Obsessive Compulsive Disorder

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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.
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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.

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What is OCD?

• Repetitive pattern of obsessions and/or
  compulsions.
• Time-consuming.
• Create significant distress or impairment.

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Its not just avoiding cracks or washing your
hands.
People think its like Jack Nicholson in As
Good As It Gets, but its so much more than
that.
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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

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Video Describe your Obsessions Q4
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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

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(No Transcript)
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Video Describe and Demonstrate you compulsive
behaviors Q2
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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.

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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.

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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.

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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).

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Video When did you first notice symptoms of
OCD? Q1
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Distinguishing OCD from Habits of Childhood
(Chansky, 2000)

• 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

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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.

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Neuropathological Framework

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

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OCD Orbital-Frontal Cortex
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OCD Caudate Nucleus
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Neurotransmitter Issues

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

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

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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.

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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.

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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.

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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.

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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.

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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.

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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.

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Ecological Treatment Package (ETP)

• Ecological Assessment
• Individual Cognitive behavioral therapy
• Family therapy
• Parent training
• School Consultation
• Linking clinic, school and family treatment

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Clinical Model
Clinician
Family
Client
Psychiatrist
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ETP Model
Clinician
Consultant
Family
Client
School
Psychiatrist
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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)

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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)

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Ecological Assessment (continued)

• Pretreatment assessment (Clinician)
• NIMH Global O-C Scale
• Clinical Global Impairment Scale
• Pretreatment assessment (Teacher if indicated)
• BASC

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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

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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

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Psychoeducation

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

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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

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

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

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Rewards

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

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Video Did Treatment Help you Manage your OCD? Q8
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Family Sessions

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

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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

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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

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Video Describe your exposures Q10b
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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

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Video E/RP Prevention E/RP
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Relapse Prevention

• Session 19
• Explain concept of relapse prevention
• Define and differentiate between slip and lapse
• Imaginal exposure have child imagine expectable
  slip, describe incident in detail, and use toolkit

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Graduation

• Session 20
• Certificate of achievement
• Encourage notifications
• Invite friends, family members, whomever child
  would like to be invited

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Maintenance

• Session 21 (6 months post-graduation)
• Review past 6 months for residual and new
  symptoms
• Focus on how child used strategies successfully
• Celebrate successes
• Review toolkit and make modifications as necessary

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Post Treatment Assessment

• Session 20 (Client)
• 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)

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Post Treatment Assessment (continued)

• Session 20 (Parent)
• 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)

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Post Treatment Assessment (continued)

• Session 20 (Clinician)
• NIMH Global O-C Scale
• Clinical Global Impairment Scale
• Clinical Global Improvement Scale
• Session 20 (Teacher)
• BASC
• OCD Teacher checklist

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Video Was CBT Helpful? Q13
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Six-month follow-up Session 21

• Client and Parent
• CY-BOCS
• Clinician
• NIMH Global O-C Scale
• Clinical Global Impairment and Improvement Scales
• Teacher
• OCD Teacher checklist

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Linking clinic, school and family treatment

• Therapist works with consultant to help
  coordinate services between clinic and school
• Therapist works with family to help coordinate
  services between clinic, other medical personnel,
  and school
• Hallmark of the ecological treatment package is
  the coordination of services across different
  settings

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Consultation An Overview
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What Is Consultation??

• An indirect form of service-delivery that
  involves the cooperative, problem-solving efforts
  of two or more persons to clarify a clients
  needs, and to develop, implement, and evaluate
  appropriate strategies for intervention
• (Brown et al., 1991 Sheridan Kratochwill,
  1990 Zins et al., 1988).

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Video How does OCD effect your performance in
school? Q5
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Conjoint BehavioralConsultation (CBC)
(Sheridan Kratochwill, 1992)
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Conjoint Behavioral Consultation A Definition

• A structured, indirect form of service delivery
  in which teachers and parents are brought
  together to collaboratively identify and address
  students needs (Sheridan Kratochwill, 1992).
• Emphasizes meaningful parental/family
  participation in their childs education
• A consultation model that goes beyond the school
  setting, promoting and supporting home-school
  partnerships in the context of cooperative and
  collegial problem-solving

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CBC Model
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Key Characteristics of Consultation/CBC

• Indirect service delivery (triadic model)
  carried out via a joint, problem-solving process.
• Work-related focus (not therapeutic)
  consultation is NOT counseling!
• Participants Consultant, consultee, client.
• Voluntary, collegial relationship that involves
  parity interdependence
• Roles of participants are both defined and
  varied each participant brings his or her own
  expertise to the process.

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Conceptual BasesEcological-Behavioral Theory

• Combines the empirical technology of behavioral
  theory/analysis with the conceptual advances of
  ecological theory
• Allows for a comprehensive and functional
  understanding of a clients needs
• Recognizes the importance of broad-based data
  collection and cross-setting intervention.
• Stresses the importance of looking at the entire
  system surrounding clients, as well as
  coordinating these systems.

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CBC Outcome Goals

• Obtain comprehensive and functional data over
  extended temporal and contextual bases
• Identify potential setting events that are
  temporally or contextually distal to target
• Improve skills and knowledge of all parties
• Establish consistent programming across settings

• Monitor behavioral contrast and side effects
  systematically via cross-setting treatment agents
• Develop skills and competencies for future
  conjoint problem solving
• Enhance generalization and maintenance of
  treatment effects

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CBC Process Goals

• Improve communication and knowledge about child
  and family
• Increase commitments to educational goals
• Address problems across, rather than within,
  settings
• Promote shared ownership for problem
  identification and solution

• Promote greater conceptualization of a problem
• Increase the diversity of expertise and resources
  available
• Establish and strengthen home-school
  partnerships enhance the home-school relationship

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Stages in Behavioral Consultation/CBC

• Conjoint Problem Identification
• Conjoint Problem Analysis
• Conjoint Treatment Implementation
• Conjoint Treatment Evaluation

Stages are procedurally operationalized through a
series of behavioral interviews requiring both
process and content expertise.
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Putting CBC to Work to Address OCD in the School
Setting

• Important Key Components
• Psycho-education of teachers school personnel
• Understanding of OCD how it may impact school
  functioning academic performance
• Neurobehavioral approach
• Psycho-education is an on-going process
  throughout consultation
• May be advantageous to invite the student
  (client) to a meeting with teachers (consultees)

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Putting CBC to Work to Address OCD in the School
Setting

• Important Key Components (cont.)
• 2) Creating a Common Language
• Consistency in the understanding of approach to
  dealing with the students OCD across home
  school settings
• Create a partnership between home school to
  set-up optimal environments to help the client
  fight back to OCD

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Putting CBC to Work to Address OCD in the School
Setting

• Important Key Components (cont.)
• 3) Environmental manipulation
• OCD is still addressed as a neurobehavioral
  disorder
• However, by using the stages of CBC, we can begin
  to assess what behaviors are of concern, whether
  these problem behaviors may be a manifestation of
  OCD systematically examine the function of
  these behaviors
• Example of music stand

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Conjoint Problem Identification

• Identify the specific concern
• Discuss, in general, the influences that may be
  related to clients difficulties
• Generate a consultation / intervention goal
• Develop baseline data collection procedures

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Problem Identification Interview A Case Example

• Specific concerns
• Teacher Client sleeping in class, not completing
  assignments
• Mother Client not doing homework
• Influences
• Obsessive-compulsive disorder
• Anxiety / avoidance
• Medication
• Goal
• Increase class participation assignment
  completion

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Conjoint Problem Analysis

• Review baseline data
• Conduct strength conditions analyses
• Design intervention

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Case Example Utility of Data Collection
Sleeping behavior corresponded with study time
or tests Participation occurred during lecture
or group activities
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Developing a Treatment Plan Case Example

• Functional assessment revealed clear pattern to
  behavior
• Hypothesized that client was sleeping as a
  coping mechanism to reduce anxiety related to
  assignment completion impacted by OCD
• Plan a) teacher would provide modified
  assignments during study time, b) student would
  leave assignments on desk at the end of the class
  period, c) teacher would provide positive
  feedback when he attempted to and/or completed an
  assignment

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Treatment Implementation Evaluation

• Consultee completes a plan checklist
• Consultee continues to document target behavior
  (e.g. percentage of time student participated in
  class)
• Consultee also completes a weekly OCD Teacher
  Checklist
• Review clients progress and make any necessary
  modifications to treatment plan

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Gradual Learning Process

• Teachers are often frustrated with the student
  may think that the student lacks motivation, is
  non-compliant, or just doesnt care
• Internal nature of OCD makes intervention more
  complex challenges seeing is believing adage
• Often teachers parents are required to make a
  mind-set shift in order to optimally help student

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Benefits to Utilizing CBC Procedures in OCD
Treatment

• Allows for psycho-education of school personnel
  with regard to obsessive-compulsive disorder
• Fosters collaboration between home, school
  support systems to help aid student in fighting
  back to OCD
• Helps to ascertain how OCD is impacting the
  students in the school setting provides a
  structure for the identification, assessment
  treatment of problem manifestations
• CBC is very data-driven as such, allows for
  continued monitoring of OCD symptomatology
  treatment progress

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Video What do you think is the most
misunderstood aspect of OCD? Q17
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For More Information

• Contact the Cormorbidity in Youth
  Obsessive-Compulsive Disorder Project (COCD)
• At the University of Nebraska-Lincoln
• Susan Swearer, Ph.D. (Project Director)
• Susan Sheridan, Ph.D.
• Debra Hope, Ph.D.
• John Eagle, M.S.W.
• Courtney Miller, Ed.S.
• OR
• Visit Web Pagewww.unl.edu/schpsych/cacs/cocd.htm