Obsessive-Compulsive Disorder in Children and Adolescents: Family Based Strategies and Interventions

1. Obsessive-Compulsive Disorder in Children and Adolescents: Family Based Strategies and Interventions James A. Gall, Ph.D., PLLC

2. Overview • Family dysfunction does not cause OCD, however family members affect and are affected by a child with OCD • OCD disrupts the psychosocial and academic performance of roughly 1 in 200 children/adolescents (Academy of Child and Adolescent Psychiatry) • Treatment tailored to a child’s developmental needs and family context may reduce chronic nature of OCD

3. Objectives • Understand the epidemiology of OCD, diagnostic criteria, symptoms, developmental factors, and comorbidity • Understand the importance of parental involvement in all phases of treatment for children experiencing OCD • Understand the importance of treatment tailored to a child’s developmental characteristics

4. Objectives • Understand the family/parental role as co-therapists in helping a child learn to manage their symptoms • Understand how the family context and parental reactions affect a child with OCD • Learn strategies for working with the school as well as strategies for improving the overall family functioning

5. Definition (DSM-IV) Obsessions as defined by: • Recurrent and persistent thoughts, impulses, or images which are intrusive and cause marked anxiety or distress • Thoughts, images, or impulses are not simply excessive worries about real problems • The person attempts to suppress the thoughts, images, or impulses, with some other thought or action

6. Definition The person recognizes that he obsessions are a product of his/her own mind Compulsions as defined by: • Repetitive behaviors that the person is driven to perform in response to an obsession • The behaviors of mental acts are aimed at reducing or preventing distress or some dreaded event

7. Definition • The person recognizes that the obsessions or compulsions are excessive and unreasonable Note: This does not apply to children The obsessions or compulsions cause marked distress or significantly interfere with normal routine (school, social activities, relationships)

8. Children at Risk • OCD affects as many as 1% of children (as common as childhood asthma; 3-5 youngsters with OCD per average-sized elementary school) • 50% of adult cases of OCD are diagnosed before age 15 • 2% of children are diagnosed between ages of 7-12 • OCD is more prevalent in boys (2:1 ratio) • 20% of children with OCD have a family member with OCD

9. Children and Rituals • Some compulsive and ritualistic behaviors in childhood are part of normal development – most common between the ages of 4-8; an attempt to master fears and anxieties • Many children collect objects, engage in ritualized play, avoid imaginary contaminants

10. Children and Rituals • Many childhood rituals advance development, enhance socialization, assist with separation anxiety, and help define their environment • Childhood rituals disappear on their own – rituals of a child with OCD persist well into adulthood

11. Symptoms at Home • May be worse at home than at school • Repeated thoughts they find unpleasant – not realistic • Repeated actions to prevent a feared consequence • Consuming obsessions and compulsions • Distress if ritual is interrupted • Difficulty explaining unusual behavior • Attempts to hide obsessions or compulsions

12. Symptoms at Home • Resistance to stopping the obsessions of compulsions • Concern that they are “crazy” because of their thoughts

13. Symptoms at School • Families often seek treatment once symptoms affect school performance • Difficulty concentrating – problem finishing or initiating school work • Social Isolation • Low self-esteem

14. Symptoms at School • Other conditions – ADHD • Learning disorders/cognitive problems which are often overlooked • Daydreaming – the child may be obsessing • Repetitive need for reassurance

15. Symptoms at School • Rereading and re-writing, repetitively erasing – look for neatness, holes in paper • Repetitive behaviors – touching, checking, tracing letters • Fear of doing wrong or having done wrong

16. Symptoms at School • Avoid touching certain “unclean” things • Withdrawal from activities or friends

17. Treatment “There is nothing that is wrong with me that what's right with me can’t fix”

18. Treatment: Psychological Interventions • Family-based cognitive behavioral therapy is uniquely tailored to the child’s developmental needs and family context (Bradley Hasbro Children’s research Center, 2008). • Family based CBT provides the child and parents with a set of tools to help manage and reduce the OCD symptoms • Young children require parental guidance and have less emotional awareness

19. Treatment: Psychological Interventions • The need for education – not their fault • Differentiate between the child and OCD • Explain OCD in understandable language • Listen to and observe your child • Personifying the obsessions – give it a name • Stop blaming yourself – bad parenting does not cause OCD • Instill hope, learn to fight back, engage in exposure therapy – parents are co-therapists

20. Interventions at Home • Therapist must work with the school- NO EXCEPTIONS! • Provide a sympathetic and tolerant environment • Understand the disorder • Listen to your child’s feelings • Plan for transitions

21. Interventions at Home • Adjust expectations until the symptoms improve • Praise your child’s efforts to resist symptoms • Plan for what to say to people outside the family • Understand parental limits • “It’s the OCD talking.”

22. Interventions at Home • Celebrate accomplishments • Foster hope and normalized developmental behavior • Understand parental role in supporting therapy interventions at home – help child commit to exposure therapy and boss back OCD

23. Interventions at School: Modifications, Accommodations, and Strategies • Develop a collaborative relationship with the school, especially the teacher and counselor. • Most school officials want to help the child and work with the therapist – they want help too! • Allow more time to complete certain type of assignments

24. Interventions at School: Modifications, Accommodations, and Strategies • Accommodate late arrival due to symptoms at home • Give the child a choice of projects • Adjust the homework load • Anticipate issues such as school avoidance • Assist with peer interactions

25. Interventions at School: Modifications, Accommodations, and Strategies • Monitor transition periods • Support and reinforce behavioral strategies developed by the clinician • Encourage the child to problem-solve • Allow alternative ways to complete work or take tests – be creative!

26. Interventions at School: Modifications, Accommodations, and Strategies • Eliminate undesirable options, e.g., use a pencil without an eraser • Have the student identify and substitute less disruptive compulsive behaviors • Find solutions for restroom problems

27. Interventions at School: Modifications, Accommodations, and Strategies • Do not punish the child for behavior they have no control over • Never tolerate teasing directed towards a child with OCD • Monitor for special educational services/resources

28. Interventions at School: Modifications, Accommodations, and Strategies • Flexibility and a supportive environment are essential for a student to achieve success in school “There is nothing that is wrong with me that what's right with me can’t fix”

29. We are Done! Questions & Answers

30. References and Resources • The OCD Foundation of Michigan – 313.438.3293 www.ocdmich.org • The International OCD Foundation: www.ocfoundation.org • Anxiety Disorders Association of America www.adaa.org

31. James A. Gall, Ph.D., PLLC • Office phone: 810. 543. 1050