Cognitive Behavioral Interventions for Students with Obsessive- Compulsive Disorder

1. Cognitive Behavioral Interventions for Students with Obsessive- Compulsive Disorder National Association of School Psychologists Annual Conference, 2011 San Francisco, CA Douglas T. Jones, Michael L. Sulkowski, & Robert J. Wingfield

2. Introduction • Overview • Etiology • Associated Issues • Cognitive Behavioral Therapy • Conceptualization • SUDs and Hierarchy • Exposure and Response Prevention (ERP) • Treatment Practice • Treatment in schools

3. Overview

4. Obsessive Compulsive Disorder (OCD) • OCD is characterized by obsessions and/or compulsions that are significantly impairing and distressing • Functional impairment for more than 1 hr per day American Psychiatric Association. (2000).

5. OCD Prevalence • 1-3% of U.S. Youth (McKay & Storch, 2009) • Child OCD – more than 1 in 100 • 4th most common psychiatric disorder in the United States (Leahy & Holland, 2000).

6. OCD Onset / Treatment • Usual onset in late teens or early twenties (Kessler, 2005 & Wewetzer et al., 2001). • 6-15 for males • 20-29 for females • 80% of adults with OCD have childhood onset (Kessler, 2005). • Average total of 17 yrsbetween onset of symptoms (age 14.5) and appropriate treatment (age 31.5)

7. OCD Etiology • Biological Model • Neurobiological abnormalities • PANDAS • Cognitive Behavioral Model • Obsessive-Compulsive cycle • Behavioral conditioning • Cognitive distortions

8. Obsessive Compulsive Disorder (OCD) • Obsessions: • Recurrent or persistent thoughts, impulses, or images seen as intrusive or inappropriate that cause marked anxiety/distress • Not simply excessive worries • Attempts are made to suppress or neutralize obsessions American Psychiatric Association. (2000).

9. Obsessive Compulsive Disorder (OCD) • Compulsions: • Repetitive behaviors or mental acts driven to perform in response to obsession, or according to rules rigidly applied • Behaviors or mental acts are aimed at preventing or reducing distress or preventing dreaded event or situation American Psychiatric Association. (2000).

10. The Obsessive-Compulsive Cycle Obsessions Fear/Anxiety Reduction in Distress Compulsions Negative Reinforcement (Piacentini et al, 2006)

11. Ritual Cycle SUDS = Subjective Units of Distress (0-10)

12. Common OCD Symptom Patterns • Contamination and cleaning (hand washing) • Self doubt and checking, re-writing, repeating, hoarding • Organizing / need for symmetry • Scrupulosity (religious obsessions) • Aggressive obsessions (fear of harming others)

13. Signs of OCD in Children • Contamination Behaviors • Frequent cleaning/hand washing (red, chapped hands) • Long frequent trips to the bathroom. • Avoidance of the playground, art supplies, sticky substances. • Untied shoe laces (may be contaminated) • Checking and redoing activities/behaviors • Compulsively going over letters and numbers with pencil. • Taking excessive time to perform tasks. • Rereading and rewriting, and frequent erasing.

14. Signs of OCD in Children (Cont.) • Reassurance Seeking • Am I okay, is this right? • Asking frequent questions when the answer is already evident. • Anxiety and Avoidance • Withdrawal from usual activities or friends. • Excessive fear of bad things happening to self or others. • Excessive fears of making mistakes. • Persistent lateness. • Counting and Organizing

15. Associated Issues • Academic Difficulties • Work completion issues • Disruptive Disorders • ADHD • ODD • Depression and Anxiety Disorders • Generalized Anxiety • Trichotillomania

16. Vignettes • Mary • Obsessions – Perfectionistic, Not-good-enough worries • Compulsions – Checking, Studying, Re-writing • Joey • Obsessions – Just right feeling • Compulsions – Touching others, Pulling threads • John • Obsessions – Contamination, sexuality • Compulsions – Cleaning, avoidance

17. COGNITIVE BEHAVIORAL THERAPY

18. Early Psychological Treatments: The “T” in CBT • OCD once was thought to be resistant to psychological treatment • Traditional treatments even could worsen symptoms (Christensen, Hadzi-Pavlovic, Andrews, & Mattick, 1987) • Can increase doubting symptoms and accommodate rituals • Traditional behavioral treatments also proved ineffective (e.g., thought stopping, relaxation training; McKay, Storch, Nelson, Morales, & Moretz, 2009).

19. The “B” in CBT • E/RP breaks the association between specific stimuli, situations, or anxiety-provoking thoughts and reliance on anxiety reducing rituals (Foa, Abramowitz, Franklin, & Kozak, 1999) • The therapy has a biological basis • Facilitates habituation and may affect action in basolateral amygdala, hippocampus, and the medial prefrontal cortex (Quirk & Mueller, 2007)

20. The “C” in CBT • Highlight the role of dysfunctional beliefs and interpretations that sustain rituals • More appropriate and applicable to treating adults • Cognitive therapy must be done carefully • Can reinforce rituals or engender new ones • Use CT to externalize OCD symptoms or motivate children • The OCD monster • Let’s try an experiment

21. Dysfunctional cognitions • Black and white/all or nothing thinking • “If it is not perfect, then it’s garbage.” • Magical thinking • “If I think a bad thought, then something bad will happen.” • Overestimation of risk • “If I even take the slightest chance, something bad will happen.” • Hypermoraity • “Ill go to hell if . . .”

22. Dysfunctional cognitions • Thought/action fusion (similar to magical thinking) • “If I have the bad thought, it will happen.” • Overimportance of thought • “I cannot have bad thoughts—I must have a pure mind.” • “What if” thinking • “In the future, what if I . . . Make a mistake? Get AIDS? Hurt someone? • Intolerance of uncertainty • “I cannot relax unless I am 100% certain that I will be okay, safe, certain. • The martyr complex • “I choose to . . . To prevent . . . “

23. CBT For Pediatric OCD • Pioneered by Dr. John March (March & Mulle, 1998) • Must consider developmental and cognitive level • Should include family members/caregivers • Collaborative efforts between the child, caregivers, and child • Should appeal to children and be fun • Incorporate elements of play into therapy

24. Efficacy of CBT for Pediatric OCD • Generally large effects sizes across studies of randomized and non-randomized trials of CBT in youth (Watson & Rees, 2008) • Effect sizes range from 0.95 to 2.56 • These results are similar to those found in adult OCD treatment studies (Abramowitz, 1998)

25. CBT for Pediatric OCD • Assessment • Psychoeducation • Socialization to treatment • For child and family • Development of an OCD symptoms hierarchy • Engage in exposures and active treatment • Conclude treatment • Offer booster sessions as needed

26. Assessment • Omnibus behavior screeners • BASC-2, CBCL • Single construct measures • BAI, RCMAS-2, • Structured/semi-structured interviews • OCD specific measures • OIC-R, FOCI • CY-BOCS (the “gold standard”)

27. Psychoeducation • Provide information on OCD to children and caregivers • Prevalence • Course of the disorder • Impact on families • Nature of symptoms • Describe CBT • Treatment components • Efficacy of the treatment, especially for OCD • Typical number of sessions, length of sessions

28. Socialization to Treatment • Emphasize that exposures will be gradual • May need to motivate some youth • Be dispassionate and firm • Motivational interviewing techniques • Exposure intensity corresponds with positive treatment outcomes • The therapist should establish rapport • Convey warmth, optimism, confidence, and even a playful attitude • Get parents/caregivers on board

29. Development of a Symptoms Hierarchy • Day 1 or 2 (the easiest part of treatment) • Work with child to develop a list of feared stimuli or situations • Write down everything and ask clarifying questions • Rank order items on a scale (1 – 10; 1 – 100) • “Everything is a 10!” • “Nothing scares me” • Use of anchor points and contrasts

30. OCD Hierarchy

31. Ranking Your Own Fears • Work with a partner to rank order your fears • List fears and corresponding thoughts • (e.g., spiders, death, heights, elevators) • Come up with a list of ways to engender these fears (exposures) • (e.g., licking a doorknob, leaving the house unlocked when nobody is home)

32. Exposure and Response Prevention

33. Exposure and Response Prevention • CBT with exposure and response prevention (ERP) is the best established psychological treatment for OCD. • Gold standard (DeRubeis & Crits-Christoph, 1998). • 63% to 83% of participants obtained some benefit, many long term after ERP (Abramowitz, 1997; Foa & Kozak, 1996; Stanley & Turner, 1995).

34. Exposure and Response Prevention • How does it work? • E/RP breaks the association between specific stimuli, situations, or anxiety-provoking thoughts and reliance on anxiety reducing rituals (Foa, Abramowitz, Franklin, & Kozak, 1999) • The therapy has a biological basis. • Facilitates habituation and may affect action in basolateral amygdala, hippocampus, and the medial prefrontal cortex (Quirk & Mueller, 2007)

35. Informal progress monitoring strategies • Subjective units of distress (SUDs) • Thumbnail judgments of distress • Can be taken any time during therapy • Children can monitor and document their own SUDs

36. ERP • Exposure (in vivo) • Children are gradually exposed to anxiety-provoking stimuli… • Prevention • While refraining (or prevented) from engaging in anxiety-reductive compulsive behaviors. • Exposure (imaginal) • Children expose themselves to feared thoughts through scripting. • Scripting: written in the first person containing sufficient detail to evoke an anxiety response; usually 3to5 minutes long • Verbalizing: repeatedly read the script aloud until the anxiety decreases or record the scenario on an audiotape and repeatedly listen to the tape. • Focus is getting used to one’s thoughts

37. ERP • Exposure Practice • Predictability and Control: combination of allowing client as much control and predictability as possible while continuing to push and challenge is the best strategy. • Distraction: Encourage as much focus on the feared stimulus during exposure as possible. • Length of Exposures: • Outcomes studies indicate exposure sessions generally range from 30 to 120 minutes. • Longer sessions were correlated with larger effect sizes on measures of OCD symptoms • Thus, 90 to 120 minute sessions may be the most useful length of session.

38. ERP • Troubleshooting: • Motivational Issues: level of readiness to change significantly predict treatment attrition (Wilson, Bell-Dolan, & Beitman, 1997) • Encourage child to voice reasons for change, explore future costs and benefits of change • Reassurance Seeking: Therapist and family must refrain from answering questions during exposures if the answer may provide reassurance. Reassurance seeking is another form of a compulsion.

39. How ERP Works S U D S Storch, 2006

40. School Psychologists’ Reports on OCD • Sloman et al. (2007) • 89.8% of respondents had experience with at least one OCD case. • 82.4% reported that they were “much or very much” influenced by evidence based treatments AND • 89.5% of participants adhered to a cognitive behavioral theoretical orientation AND • 81% reported that they were “much or very much” inclined to implement CBT as a choice of treatment. • Results • Only 7.1% reported using exposure based elements “much or very much” in the treatment of OCD. • Nearly half (46%) stated that there was “minimal to no change” in outcome. (Storch , 2006)

41. What can school psychologists do in the school setting? • Help school personnel recognize that OCD is a neurobehavioral disorder that reflects abnormal information processing in the CNS and not “oppositional behavior.” • Help personnel view the child with OCD the same as child with diabetes or asthma • Refrain from punishing the student for situations or behaviors he or she has no control over (e.g., being tardy, absent, no attending to work) • Record changes in a child’s behavior (both negative and positive) that may be a result of medication and/or behavioral interventions.

42. What can school psychologists do in the school setting? • Allow breaks during testing • Extended time for homework and projects (only until child overcomes being “bossed around by OCD”) If misapplied this could reinforce OCD. • Monitor child to ensure he or she isn’t using OCD as an excuse to avoid academic demands • Students with OCD are generally eligible for 504 Plans (Marche and Mulle, 1998)

43. Exposure and Response Prevention Activity • Part One - Imaginal Scripting • Using your hierarchy formed in the previous activity create an imaginal script or exposure for a distressing item (SUDS around 7 or 8). • Examples • Funeral of a loved one • Skydiving

44. Exposure and Response Prevention Activity • Part Two - En Vivo ERP • Form into groups of three – be the therapist / student • Take turns leading one another through your exposure • Monitor SUDs level! • Do not flood • Do not go above a 5 or 6… • Proceed until SUDS level drops by half

45. Questions Email Contacts djonesnd2000@ufl.edu

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