Obsessive Compulsive Disorder:

1. Obsessive Compulsive Disorder: Treatment of obsessive-compulsive disorder utilizing an ecological treatment package (ETP). Susan M. Swearer, Ph.D.John W. Eagle, M.S.W.Courtney K. Miller, Ed.SSusan M. Sheridan, Ph.D. NASP Annual Convention2001 – Washington D.C.

2. Objectives • Description of the disorder. • Prevalence and etiology of OCD. • Impact upon academic, behavioral and social performance in schools. • Ecological Treatment Package (ETP; Swearer & Eagle, 2000). • CBT treatment. • Conjoint Behavioral Consultation (CBC; Sheridan & Kratochwill, 1992) and OCD. • School related issues.

3. What is OCD? • Repetitive pattern of obsessions and/or compulsions. • Time-consuming. • Create significant distress or impairment.

4. It’s not just avoiding cracks or washing your hands. “People think it’s like Jack Nicholson in ‘As Good As It Gets,’ but it’s so much more than that.”

5. Obsessions • Persistent ideas, thoughts, impulses or images. • Create marked disturbance or distress. • Most common • Contamination • Doubting • Need to have things ordered • Horrific impulses • Sexual imagery

6. Video – Describe your Obsessions Q4

7. Compulsions • Repetitive behaviors or mental acts with goal of preventing/reducing distress or anxiety. • Most common • Washing/cleaning • Counting • Checking • Requesting/demanding assurances • Repeating actions • Ordering

9. Video – Describe and Demonstrate you compulsive behaviors Q2

10. Prevalence • 1 in 200 children and adolescents (Flament, 1990). • 1 in 50 adolescents (OC Foundation, 1999). • Generally considered to affect 2% of the total population. • 3 or 4 children in each elementary school. • Up to 20 teenagers in most average-sized high schools.

11. “Hidden Epidemic” (Jenike, 1989) • Only 4 of 18 high school students found to have OCD were under professional care (Flament et al., 1988). • None of the 18 had been correctly identified as suffering from OCD. • OCD is typically underdiagnosed and undertreated.

12. Other facts… • Age-of-onset for children with OCD is approximately 10.2 years old (Chansky, 2000). • Males tend to develop OCD earlier than females; females develop OCD in adolescence (Adams & Torchia, 1998; Chansky, 2000). • 80% of adults with OCD identify an onset of symptoms before the age of 18 (Pauls, Alsobrook, & Goodman, 1995). • Childhood OCD is typically considered a chronic condition.

13. Developmental Perspective Developmentally, most children experience obsessive-compulsive symptoms as part of the normal process of achieving mastery and control over their environment. However, the difference between normative OCD symptoms and pathological symptoms is that the pathological variety produces “dysfunction rather than mastery” (March, 1995).

14. Video – When did you first notice symptoms of OCD? Q1

15. OCD Behaviors Time-consuming Disruptive of normal routine Create distress/frustration Believes has to do them Appear bizarre/unusual Become elaborate and demanding with time Must be executed precisely to prevent adverse consequences Non-OCD Habits Not overly time-consuming Do not interfere with routine Create enjoyment or sense of mastery Habits child wants to do Appear ordinary Become less important and change over time Can be skipped/changed without consequence Distinguishing OCD from Habits of Childhood (Chansky, 2000)

16. There is no single, proven cause of OCD • Research suggests that OCD involves problems in communication between the front part of the brain (the orbital cortex) and deeper structures (the basal ganglia). • These brain structures use the chemical messenger serotonin. It is believed that insufficient levels of serotonin are prominently involved in OCD. Drugs that increase the brain concentration of serotonin often help improve OCD symptoms.

17. Neuropathological Framework • Dysfunction of this neuropathological circuitry. frontal cortex / basal ganglia / thalamus / frontal cortex

18. OCD – Orbital-Frontal Cortex

19. OCD – Caudate Nucleus

20. Neurotransmitter Issues • Depressed levels of serotonin in the frontal cortex. • Dopaminergic overactivity in the basal ganglia. • Areas targeted by pharmacological treatments.

21. Impact upon academic, behavioral, and social performance in schools.

22. Contamination • Common obsessions focus on contamination and cleanliness Examples: • Frequent lengthy trips to the bathroom. • Chapped hands. • Avoidance of direct contact with other kids, doorknobs, chalk, and books.

23. Checking and/or Repeating • Rituals are performed to prevent something from happening or to make sure everything is alright. Examples: • Locking and relocking a locker, • Erasing and rewriting papers, • Packing and repacking a bookbag, • Asking the same question over and over, • Difficulty leaving the classroom.

24. Symmetry • Student feels that to avoid disaster or bad luck, movements and/or objects must be symmetrical. Examples • Tapping on one side of his/her body and then the other, • Walking down the hallway in an unusual pattern, • Arranging objects on desk to achieve the right balance.

25. Lateness • Most likely the result of rituals that the student feels must be performed. Examples • Being late to school, classes, and getting home; • May result from washing off contamination, packing bookbag perfectly, or getting dressed.

26. Difficulty with Decision Making • Students may have a difficult time making decisions because of their obsessional thinking. Examples • Choosing answers on multiple choice tests. • Deciding on a topic for a paper. • Selecting classes, and social decision making.

27. Perfectionism • Students often display perfectionism that is related to their compulsive behavior. Examples • Working slowly and exactly. • Trying to make each letter look perfect. • Filling in multiple choice test blanks carefully. • Writing a paper over and over again. • Lining up pencils and notebooks. • Sharpening pencils for a perfect point.

28. Reassurance • Students often seek reassurance from their teachers. Examples • Repeated questioning over exactly what was said. • Questioning whether something is right and/or if there was something disturbing in the news. • Reassurance that they and their family are safe.

29. Depression and Self-Esteem(Comorbid Factors) • Depression is a common problem for students with OCD. • The anxiety of living with OCD is demoralizing. • Signs of depression: withdrawal, sadness, irritable mood, changes in appetite, crying, etc. • Important to assess and treat comorbid conditions.

30. Ecological Treatment Package (ETP) • Ecological Assessment • Individual Cognitive behavioral therapy • Family therapy • Parent training • School Consultation • Linking clinic, school and family treatment

31. Clinical Model Clinician Family Client Psychiatrist

32. ETP Model Clinician Consultant Family Client School Psychiatrist

33. Ecological Assessment • Pre-assessment Interview • Pretreatment assessment (Client): • K-SADS-E clinical interview (Orvaschel, 1995) • CY-BOCS interview (Goodman et el., 1991) • Family Environment Scale (Moos, 1994) • Multidimensional Anxiety Scale for Children (March, 1997) • Behavior Assessment System for Children (Reynolds & Kamphaus, 1998) • Modified Stroop Task (Hope, 1991)

34. Ecological Assessment (continued) • Pretreatment assessment (Parent): • K-SADS-E clinical interview (Orvaschel, 1995) • CY-BOCS interview (Goodman et el., 1991) • Family Environment Scale (Moos, 1994) • Parenting Stress Index (Abidin, 1995) • Behavior Assessment System for Children (Reynolds & Kamphaus, 1998) • Anxiety Disorders Interview Schedule for DSM-IV (Brown, DiNardo, & Barlow, 1994)

35. Ecological Assessment (continued) • Pretreatment assessment (Clinician): • NIMH Global O-C Scale • Clinical Global Impairment Scale • Pretreatment assessment (Teacher – if indicated): • BASC

36. Cognitive Behavioral Therapy • March & Mulle (1998) • Delivered by therapists who have had training in cognitive behavioral treatment modalities • Typically lasts 12 – 20 sessions • Four main components • Psychoeducation • Cognitive Training • Mapping OCD • E/RP

37. Weekly Assessment • Participant: SUDS score, CY-BOCS checklist, OCD self checklist • Parent: OCD parent checklist • Clinician: NIMH Global O-C Scale, Clinical Global Impairment Scale, Clinical Global Improvement Scale • Teacher (if indicated): OCD teacher checklist

38. Psychoeducation • Session 1 • Define OCD, obsessions, compulsions, epidemiology, common treatments • Focus on OCD as medical condition • Externalize OCD – nickname • Explain treatment process

39. Mapping OCD • Sessions 2, 3, and 4 • Venn Diagram – identify where OCD wins, where child wins, and where both win • Explain transition zone (TZ) and that this zone will change as treatment progresses • Introduce the “tool kit” • Generate list of all OCD symptoms and place on the map with a fear thermometer rating

40. Venn Diagram OCD Client TZ Eating Greasy Foods Brushing Teeth Washing Hands Driving Car Asking for Reassurance Opening School Locker Checking Locks Counting Objects

41. Venn Diagram OCD Client TZ Brushing Teeth Washing Hands Driving Car Counting Objects Asking for Reassurance Opening School Locker Eating Greasy Foods Checking Locks

42. Venn Diagram OCD Client Driving Car TZ Brushing Teeth Washing Hands Asking for Reassurance Opening School Locker Eating Greasy Foods Checking Locks Counting Objects

43. Cognitive Training • Session 3 • Mapping OCD and review the symptom list • Constructive Self-talk • Cognitive Restructuring • Cultivating Detachment

44. Rewards • Introduced in session 4 • Plan for ceremonies, notifications • Provide certificates • Lots of verbal praise and a positive attitude

45. Video – Did Treatment Help you Manage your OCD? Q8

46. Family Sessions • Handout at Session 1: “Tips for parents.” • Sessions 7 and 12 • Focus on helping parents stay out of their child’s rituals • Parents are taught to help their child fight OCD • Therapist works with parents to help facilitate positive communication

47. Parent Training • Help educate parents about OCD • Recommend: Freeing your child from obsessive-compulsive disorder (Chansky, 2000) • May include a parent check-in throughout treatment, depending upon need • Parents are included in school consultation, if needed

48. Exposure & Response Prevention • Sessions 4 - 19 • Exposure: Coming into contact with the anxiety-provoking or feared stimulus • Response prevention: Refraining from performing a compulsive ritual • Contrived versus uncontrived • Graduated E/RP • Imaginally versus in vivo • Client is said to habituate to feared stimuli

49. Video – Describe your exposures Q10b

50. Exposure & Response Prevention (continued) • In-session exposures – first • Homework assignments • Between session phone calls • Parents are taught to reward their child for E/RP tasks • Parents take on the role of “cheerleader” for their child