Empowering Families in the Treatment of Children with OCD

1. Empowering Families in the Treatment of Children with OCD Katherine Yost, PhD, LMFT

2. Introduction • Topic: Empowering Families in the Treatment of Children with OCD • This experiential workshop will show how to include family members in the treatment of Obsessive-Compulsive Disorder (OCD) for children. There will be a review of the most common forms and causes of OCD in children. The current research on the enhanced effectiveness of using family therapy will be presented and then four specific strategies will be demonstrated, using audience participation.

3. 4 Learning Objectives • Participants will know the most common presenting forms of OCD in children • Participants will know the prevalence and causes of OCD in children • Participants will learn about the current research on pediatric OCD and family therapy • Participants will learn 4 strategies for involving the family in the treatment of children with OCD

4. Introductions • Katherine Yost, PhD, LMFT, has over 30 years of experience and maintains a private practice in Bellevue, WA. She is a Clinical Fellow and Approved Supervisor for the American Association for Marriage and Family Therapy. She is a past-President for the New Jersey Division of AAMFT and is currently serving on the board for the Washington Association for Marriage and Family Therapy.  Dr. Yost has taught at Antioch University in Seattle, Rutgers University in NJ, and several other colleges and universities. Currently she is excited to be forming the Eastside Anxiety Center. • Alternatively: • Over 30 years of exp as LMFT; AAMFT Clinical Fellow and Approved Supervisor • Past President of NJ-AAMFT and currently on Board for WAMFT • Formerly a prof at Rutgers and currently adjunct for Antioch Univ Seattle • 15 years treating OCD • Currently forming the Eastside Anxiety Center with 5 other colleagues

5. Introductions (cont) • Audience • Experience with OCD? • Treat clients with OCD? • Children with OCD and their families? • Familiarity with CBT/ERP? • Know someone with OCD? • Attended the IOCDFoundation conf? • Summer 2014 it will be in LA • Great experience because it includes clients, their families, researchers, and clinicians

6. Format • Format • Lecture/disc with audios and videos • Experiential • Feel free to ask questions as we go • Handouts • Download from AAMFT conference site • I will have the handouts posted on my website at ksyost.com until the end of this year • Include: PowerPoint, sample assessment instruments, suggested readings for lay people and adults, and references referred to in this workshop

7. Preview • Pediatric OCD • DSM 5 • Prevalence • Etiology • Common Forms • Assessment Instruments • Current Research on the Systemic Impact of OCD and the family (see handouts) • 4 Strategies for empowering the family in the treatment of children with OCD

8. Pediatric OCD • Metaphors for OCD • French call it the “malady of doubt” • Schwartz (1996) calls it trouble with the gear shift • Often referred to as brain “hiccups” • Like an iPod that won’t stop playing awful rap music • Children love metaphors • But my current favorite is when the GPS/smartphone keeps giving the wrong instructions • *** in Calif, driving a rental car in the dark canyon no street lights . . .

9. Japanese Tourist in Australia

10. GPS metaphor • Clients come to you hoping you can help them turn the *dang* thing off • More accurate to say that you will help them to learn how to control the volume • The therapist empowers child and the family with toolboxes so that they can learn to be the boss of OCD

11. OCD Screener for Children • Does the child repeatedly wash her hands, use hand sanitizers, or take long showers? • Does he have to apologize repeatedly or say goodbye or goodnight in a certain sequence and is very distressed when the sequence is interrupted? • Does she erase her printing or writing excessively and insist that it must be perfect or "just right"? • Seehandoutfor complete list or http://www.austinocd.com/childtest.shtml

12. DSM 5 • How many of you have had a chance to read the new chapter on OCD and related disorders? • Review the changes together • What is important • What is new • See the handout

13. DSM 5 • New: OCD comes right after Anxiety (to show they are related) but now has it’s own chapter. The code is the same: 300.3 • The chapter also includes hoarding, skin picking, body dismorphic disorder, and trichotillamania

14. Obsessions • Presence of Obsessions defined by 1 and 2 • Recurrent and persistent thoughts, urges [replaces “impulses”] or images that are experienced . . .as intrusive and unwanted. . .and that cause marked anxiety and distress • The individual attempts to ignore, suppress, or neutralize with some other thought or action (compulsion)

15. Obsessions (cont) • n.b. Young children may not be able to articulate the aims of these behaviors or mental acts. • *** Listen to woman describing her experience as a young girl (all audios are from NPR and in the public domain) • Not as important to get children to articulate obsessions because the tx is more likely to be behavioral (ERP)

16. Obsessions (cont) • Note how obsessions wrap themselves around what is important to a person: • Accountants are checkers • Adolescent boys worry about sexual deviation • What do children care about? *** aud • Listen to another audio from Mark Sommers, the host for Double Dare ***

17. Compulsions (Rituals) • Repetitive behaviors or mental acts that the individual feels driven to performs in response to an obsession or according to rules that must be applied rigidly. • These behaviors or mental acts are aimed at preventing or reducing anxiety or distress or preventing some dreaded event or situation; however they are excessive and not realistic. [underlines added]

18. Compulsions • Children may not be able to articulate the aims of behaviors or mental acts • Children often insist on AVOIDANCE • ***Scat mat demo • Sam and his friends • Aud participation

19. More on DSM 5 • Specify insight [new]. Young children usually don’t have it, improves with age, maybe it can be taught (Adelman & Lebowitz, 2012). Egodystonic for adults generally but can vary • Specify tic disorder (common for young males) • Must take at least one hour daily • Must significantly interfere with daily life at school or at home • Frequently comorbid with anxiety, depression, behavioral problems, ADHD, tics, and TS

20. Differential Dx with Normal Developmental Quirks • Children have developmentally appropriate rules and rituals that are not necessarily OCD. (Freeman, 2009) • Age 2: children can be rigid about eating, bathing, and bedtime routines • Between 3 and 5, children like to repeat activities (building a tower and knocking it down) • 5-6 yo, attuned to rules in games, distressed if changed • 6-11 yo superstitious behavior to prevent bad things from happening; interest in collections • 12 and older may become very absorbed in a particular activity (eg, video games) or person (Bieber); superstitious behavior to make good things happen (sports performance) • Indv evaluate each child

21. Prevalence • Roughly 1-2% of children, 2%-4% of adults • 25% of cases start by age 14 • Under 10 yrs, more often males with tic disorder (esp. symmetry and forbidden thoughts) • If tic disorder is present, habit reversal may be more effective than ERP • Females at puberty or pg (esp. contamination / cleaning) • Statistics on remission vary from 6% to 40%

22. Etiology • Freud was wrong; this has nothing to do with toilet training • Clear neurobiological basis: orbitofrontal cortex, anterior cingulate cortex, and striatum (esp basal ganglia) • Schwartz *** fMRI or PET demonstrate that certain areas of the brain light up and stay lit up –the off switch doesn’t seem to work right

23. Schwartz and Beyette (1996)

24. Common and Rare Causes • Heritability (epigenitc? endophenotypic?) (Taylor, 2012) • No gene identified yet, probably an environmentally triggered predisposition • 2x with first degree relative • 10x young male with tic • 80% with identical twins • ***Colas / parents • Head trauma • PTSD (think rape + showers) • PANDAS (Pediatric Autoimmune Neuropsychiatric Disorder Associated with Strep) or PANS –sudden onset. Might improve and disappear with timely and massive treatment of antibiotics • Hx of child abuse

25. Common Forms of OCD in Children Research: (Storch, et. al. 2009) • Concerns with contamination (dirt or pollution) or getting sick • Just so (counting, arranging, evening up) • Repeating routine actions (putting on shoes) a certain number of times or until it feels just right • Need to confess or ask for reassurance • ***youtube teenager who runs CX

26. Assessment Tools • See handouts • CY-BOCS – administered by professional • Gold standard for research • http://www.permanente.net/homepage/kaiser/pdf/62542.pdf • Self report/Include versions for parents and teachers • Children: • http://cehs.unl.edu/schoolpsych/Forms/OCDforms/Self%20checkilist%20for%20OCD%201-17-01.pdf • Parents: http://cehs.unl.edu/schoolpsych/Forms/OCDforms/Parent%20checklist%20for%20OCD%201-17-01.pdf • Teachers: http://cehs.unl.edu/schoolpsych/Forms/OCDforms/Teacher%20checklist%20for%20OCD%201-17-01.pdf • Child Florida OCI: http://ocfoundation.org/btti/Pediatric%20BTTI%20Assessment%20Materials%20and%20Other%20Useful%20Documents/Assessment%20Tools/C-FOCI.pdf • COIS http://www.pgepsychiatry.com/images/9/90/CHILDOCDIMPACTSCALE.pdf • Family Accommodation Scale: http://www.dmertlich.com/assets/FAS.pdf

27. Using Assessment Tools in Clinical Practice • Don’t focus on the score, focus on the issues • Use for ERP to establish hierarchy for treatment • Very useful to have input from client and family members –who is right? • Retest at intervals • SUDS thermometer • Severity Pizza

28. SUDS Thermometer

29. Severity Pizza

30. Sample of Current Research on Family Therapy for Pediatric OCD • Accommodation (= enabling) • Family Accommodation Scale (Pinto, Van Noppen, & Calvocoressi, 2013) • Accommodation is when the family is inducted into the OCD system • Forced to humor the OCD • Forced to participate in ritual • Assist with avoidance • Ex: “Goodnight, Mom” • Ex: Sam closing the cupboard, pouring the milk

31. Why is Accommodation a problem? • Worse for the child (Storch et al., 2007) • Validates and reinforces the OCD ritual • Reinforces the neural pathway • Families with higher levels of accommodation have greater severity and worse prognosis (Geffken, Sajid, &Macnaughton, 2005) • Worse for the Family (Storch et al., 2008) • Higher levels of distress and depression in parents and siblings • Poorer family functioning (Steketee & Van Noppen, 2003)

32. The Reassurance Game

33. The Reassurance Game • Very common for children with OCD to seek reassurance (Koburi et al., 2012) • Demo with vomit *** • Temporarily relieves anxiety (but reinforces OCD) • Family wants to be helpful, but eventually feels worn out, irritated or worse • Confessing is a common variant

34. Dealing with Reassurance • Client must agree to or at least understand what is being changed and why. Don’t start here. It is very hard to change. • Answer once • Say “maybe” • Say “ yes, buckets” • Reassurance Book or cards • Being supportive without reassuring (Gillihan et al., 2012) • I know this is hard, and I know you are strong enough to fight OCD • You seem to be seeking reassurance, what else can you do? • OCD is really bothering you, what have you learned to do to fight back?

35. Treatment • CBT (75-80% effective) • ERP • ACT with ERP • Strategic CBT • CTx • Meds (60%) • SSRI • Augment with antipsychotic Professor Gallagher and his controversial technique of simultaneously confronting the fear of heights, snakes, and the dark.

36. Empowering the Family in the Treatment of Childhood OCD • There is now a common consensus among researchers and clinicians that the family should be included in treatment • 4 Strategies • (1)Psychoed (everyone in the room at the same time) • Parents cannot cause OCD, but they can help it to improve • Neurobiological basis • Not common sense rules for how to respond • Distraction • reassurance • Kid cannot stop by just trying harder • ***Metaphor of the Elephant

37. Strategy 2 • Change the Family Narrative • Externalize the OCD • Unwelcome but persistent visitor • Name the OCD • ***YoutTube example of naming OCD • Family no longer POWs in OCDland • Family as part of the team that fights OCD and its rules • Family as coach • Strategize together with child on how to change accommodation (children tend to resist. . .) • ***TP example

38. Strategy 3 • Family CBT (Piacentini et al., 2011) • Externalize the OCD • ERP interventions planned with child and family • Parent empowered to be the ERP coach • Done weekly to “change family dynamics” vs. little catch up meetings • Twice as effective as indv CBT + Relaxation and Psychoed • ***YouTube Michelle with her mom as coach

39. Strategy 4 • Structural Family Therapy to create 2nd order change • Ex of Sam and the sock • Changes family structure • Changes family interaction pattern • Facilitates treatment by increasing motivation • Whole family participates in redefining OCD and the treatment • Sam’s permission and genogram

40. Sam’s Genogram

41. Conclusion • We have covered our 4 learning objectives • We have covered 4 ways to empower families in the treatment of childhood OCD • And, the next time you make a wad of TP, think of me and how OCD inspires our creativity • Thanks!