused on the role of obsessive beliefs in OCD children or early adolescents with OCD and the available data appear inconsistent [20-21]. In a small clinical sample, OC symptoms resulted weakly associated with Perfectionism and Intolerance of Uncertainty and moderate associations with the other obsessive beliefs [20]. In community and OCD samples of children and adolescents, all the obsessive beliefs differentiated patients with OCD from community control subjects, but the associations between all the obsessive beliefs and OCD symptoms were comparable to those between the obsessive beliefs and symptoms of anxiety or depression [21]. All the obsessive beliefs were related to OC symptoms in a comparable manner as to symptoms of anxiety in another community sample, while raising again doubts about the specificity of some of the obsessional beliefs in children and adolescents [22].
The specificity of Inflated Responsibility beliefs to OCD was investigated through a meta-analysis of 58 studies (n = 15678) including studies in children or adolescents [17]. The results showed a medium effect size of this association, although there was a significant difference between the effect sizes in adult versus child-adolescent samples: Inflated Responsibility beliefs appeared more strongly endorsed by adults than by children/adolescents [16]. In addition, this domain was more strongly associated with OCD than with depressive disorders, but equally with anxiety disorders [16]. Evidence from more recent primary studies in large community or clinical samples of adolescents [23-24] supported the cross-sectional association between Perfectionism and Intolerance of Uncertainty and OCD even when controlling for anxiety and depressive symptoms. Other studies found a specific relation of Perfectionism and Intolerance of Uncertainty with symmetry and ordering symptoms [25]. In a group of adolescents with OCD, very strong correlations between overvalued ideation were reported, a cognitive domain which is similar to the Importance of Thoughts belief, and OCD severity [26].
Immigration and OCD in youth: an under-studied relation
The relationship between immigration and the development of psychopathological conditions is a quite long-debated question [27]. The migration process and all the factors it entails (e.g., the event of migration, adaptation to a new socio-cultural context, being part of a minority, low socio-economic status) can have a highly stressful impact on the psychological wellbeing of the individual and contribute to the development of different forms of psychopathology [28].
Several systematic reviews conducted in immigrant samples with different ethnic minorities and across different socio-cultural contexts showed that immigrants report a higher risk of different psychiatric symptoms or disorders than natives [29-31]. Other studies suggested a more complex relationship between immigration and mental health. According to a recent meta-analysis of epidemiological studies, first-generation immigrants would be at higher risk of psychiatric disorders than second-generation ones and male gender would be a predictive factor of a higher risk [32]. This result was confirmed also by primary studies conducted in youth that showed higher levels of psychopathology in first-generation cohorts than second-generation ones [e.g., 33-34]. However, other studies in youth found no differences on psychopathological symptoms across generation cohorts [e.g., 35-36].
While most of the literature focused on severe or major psychiatric symptoms or disorders, i.e., psychosis, mood, and anxiety disorders [37-41], the relationship between immigration and OCD symptoms is under-studied, though it is progressively drawing the attention of researchers, practitioners, and policy makers. As suggested [39], immigrants are generally under-represented in clinical studies on OCD, even because they have often poor access to mental health services [40].
The few existing studies showed a higher risk of OCD symptoms in immigrant adults [42-44]. However, there is a lack of data on the relation between immigration and OCD in youth. In addition, the available studies did not report whether the ethnic minorities were natives or first- or second-generation immigrants.
A study carried out on students reported that some ethnic minorities showed higher levels of OCD-related features including general symptoms, subtype traits (checking, washing, and obsessing), and obsessive beliefs (Inflated Responsibility/Threat Overestimation and Importance/Control of Thoughts) [45]. These data were consistent with previous studies on students [46].
Immigration to Italy is a relatively recent phenomenon that witnessed a greater increase in recent years, unlike other European countries [47]. According to a report published in 2019, Italy is third amongst European Union countries for the number of migrants present in the country [48]. A recent survey showed that in 2017 the migratory flow to Italy involved over 300,000 foreigners highlighting a sharp increase of 15% compared to the previous year, including an increase of immigrant children and early adolescents [49].
Rationale and objectives
In the Italian socio-cultural context, there are no data on OCD symptoms and the related vulnerability factors in immigrant children and early adolescents. The investigation of the obsessive beliefs in youth in the community is important, as it might inform screening and potentially early intervention strategies with children and early adolescents, which is a still neglected topic in OCD research overall [10, 50].
Therefore, in a large sample of children and early adolescents the current study aimed at (a) comparing the levels of OCD-related features (general symptoms, subtype traits and vulnerability cognitive factors) amongst three groups, i.e., Italian natives, first-generation immigrants, and second-generation immigrants; (b) investigating whether vulnerability cognitive factors for OCD (i.e., obsessive beliefs) can moderate the relation between immigrant status and OCD symptoms and subtype traits, controlling for the effects of other socio-demographic and clinical variables (age, gender, anxious and depressive features). Based upon previous theoretical proposals suggesting the stressful effects of immigration on mental health [28] and previous evidence showing a higher risk of various psychopathological symptoms including OCD features in adult immigrants [29-31, 38, 44], we hypothesized that both first- and second-generation immigrants would show higher levels of OCD general symptoms, subtypes and beliefs than natives and that first-generation immigrants had higher levels than the other two groups, controlling for other variables such as socio-demographics (age and gender) and anxious and depressive features. In addition, based upon the cognitive model of OCD [15] and previous evidence on the obsessive beliefs in ethnic minorities [45], we hypothesized that the obsessive beliefs would moderate the relation between immigrant status and OCD symptoms, i.e., first- and second-generation immigrants with higher obsessive beliefs have higher OCD symptoms.