Obsessive-Compulsive Disorder

1. ACT-Relevant Constructs in Child Therapy Process: The Role of Child Experiential Avoidance, Willingness, and Safety Seeking Behaviors in a Family-Based CBT for Young Children with OCD Elizabeth Davis, Lisa W. Coyne, Evan R. Martinez, Angela M Burke, Abbe M. Garcia & Jennifer B. Freeman

2. Obsessive-Compulsive Disorder • Obsessive-Compulsive Disorder is defined as: a disorder marked by recurrent and persistent obsessions and/or compulsions that cause marked distress. In children, it is not required that the person recognize the excessiveness of the obsessions or compulsions (DSM-IV-TR, American Psychiatric Association) • Approximately 1 in 200 children are diagnosed with OCD • 33-50% of adults with OCD experienced a childhood or adolescent onset (Beer et al., 2002) • Up to 71% of children with OCD have a parent who experiences obsessive-compulsive symptoms or is diagnosed with OCD (Riddle et al., 1990)

3. Therapy process variables in exposure • Only one other study has examined process variables in exposure-based treatment for children with OCD • Two studies have examined process factors in exposure-based treatments for OCD in adults, and found the following to be related to treatment outcome: • Therapeutic alliance, willingness to participate, and client expectancy (de Haan et al., 1997; Vogel, Hanson, Stiles, & Gotestam, 2006). • Process variables that have been found to be significantly related to treatment outcome in treatment for depression and anxiety in children include: • Parent and child willingness (Karver, Handelsman, Fields, and Bickman, 2006) • Child involvement (Chu and Kendall, 2004) • Positive therapist-parent, and child-therapist alliances (McLeod & Weisz, 2005) • Therapist “collaboration” behaviors (Creed & Kendall, 2005)

4. Considerations for treatment with young children • Treatment can be taken out of children’s control – determined by parents/teachers • Young children may have more difficulty describing gradations in their feelings, making designing an exposure hierarchy more difficult • Children may feel coerced to participate in the exposure • Involvement of parents in management/enabling of OCD rituals (King, Leonard & March, 1998) • Children are often embarrassed or defensive about symptoms (King, Leonard & March, 1998) • Treatment of OCD in young children requires parent participation to guide and reinforce exposures within sessions and between sessions

5. Emotion regulatory strategies and treatment • Treatment efficacy may be affected by emotion regulation strategies that children and parents use, such as experiential avoidance and safety-seeking behaviors • If children feel coerced, they may be unwilling to participate in exposure, and thus exhibit experiential avoidance and safety seeking behaviors • Parents may inadvertently model experiential avoidance for their children, through statements such as “Oh, I think that might be too hard for her”. • Parent factors and family environment may also be impacting child symptoms: • Accommodation • Negative family interactions (criticism and hostility) • Cognitive and behavioral avoidance coping strategies (Derisley et al., 2005) • Exhibiting less warmth and less encouragement of independent thinking (Moore, Whaley, & Sigman, 2004)

6. Parent & Child Emotion Regulation • Behavioral Approach/Safety-Seeking • Behavior used to approach/prevent perceived danger or aversive condition • Experiential Acceptance/Avoidance • Behavior used to approach/prevent aversive private event • Willingness • Agreement to participate (saying yes) • Experiential acceptance (meaning it)

7. Study Goals • To develop a coding system to assess • Child Behaviors • Behavioral Approach • Experiential Acceptance • Willingness • Parent Behaviors • Behavioral approach/avoidance and • Experiential approach/avoidance • Therapist Behaviors • Collaboration • To explore the relationship of these variables to treatment outcome

8. Method • Participants • 23 children aged 4-8 years (mean age 6.61 years), 60.9% female, with (1) Primary OCD (2) symptom duration of at least 3 months; (3) at least one parent able to attend all sessions • Family-Based CBT: 14 week, 12 session protocol • Sessions 4 (therapist), 4 & 7 (children) & 7 (parents) were coded

9. Measures • Kiddie Schedule for Affective Disorders and Schizophrenia for School Age Children-Present and Lifetime Version (K-SADS-P/L) (Chambers et al., 1985; Kaufman et al., 1997) • Child Yale-Brown Obsessive Compulsive Scale (CY-BOCS) (Scahill et al, 1997)

10. Coding Manual • The Observational Coding Manual (OCM-R; Coyne, Burke, & Davis, 2007) • Based on the theoretical framework of Acceptance and Commitment Therapy (ACT; Hayes, Strosahl, & Wilson, 1999) • Assesses parent, child, and therapist variables • Used during in session exposure planning, and exposure

11. Manual Development • A preliminary set of theoretically-driven codes were submitted for expert review, and then revised to accommodate expert feedback • Pilot coding of treatment videos was conducted in order to further refine the code definitions

12. The OCD Coding Manual (OCM): Parent and Child Versions • Behavioral Approach • Adapted from Heidtke (2005) • Sequential and global codes • Experiential Acceptance • Sequential and global codes • Collaboration • Adapted from McLeod and Weisz (2005) • Willingness • Task Agreement + Experiential Acceptance

13. Descriptions of codes • Experiential Acceptance • Coded globally on a scale from 1-5 • Statements coded as “1” were experientially avoidant, and included anything suggesting a task was too difficult (“I think it’s too hard for him; I can’t stand touching this sticky stuff!!”) • Behavioral approach • Coded globally on a scale from 1-6 • Behavioral approach was demonstrated through statements or behaviors that encouraged approach to the stimulus during exposure (“Wow, look how dirty your hands are getting”; child putting hands in the dirt)

14. Description of codes • Agreement to participate • Coded on a scale from 1-5 • This code was comprised of a conglomerate score adding ratings of attentiveness, responsiveness, adding detail, active interest, and distraction to comprise one overall agreement to participate score • Therapist collaboration • Coded globally on a scale from 0-5 • This code was designed to measure specific therapist behaviors representative of collaboration The code was broken down into 5 yes/no questions: • Does the therapist use the words “we”, “us”, “let’s” in > 1 instance • Does the therapist initially provide at least one opportunity for the child to contribute to exposure planning in a generalized and collaborative way • Does the therapist provide the child with options for exposure and/or give the child the opportunity to choose the task • Does the therapist communicate verbally and/or behaviorally that the child/parent/therapist will work toward the goals of exposure together as a team • Does the therapist praise/encourage the child’s collaborative efforts during exposure planning (i.e. problem solving, generating ideas, participation)

15. Intraclass Correlations for OCM __________________________________________________ Exposure Planning EA BA Agreement to Participate .64 -- .83 Exposure EA BA Agreement to Participate .94 .88a .67 __________________________________________________________ Note.aPercent Agreement Properties of the OCM: Parent Variables

16. Intraclass Correlations for OCM __________________________________________________ Exposure Planning EA BA Agreement to Participate .97 -- .96 Exposure EA BA Agreement to Participate .86 .90 .91 Bond .83 __________________________________________________________ Properties of the OCM: Child Variables

17. Parent EA, BA, & Treatment Outcome • Contrary to hypotheses… • Parent modeling of behavioral approach/safety seeking and experiential acceptance/avoidance were not associated with child outcome at end of treatment or 3 month follow-up

18. Did Child EA During Exposure Planning Affect Treatment Outcome? ___________________________________________________________ CYBOCs ET CYBOCs FU Session 4 Freq. EA-.39†-.73* Global EA -.33 -.29 Session 7 Freq. EA -.33 -.33 Global EA-.25 -.16 ___________________________________________________________ Note. * p < .05, †p < .10; N=19 for session 4; N = 11 for session 7

19. What About Child BA/EA During Exposure? ______________________________________________________ CYBOCs ET CYBOCs FU Session 4 Freq. EA -.06 -.39 Global EA -.56* -.33 Freq. BA -.56* -.06 Freq. SS -.61* -.32 Global BA -.13 .17 Session 7 Freq. EA -.16 -.25 Global EA -.47†-.60 Freq. BA -.59* -.47 Freq. SS -.06 .18 Global BA -.12 -.15 ______________________________________________________ Note. *p < .05; †p < .10;N=14 for session 4; N = 8 for session 7

20. What About Therapist Collaboration? ______________________________________________________ CYBOCs ET CYBOCs FU Session 4 Therapist Collaboration-.13-.64* ______________________________________________________ Note. *p < .05, N=14 at ET, N=8 at FU

21. What Was the Role of Child Willingness? • Children who displayed better task agreement during exposure at Session 4 had more symptom reduction post-treatment (r = -.56, p < .05, n = 14) • Task agreement was highly correlated with experiential global experiential avoidance, which suggests they measure similar constructs

22. Study Strengths • First study to develop an observational coding system to assess experiential avoidance • First study to explicitly examine these variables in the context of specific session components, namely, exposure planning and exposure • First study to find a relationship between therapist collaboration and symptoms at follow-up in a sample of young children with OCD • Looking at late vs. early parent involvement, later in the process of “transfer of control” from therapist to parent

23. Study Limitations • Descriptive only • Teeny n, thus very low power to detect effects • Lower reliability in parent codes, thus potentially attenuating relationships • Cannot make any statements about directionality • Nature of sequential relationships not fully explored • Did not control for CY-BOCS scores at baseline

24. That being said, findings may suggest… • Creating child “willingness” early in treatment is important • Child Experiential Acceptance behaviors during exposure are significantly related to treatment outcome • Treatment may work, in part, through: • Addressing child emotion regulatory strategies • Behavioral approach/Safety Seeking • Experiential approach/Avoidance • Fostering agreement and bond between child and therapist • Enduring through difficult exposure tasks • Therapist collaboration with child

25. Future Directions • Need more data! Larger N! • Why didn’t it work for parents? • Looking at functional (sequential) relationships between parent, therapist, & child behaviors • Assessing the convergent and divergent validity of the coding system with additional baseline measures of experiential avoidance, parent accommodation, etc.

26. Thank you!! Acknowledgements: Dr. Lisa Coyne Angela Burke Dr. Jennifer Freeman Dr. Abbe Mars Garcia Dr. Amy Przeworski The Coyne Family