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Title: Evidence-Based Approaches to the Treatment and Prevention of Pediatric Obsessive-Compulsive Disorder in Educational and Residential Settings:


1
Evidence-Based Approaches to the Treatment and
Prevention of Pediatric Obsessive-Compulsive
Disorder in Educational and Residential
Settings
  • Real World Challenges and Successes
  • Andre P. Bessette, Ph.D.
  • Clinician Director of Day Program Services
  • The Learning Clinic
  • Brooklyn, CT

2
PurposeTo
introduce mental health and educational
professionals and paraprofessionals to the
construct of pediatric Obsessive-Compulsive
Disorder (OCD), and especially as it is
encountered in our educational and residential
settings.To learn to identify and understand
the many complex challenges and functional
impairments of pediatric OCD as it is encountered
in these educational and residential
settings.To develop the basic skills to help
structure multisystemic (e.g. clinical, familial,
school, environmental, community) interventions,
as well as preventive/ resilience-building
supports to help students manage this
debilitating condition and lead healthy,
productive lives.
3
Introduction to OCD and Pediatric OCD in
Particular
  • Obsessive-Compulsive Disorder (OCD) is recognized
    as a very serious, debilitating, socially
    stigmatizing neurobehavioral condition. It is
    often referred to as a silent epidemic because
    of the embarrassment and shame associated with it
    and individuals attempts to hide it.
  • OCD affects 1.8 to 2.5 of the general U.S.
    population (Weissman et al., 1994),
  • and anywhere from 1 to 4 of the child and
    adolescent population in this country (Douglass,
    Moffitt, Dar, McGee, Silva, 1995 Flament et
    al., 1988 Valleni-Basile, Garrison, Jackson,
    1994).

4
Introduction (contd.)
  • However, given our nascent diagnostic precision
    and individuals tendency to underreport, it is
    likely that these rates are considerably higher.
  • Of OCD cases recognized in adults, 80 experience
    symptom onset before the age of 18 (Pauls,
    Alsobrook, Goodman, Rasmussen, Leckman, 1995)
    and some may even demonstrate clear OC symptoms
    as young as 3 years.
  • Estimates as to the social and economic costs of
    treating OCD in 1990 hover around 8.4 billion
    (DuPont, 1994).
  • However, the true costs of pediatric OCD are most
    apparent in the formative social, academic,
    family, developmental opportunities, and related
    personal potential, that a majority of these
    individuals may never fully experience
    (Piacentini, Bergman, Keller, McCracken, 2003).

5
DSM-IV-TR Diagnostic Criteria
  • Obsessive-Compulsive Disorder (OCD) is an anxiety
    disorder.
  • Largely chronic condition involving intrusive
    thoughts, impulses, or images (i.e. obsessions)
    that an individual experiences as inappropriate
    and undesired, and which lead to intense anxiety
    and distress, and repetitive behaviors that a
    person feels driven to carry out (i.e.
    compulsions) in an effort to neutralize the
    obsessions and reduce the anxiety, distress, or
    sense of perceived threat.

6
DSM-IV-TR Diagnostic Criteria
  • Two core features of compulsions are that
  • 1) They can be physical acts or mental rituals
    (e.g. counting, praying, prioritizing) meant to
    reduce distress, prevent a threatening event, or
    atone for a transgression, and
  • 2) These acts are not logically or functionally
    related to the situation they are intended to
    address (e.g. touching a railing 7 times to ward
    off possible intruders as opposed to repeatedly
    checking a stove to ensure that it has been
    turned off).

7
DSM-IV-TR Diagnostic Criteria
  • 4 key criteria that are necessary to make the
    diagnosis of OCD are
  • 1) At some point the individual demonstrates at
    least some insight in recognizing these
    obsessions and compulsions as excessive or
    unreasonable (however, this can vary for
    youngsters depending upon developmental level)
  • 2) These behaviors are ego-dystonic, or
    experienced as unacceptable and distressing (this
    can also vary somewhat with younger individuals),
  • 3) They consume an inordinate amount of time and
    energy (sometimes three to four or more hours per
    day)
  • 4) These experiences thus significantly impair
    social, occupational, family, and/or academic
    functioning.

8
Some Examples of OCD, Particularly in Youngsters
  • Handwashing
  • Stove checking
  • Ordering toys/belongings- even thoughts (example
    of Allen)
  • Repetitive threshold crossing
  • Ritualistic tapping
  • Counting
  • Repetitive praying
  • Spinning and other gestures
  • Avoiding, altering, or separating foods
  • Most common obsessions concerns involving family
    catastrophes, hoarding, contamination, and
    sexual, somatic, and religious preoccupations
    (Geller et al.,1998)

9
Comorbidity- What tends to come with the OCD
territory
  • OCD rarely emerges alone.
  • In fact, as many as 70 of OCD individuals
    present with at least one co-occurring, or
    comorbid, disorder such as a tic disorder
    (including Tourettes Disorder),
    Attention-Deficit Hyperactivity Disorder (ADHD)
    (see Geller et al., 2002), Oppositional-Defiant
    Disorder (ODD), Major Depressive Disorder, and
    other anxiety disorders such as phobias and
    Generalized Anxiety Disorder (Swedo et al.,
    1989).
  • Pediatric study in India (Reddy et al., 2000)
    Comorbidity rate of 69. The most common
    accompanying conditions were disruptive behavior
    (i.e. acting out) disorders (22), mood disorders
    (20), other anxiety disorders (19),
  • and tic disorders (17).
  • 930 individuals (Douglass et al.,1995) Most
    common comorbid conditions were depression (62),
    social phobia (38), and substance dependence
    (alcohol 24 and marijuana 19).
  • Study of over 400 OCD patients (Yaryura-Tobias et
    al., 2000) . 32.2 developed at least one other
    Axis I disorder (i.e. clinical disorders such as
    anxiety and depression).
  • Order that these conditions tended to emerge over
    time First another anxiety disorder. Second a
    mood disorder. Finally eating disorder, or a tic
    disorder.

10
Prevalence- including region
  • Fairly broad prevalence range
  • UK 0.25
  • Germany 0.5
  • Canada 0.6
  • USA 1 to 4
  • Denmark 1.33
  • Israel 3.6
  • Japan 5

11
Gender
  • Some studies have found a slight male
    predominance.
  • More commonly, however, the empirical evidence
  • indicates that no significant gender difference
    exists with regard to prevalence but that gender
    differences may
  • be more apparent in symptom profiles

12
Functional Impairment
  • While the symptoms of pediatric OCD may be
    obvious and clearly debilitating in and of
    themselves, their impact on these youngsters
    psychosocial functioning can be devastating.
  • Disruptions in social adjustment, family
    relationships, academic performance,
    extracurricular opportunities, developmental
    tasks, occupational potential (especially in
    older adolescents), and ones sense of identity
    can be devastating and chronic if left untreated.
  • Likely child presentation to teachers defensive,
    inattentive, stubborn, unmotivated, or
    oppositional, and thus may be inappropriately
    treated as such, drawing undue consequences.
  • Excessive time spent engaging in rituals at
    school may be seen as bizarre or crazy and can
    attract social ostracism and ridicule, resulting
    in the youngsters self-isolation and further
    social maladjustment.
  • In the home, odd and time-consuming rituals can
    be disruptive and stressful for a family,
    especially when siblings and parents have their
    own lives to live.
  • Family members commonly become involved in the
    rituals.
  • In such situations, disruptions in family
    activities, loss of friendships, financial
    problems, marital discord, and sibling conflict
    have been found (Cooper, 1996).
  • Children are perhaps more aware of the impact of
    their OCD condition on others than we think.
  • Given sufficient exposure to such shaming
    experiences, it is not uncommon for them to
    develop a very negative self-concept built around
    these perceived failures. This could reinforce
    the notion that the world can be a threatening
    place, further erode their self-efficacy, and
    thus render these youngsters at risk for further
    problems such as depression, anxiety, or
    externalizing behaviors.

13
Functional Impairment (contd.)
  • 151 children and the range and degree of the
    impact of OCD on school, social, and family
    functioning (Piacentini et al., 2003).
  • Most common parent concerns
  • Concentrating on schoolwork (47)
  • Doing homework (46)
  • Preparing for bed at night (42).
  • Children reports
  • Concentrating on schoolwork (37)
  • Doing homework (32)
  • Doing household chores (30)
  • Mastering key developmental tasks (e.g. object
    constancy, individuation, autonomy and agency,
    perspective-taking, moral reasoning, and the
    capacity for emotional investment in
    relationships) can be seriously impacted.

14
Differential Diagnosis
  • More developmentally or culturally-common
    obsessions and rituals Such behaviors, however
    odd they may seem, tend to be volitional,
    manageable, temporary, innocuous, and do not
    cause excessive distress or functional impairment
    (e.g. Leonard, Goldberger, Rapoport, Cheslow,
    Swedo, 1990).
  • Examples childhood rituals, magical beliefs
    superstitions, and self-soothing compulsions
    outlined previously in the overview of pediatric
    OCD, that may remit over time or become
    incorporated into a somewhat functional
    lifestyle.
  • However, can such normal rituals in fact be a
    sign of premorbid OCD? Evidence seems to be
    mounting in support of this notion.
  • Early and seemingly normative obsessive-compulsive
    /ritualistic behaviors may in fact be precursors
    to the bona fide condition.
  • One study found that while OCD children and
    controls did not differ in frequency and type of
    superstitions, parents of the OCD children
    reported significantly more remarkable patterns
    of early ritualistic behaviors than did parents
    of the control group of children (Leonard et al.,
    1990) .

15
Differential Diagnosis (contd.)
  • Asperger Syndrome (AS) Social oddness/ineptitude,
    obsessive need
  • for sameness), hyperfocus on minute details as
    opposed to seeing the whole or the gestalt of a
    situation, and cognitive inflexibility (see APA,
    2000 DuCharme McGrady, 2003 Klin 2000).
  • Some of the more OC-type behaviors often seen in
    an AS persons perseverative ideation/fixation on
    certain themes (such as particular celebrities,
    romantic interests, computers, trains, foods,
    principles such as fairness), rigid need for
    consistency/predictability (e.g. arrangement of a
    room, rules, activity plans), and anxiety and low
    frustration tolerance when these processes are
    challenged or disrupted, can easily masquerade as
    OCD and thus require a clinicians careful
    scrutiny in the diagnostic and treatment process.
  • The clear differences In AS, these obsessions
    and fixations tend to
  • be desired, non-distressing, and ego-syntonic.
    There is no identifiable obsession-compulsion
    cycle maintained by negative reinforcement, and
    these preoccupations and impulsively acting upon
    them do not produce distress.
  • Of the 20 AS students at The Learning Clinic, and
    most with notable
  • OC-like behaviors, 3 of 6 were originally
    misdiagnosed with OCD. After careful differential
    diagnosis review, only 3 currently qualify for a
    comorbid diagnosis of OCD.

16
Differential Diagnosis (contd.)
  • Childhood Bipolar Disorder Not a condition that
    normally is thought of as sharing many traits
    with pediatric OCD.
  • However, the perseverative ideation, intense
    internal focus, fixation on particular
    themes/principles and the minutiae of certain
    situations, irritability, and extreme cognitive
    rigidity common in young individuals with Bipolar
    Disorder can often mimic obsessions.
  • The actions that such individuals take to gratify
    their fixations are often mistaken for
    compulsions.
  • The tenacity with which some youngsters cling to
    and defend these ideas and behaviors, and their
    intense response to being thwarted or challenged
    bears some similarity to the anxiety and
    frustration experienced by OCD youngsters.
  • Key distinguishing factor the marginal or
    absence of distress in Bipolar Disorder at
    recognizing such patterns of behavior. Another is
    the mechanism by which in pediatric OCD,
    compulsions are carried out to prevent or
    neutralize certain events and accompanying
    anxiety.
  • Case example of Tony

17
Differential Diagnosis (contd.)
  • Disentangling Pediatric OCD from other anxiety
    disorders
  • Obsessions in the absence of compulsions are
    rare.
  • Other anxiety disorders, such as Panic Disorder,
    Generalized Anxiety Disorder, and phobias tend to
    be marked by more pervasive worry and anxiety
    (except in the case of specific phobias) but an
    absence of compulsions or the overwhelming need
    to carry them out.
  • One common complicating factor is that a
    youngster may develop phobic avoidance behaviors
    in response to feared situations or stimuli that
    may mimic a compulsion or ritual.
  • Differential diagnostic keys A opposed to
    phobias 1) OCD youngsters tend to have multiple
    obsessions and rituals, 2) OCD symptoms are
    usually not tethered to one feared situation or
    stimulus, and 3) rituals in OCD tend to be less
    pragmatic and functional (or more superstitious
    in nature) compared to more reality-based
    avoidance or worrying behaviors in phobias or
    other anxiety disorders.

18
PANDAS
  • Pediatric Autoimmune Neuropsychiatric Disorders
    associated with Streptococcal Infection (Allen
    Leonard, Swedo, 1995).
  • PANDAS relation to movement disorders (e.g.
    Sydenhams Chorea) and comorbidity with tics was
    a clue.
  • Following a positive finding for group A
    beta-hemolytic streptococci (GABHS) infection.
  • Anti-streptococcal antibodies that are produced
    in response to the infection end up attacking the
    neuronal cells of the basal ganglia rather than
    the infection itself.
  • This infectious process can clearly trigger the
    sudden onset and/or exacerbation of OC and tic
    symptoms.
  • Case of Allison- sudden onset of rituals,
    aversions, social isolation, tics. Long time to
    diagnose. Significant functional impairments-
    negative reactions from teachers and peers,
    ridicule, exclusion, etc.
  • Tx- plasmapheresis, prophylactic antibiotics
  • Recently questioning pneumococcal involvement as
    well

19
Family History
  • The genetic-based familial aggregation of OCD
    appears obvious and has received strong support.
  • 54 PANDAS children 26 had at least one first
    degree relative with OCD, with 11 of parents
    qualifying for OC Personality Disorder Lougee,
    Perlmutter, Nicholson, Garvey, and Swedo (2000).
  • Twin studies significant family aggregation of
    OCD (Hettema, Neale, Kendler, 2001).
  • 2-year follow-up of children of parents with OCD
    significantly greater likelihood of OCD and other
    anxiety disorders in these children (Black,
    Gaffney, Schlosser, Gabel, 2003).
  • Larger study family aggregation of 11.7
    compared to only 2.7 in controls (Nestadt et
    al., 2000).

20
Possible Etiologies
  • Many structures and processes have been
    implicated in OCD
  • Neuroanatomical (via MRI, CT, and PET)
  • The dorsolateral prefrontal cortex (DLPFC) and
    its connection with the limbic circuitry is
    another area of interest (seen as being involved
    in governing purposeful behavior, evaluating
    external cues in order to self-adjust behavior,
    and exerting executive control over limbic
    function). Evaluation of threat.
  • The cortico-striato-thalamo-cortical circuits
    (CSTC) seen as connecting these limbic regions
    have also been identified as playing a key role
    in OCD phenomena. Using learning tests, Rauch et
    al. (1997) found that while control individuals
    accessed striatal areas (underlying implicit
    memory), OCD individuals did not, and actually
    compensated by accessing more hippocampal areas
    (implicated in explicit memory). 2000).

21
Possible Etiologies (contd.)
  • Arising largely out of pharmacologic treatment
    studies, neurotransmitters have been identified
    as playing a major role in Obsessive-Compulsive
    Disorder
  • Serotonin The fact that both non-selective
    serotonin reuptake inhibitors (SRIs) and
    selective serotonin reuptake inhibitors (SSRIs)
    have received resounding support as the
    pharmacologic treatments of choice for OCD is a
    strong indicator of this.
  • However, the serotonergic system is so complex in
    terms of its many receptor sites and subsequent
    interactions with other neurotransmitters.
  • For the most current and comprehensive review of
    the pharmacological and related aspects of
    pediatric OCD, see Grados and Riddle (2001).

22
Behavioral Model of OCD
  • Obsessions are thought to arise from an
    inherently poor tolerance for uncertainty,
    difficulty discriminating real from imagined
    threat in a situation, and subsequent efforts to
    control or make predictable a world which is
    often seen as threatening and unpredictable
    (OLeary Wilson, 1975).
  • The ambiguity and uncertainty become so
    intolerable that one feels compelled to bring
    certainty to the situation through either
    avoidance or through mental or physical rituals.
  • One perspective these behaviors become
    associated with anxiety relief by chance, but
    that they then become reinforced by the causal
    relationship that the individual erroneously
    interprets between them and the averting of
    dreaded events and concomitant anxiety.
  • Key OC individuals have difficulty
    discriminating real from illusory (or rational
    from irrational) reinforcement contingencies,
    develop a distorted sense of social causality,
    and thus engage in these exaggerated forms of
    superstitious behavior.
  • In a short period of time, the obsessions and
    anxiety return and pull for an even more potent
    obsessive response to address the distress.
  • Reparative response model for rituals like
    hand-washing? A child might do something wrong,
    experience anxiety and guilt, expect to be
    punished, and engage in some atoning or
    reparative act (that may or may not be connected
    to original misbehavior), and thus mollify their
    parents disappointment while quelling their own
    anxiety.

23
Integrated Model of OCD
  • Generalized biological (i.e. genetic),
    psychological, and specific learned
    vulnerabilities interact vulnerability to
    emotional arousal/dysregulation, poor tolerance
    for uncertainty, diminished sense of control, and
    misinterpretation of cues/events.
  • Innocuous or moderately emotionally arousing
    events occur (e.g. dirty lunch table, counter, or
    toilet seat, or an interaction with a particular
    teacher) they are catastrophically
    misinterpreted- false alarm is sounded- anxiety
    and dread are experienced in anticipation of
    catastrophic outcomes, and a perceived inability
    to control the situation.

24
Integrated Model of OCD (contd.)
  • What might be a problem is experienced as
    definitely a problem E.g. I may get sick from
    these germs experienced by most children is
    experienced as I will get sick from these germs
    by OCD youngsters. Or, in the case of aggressive
    obsessions, the unacceptable intrusive thought or
    image of hitting a teacher is experienced as if
    it is actually being acted upon- thought-action
    fusion.
  • These intrusive thoughts and images (i.e.
    obsessions) of negative outcomes and worst case
    scenarios persist. The urge to neutralize the
    threat and thus decrease the accompanying anxiety
    and make things certain grows.

25
Integrated Model of OCD (contd.)
  • I need to wash to make sure that this does not
    happen or I need to avoid such objects or
    situations so that I do not get sick, or I
    need to block this out of my mind and distract
    myself or I will act on this unacceptable urge.
  • So, active compulsions or avoidance rituals
    (safety behaviors) are carried out to
    neutralize the catastrophe and the accompanying
    distress. E.g. washing repeatedly to rid oneself
    of contamination, avoiding potentially
    contaminated objects, or distracting oneself,
    blocking out the aggressive thoughts/images (i.e.
    thought blocking), or purging the images

26
Integrated Model of OCD (contd.)
  • The averting of disaster is misattributed to the
    compulsion. Thus, the safety behavior is
    strengthened via negative reinforcement (i.e. the
    neutralization or removal of an aversive
    stimulus- in this case the anxiety and guilt
    experienced in relation to the contaminant or the
    unacceptable aggressive images respectively)
    (Wolpe, 1969).
  • Distress is eased but only temporarily- The
    doubt- or uncertainty-laden intrusive thoughts
    and images eventually return, either
    spontaneously or in relation to relevant cues.
  • Then, the compulsion is repeated.

27
Integrated Model of OCD (contd.)
  • Not unlike medicine tolerance and dependence, a
    more potent dose of the compulsion or safety
    behavior is necessary to produce relief from
    the increasing intensity of the thoughts, images,
    or urges.

28
Risk Factors Associated with Development of
Pediatric OCD and Symptom Severity
  • Behavioral inhibition (fearfulness, apprehension,
    clinginess (Kagan, 1997))
  • Avoidant coping style
  • Low self-esteem
  • Ritualistic, perfectionistic
  • Over-perceiving threat
  • Limited insight
  • Defensiveness/oppositionality
  • Family- 1st degree relatives of identified OCD
    individuals have almost a 500 higher lifetime
    prevalence than controls.
  • Parents/Dynamic- anxiety, overprotectiveness,
    perfectionism, interference, enmeshment, less
    confident in childs ability.

29
Evidence-Based Interventions for Pediatric OCD
  • Emerging from exposure-based phobia treatment
    protocols (Emmelkamp, 1994) and adult OCD
    intervention models (Dar Greist, 1992)
  • Psychosocial treatments for pediatric OCD have
    burgeoned within the past 10 years (e.g.
    Piacentini et al., 2002 March, Franklin, Nelson,
    Foa, 2001).
  • Cognitive-Behavioral Therapy, or CBT, has emerged
    as the most efficacious psychosocial treatment to
    date for pediatric OCD.
  • Integrating the behavioral, cognitive, and
    psychodynamic traditions (see Hollon Beck,
    1994 Meichenbaum, 1992), CBT approaches are
    based on the premise that ones beliefs,
    perceptions (e.g. schemas), and affect, and not
    just reinforcement or punishment, are key
    determinants of behavior, and vice versa
    (Bandura, 1978).
  • Exposure and response prevention strategies
    (E/RP) have proven most helpful in bringing about
    lasting behavioral change and symptom relief.
    This approach is predicated on the notion that
    sufficient exposure to this stimuli (Foa,
    Steketee, Millby, 1980)) and thus to the
    reality that no real threat exists, facilitates
    the resetting of the anxiety thermostat to
    normal (after an initial spike in anxiety).
  • Preventing of the compulsion or response serves
    to break the maladaptive cycle of negative
    reinforcement wherein the temporary relief from
    the obsessions and fear had reinforced the
    safety behavior that had been superstitiously
    used.

30
Evidence-Based Interventions for Pediatric OCD
  • Most Recently, clinical researchers began to
    adapt a protocol for treating youngsters (March
    Mulle, 1995 1998 March, Mulle, Herbel, 1994).
  • Still considered cognitive-behavioral in
    orientation, somewhat of a hybrid integrating the
    most effective and appropriate techniques from
    several accepted therapeutic orientations,
    thereby ensuring that it can be applied as
    flexibly and efficaciously as possible (March et
    al., 2001)
  • Cognitive Therapy techniques (CT) cognitive
    restructuring, self-talk or self-coaching, and
    attribution retraining, psychoeducation for
    children and parents around OCD and its
    neurobehavioral and chemical aspects,
  • Narrative techniques externalizing the problem
    (Chansky, 2000 White Epston, 1990) and
    addressing unique outcomes.
  • Family systems concepts focusing on integrating
    family work and addressing the reciprocal
    influences of OCD between a child and his or her
    family, more active-directive behavioral
    strategies such as limit-setting, modeling,
    homework, and contingency management (e.g.
    positive reinforcement contingent upon progress),
    and even
  • Psychodynamic approaches involving emphasizing
    the therapeutic alliance, insight, and
    internalization of behavior and perceptions

31
Pharmacologic and Combined Pediatric OCD
Interventions
  • Pharmacotherapy serotonin reuptake inhibitors
    (SRIs) and selective serotonin reuptake
    inhibitors (SSRIs), either alone or in
    conjunction with psychosocial interventions
    (Geller et al., 2003). Most common agents
    Clomipramine, Fluoxetine, Paroxetine, Sertraline,
    Fluvoxamine, Citalopram.
  • Multiple double-blind placebo studies on these
    medicines have shown similar efficacy and
    tolerability, with SSRIs emerging as first-line
    treatments combined with CBT/E/RP.
  • Pediatric Obsessive-Compulsive Disorder Treatment
    Study (POTS). (Franklin, Foa, March, 2003).
    Multi-center, randomized, masked clinical trial
    to evaluate the relative benefit and durability
    of 4 treatments sertraline (an SSRI under the
    trade name Zoloft), CBT, combined sertraline and
    CBT (COMB), and pill placebo, for children and
    adolescents. Sample of 120 participants.
  • The Expert Consensus Treatment Guidelines for
    Obsessive-Compulsive Disorder (March et al.,
    1997) 69 experts on OCD and provided a
    much-needed assessment of the above-mentioned
    factors. Specifically, selecting the components,
    pacing, and structure of treatment (e.g. CBT,
    medication, combined) based on age, patient
    response, symptoms, time constraints, medication
    side-effects, and comorbidity was a major focus.
    Consensus supports CBT or combined CBT and
    medication as the treatment of choice for
    pediatric OCD and for those with milder symptoms.
  • CBT and E/RP tacks are cited as best suited to
    clearly circumscribed symptoms such as
    contamination fears, symmetry, and hoarding,
    while less concrete symptoms such as
    scrupulosity, pathological doubt, and obsessive
    slowness are most amenable to cognitive
    approaches.

32
March MulleManualized Pediatric OCD Protocol
  • March and colleagues (e.g. March Mulle, 1998
    1995 March et al., 1994) have streamlined this
    approach into a manualized treatment protocol.
  • Explicitly designed to enhance a) patient and
    parental compliance, b) exportability to other
    populations and settings, and c) empirical
    evaluation. This involves 5 phases of treatment
    over the course of 12 to 20 sessions.

33
March MulleManualized Pediatric OCD Protocol
Visit/Step Goals Components Considerations
Weeks 1 and 2 Psychoeducation and cognitive training Establish rapport. Present neuro-behavioral model. Externalize OCD as an unwelcome visitor. Use appropriate metaphors Brain hiccups, Brain lock, False alarms. Etc. Assess treatment factors (e.g. age, developmental issues, OC features, medical profile, family psychopathology, etc). Assess OC content, severity, and impairment (CY-BOCS, OCS, CGS/CHI).
Week 2 Mapping OCD, Cognitive Training Bossing back OCD, self-talk, flexible coping strategies, positive reinforcement of accurate perceptions. Determine specific obsessions, compulsions, triggers, avoidance behaviors. Easy trial E/RP to gauge childs tolerance and compliance. Increasing sense of self-efficacy, predictability, and controllability. Map out where child has success, where OCD has control, and where they both win. Determine work zone and stimulus hierarchy what can safely be addressed first, and so on.
34
Manualized Pediatric OCD Protocol (contd.)
Visit/Step Goals Components Considerations
Weeks 3-12 Exposure and response-prevention Address therapy variables (e.g. comorbidity, symptom severity, family psychopathology, etc.) Address situation at school via behavioral consultation model (Adams et a., 1994) Graded (gradual) vs. flooding exposure? Maximize childs control of the pace within reason. Imaginal and in-vivo work. In-session practice and review. Homework monitored by clinician.
Weeks 11-12 Relapse Prevention and Generalization Training Greater use of imaginal exposure (as opposed to in vivo) and RP along with CT Discuss relapse prevention. Address termination issues and booster sessions. Focus on internalization and generalization.
35
Manualized Pediatric OCD Protocol (contd.)
Visit/Step Goals Components Considerations
Visits 1,7, and 9 Parent Sessions Graded involvement. Parents as collaborators/ coaches. Address family pathology, motivation, and involvement in/impact from OCD. Collaboration.
36
Some Treatment Study Outcomes
  • March et al. (1994) observed at least a 50
    reduction of OC symptoms in 9 of the original 15
    patients with no relapse at follow-up as far as
    18 months later.
  • Subsequent booster sessions facilitated the
    discontinuation of medication for 6 of these
    children.
  • Scahill, Vitulano, Brenner, Lynch, King (1996)
    7 children and adolescents to structured
    behavioral therapy. Mean symptom reduction of
    61, with a range of 30 to 90, and stability of
    gains for at least 3 months.
  • Wever and Rey (1997) combined CBT and
    pharmacotherapy work with 57 OCD youngsters
    resulted in a 68 remission rate with 60
    decrease in symptoms over 4 weeks.
  • Franklin et al. (1998) conducted an open clinical
    trial with this CBT protocol which produced at
    least 50 reduction in symptom severity in 12 of
    the 14 participants. Mean symptom reduction was
    67 at post-treatment and 62 at 9-month
    (average) follow-up, indicating further support
    for this approach.
  • Family Treatment (Waters, Barrett, March,
    2001) mean reduction of 60 in symptom severity,
    as well as a noticeable decrease in family
    involvement of the disorder.
  • In a more recent application (Benazon et al.
    (2002)) 10 of 16 patients experienced at least a
    50 reduction in symptoms.
  • Piacentini et al. (2002) 42 youngsters and
    found a response rate of 79.

37
Treatment in Residential School Settings The
Case of Mary
  • Articulate, polite, and friendly but socially
    awkward 16-year-old girl from the west,
  • Enrolled 3 years ago at The Learning Clinic
    (TLC) a therapeutic residential school located
    in rural New England.
  • She was initially referred to another residential
    program with a more diagnostic and psychodynamic
    approach, and experienced little success in her
    short time there.
  • As a child Demonstrated behavioral inhibition,
    poor stress resilience, anxiety, and behavioral
    peculiarities. Presented with some Asperger
    Syndrome-like traits (e.g. pedantic speech,
    social pragmatics deficits, restricted and
    idiosyncratic interests, significantly higher
    verbal than performance scores on intellectual
    measures) despite her fairly outgoing demeanor.
  • Highly perfectionistic, superstitious,
    scrupulous, indecisive, and ritualistic.
  • Preoccupations with literary idioms, romanticized
    fascination with Spanish cultures, and her
    insistence on wearing skirts and gray socks as
    opposed to pants or shorts.
  • Marys slowness, perfectionism, and difficulty
    making simple transitions made it very difficult
    for her to keep pace academically and socially.
    Despite her commendable academic success and
    sense of pride she derived from such pursuits as
    drama, music, and art, she became anxious and
    depressed.

38
Treatment in Residential School Settings The
Case of Mary
  • She endured significant peer and staff ostracism,
    withdrew from these once-preferred activities,
    and eventually came to fear the prospect of
    school, thus avoiding it altogether in favor of
    in-home tutoring.
  • Given the level of dependency Mary developed upon
    her parents throughout this time, the transition
    to TLC was highly disruptive for her, and thus
    presented an impediment that needed to be
    addressed before any focused intervention could
    be implemented.
  • Of immediate concern Her ritualized showering
    and hygiene routine (often taking up an hour or
    more), hoarding (books and swatches of familiar
    material), compulsively smelling food before
    each bite, ordering her possessions, obsessive
    slowness with transitions and schoolwork, and
    excessive reassurance-seeking.
  • More subtle symptoms such as fear of
    disinhibition (letting her feelings out all at
    once and losing control), scrupulosity, and
    mental compulsions such as praying, ordering
    ideas and tasks, and perfectionistic word-finding
    before speaking, became apparent through later
    assessment with the CY-BOCS.
  • I am planning on being at TLC for only a short
    time, and that after only a few weeks and
    addressing some of the problems that got in the
    way of my schoolwork, I will be moving back
    home. Mary was defensive of many of her
    behaviors and either marginalized their
    significance, or justified them as preferred,
    adaptive traits which she was not willing to
    relinquish. This presented some challenge for
    treatment planning in that her behaviors
    soothing function was apparent, as was their
    becoming somewhat ego-syntonic.

39
Marys Treatment Protocol
Weeks Goals Components Considerations
1-5 Rapport-building with Mary and family. Introduce treatment plan. Psychoeducation. Assessment of symptoms/impairment. Assess medication regimen. Twice weekly individual sessions. Weekly family phone sessions. In-classroom support visits. Training team on E/RP protocol. Externalizing symptoms w/ age-appropriate metaphors. Develop incentives and contracts. Mary family Fostering trust in clinician, treatment team, and in the program. Facilitating investment in the TLC program. Addressing transitional anxiety stress. Coordinate with social skill goals.
6-10 Negotiate pacing. Mapping OCD. Triaging symptoms. Cognitive training. E/RP. 3x weekly in vivo E/RP sessions in residence and school. Limit-setting Pacing for slowness/transitions. Treatment team meeting to discuss progress. Hurried pacing to address obsessive slowness. Addressing Marys defensiveness, poor insight into her symptoms, and unrealistic expectations. Cataloguing successes and unique outcomes .
40
Marys Treatment Protocol
Weeks Goals Components Considerations
11-20 Targeting secondary/ more subtle symptoms mental rituals, scrupulosity etc. Distinguishing threats from hassles. Introduction of weekly in vivo community sessions. Parent sessions preparing for home visits. More imaginal exposure. CY-BOCS assessment 2. Home visit 1. Training parents as coaches. Addressing enmeshment and enabling behaviors. Encouraging reasonable risk-taking. Evaluate home visit.
21-36 End of active E/RP. Assessment of challenges. Relapse prevention. Generalizing skills. Prescribed, systematic introduction of stressful social demands. Introduction of more insight-oriented work. Challenging Marys use of internal coping resources while supporting her and providing a safe way to fail and recover
41
Marys Treatment Protocol
Weeks Goals Components Considerations
37-52 Mapping past year successes, challenges, and new goals Planning for transition to Assisted Living level of TLC program. Assessing impending demands and Marys ability to meet them. Assess Marys ability to cope with less external structure and more demands. Assess insight. Assess level of independence.
53-Present Maintenance strengthening of gains. Relapse prevention More psychodynamic, insight-oriented work with Mary. Continued psychoeducation/ coaching with parents. Preliminary transition planning college, independent living, career. Discussing individuation a difficult topic for Mary and mother. Reflecting upon successes. Focus on meanings of individuation, new relationship roles, and future goals independent living, college, driving, etc.
42
Marys Treatment Outcomes
  • Week 6 of the process, Marys initial CY-BOCS
    score was 19 (moderate).
  • Week 22, just after active E/RP was discontinued
    and the natural structure of the program was
    allowed to take over as the therapeutic vehicle,
    this score had dropped to 14.
  • After a year, Marys CY-BOCS score was an 11,
    indicating that she was hardly symptomatic.
  • She currently reports only fleeting moments of
    mental rituals (e.g. ordering tasks/ideas) and
    minor compulsive worrying when her
    responsibilities seem to mount. Most importantly
    though, Marys stress resilience and cognitive
    flexibility have improved noticeably, her level
    of OCD-related functional impairment has gone
    from severe to between mild and none, and her
    self-advocacy has become a reference point for
    many of her peers.
  • Where once she would cry for 25 minutes in
    response to being told to set her clock to the
    correct time (and not 15 minutes ahead), or would
    become immobilized when not able to make a simple
    decision or when prompted to finish her hygiene
    routine, she now independently organizes her day,
    handles the many challenges of with confidence,
    and routinely makes difficult decisions regarding
    competing priorities in her social and academic
    life.

43
Marys Treatment Outcomes
  • Familys progress Initial home visits showed
    some promise, though moderate regression was
    obvious, with mother accommodating her behaviors
    and continuing to organize most aspects of Marys
    day for her.
  • Parents are highly motivated, caring, and
    supportive of our approach.
  • They came to recognize their role in unwittingly
    colluding with Marys rituals and dependency, and
    began to take some gradual but bold steps to
    address this.
  • Mother became attuned to how Mary cued into her
    own anxiety, and so she worked diligently at
    managing this. She also made strong efforts to
    back off the level of accommodation, thus guiding
    Mary in taking more initiative and being more
    decisive about her daily responsibilities and
    plan.
  • Most recently the major challenge has been not
    so much Marys potential for regression to old
    patterns, but parents and brothers adjusting to
    the tremendous behavioral progress and maturity
    that Mary has experienced, and what this means
    for family members changing roles in relation to
    this.

44
Marys Treatment Outcomes
  • Mary is currently at the highest privilege status
    in the TLC program and is living with a peer in
    an assisted living house on campus. There, she
    needs to plan and prepare meals, clean,
    coordinate chores with her housemate, shop,
    arrange transportation, and keep track of basic
    house-maintenance issues.
  • She holds a job at a nearby bed breakfast,
    routinely ventures into the community to do her
    laundry, and is beginning the drivers education
    process.
  • She takes voice lessons in the community and is
    active in drama and art.
  • 24 months ago, Mary would not have predicted this
    level of success, and looks back self-effacingly
    at her naive resistance, lack of insight, and
    unrealistic expectations.
  • Presently planning for her eventual transition
    back to home community, working with parents on
    managing this significant and new life phase, and
    beginning to consider her college and vocational
    opportunities.

45
Key Aspects of an Effective Therapeutic
Educational Program in Treating Pediatric OCD
  • CBT-oriented programs such as the Learning Clinic
    appear to be ideal for maximizing all aspects of
    treatment, and for addressing some perennial
    shortcomings cited in previous treatment studies
    consistent, data-based, replicable
  • Manualized but flexible/adaptable
  • High level of structure and predictability,
    reliable and effective status/privilege-based
    contingency management system
  • Highly consistent coordination of services (i.e.
    fidelity of treatment) between school,
    residential, clinical, and family components.
  • High level of accountability within and amongst
    components of the program
  • Strong family support of the program, and
    required involvement in treatment

46
Key Aspects of an Effective Therapeutic
Educational Program in Treating Pediatric OCD
(contd)
  • Ideal for generalization of gains, increased
    resilience, and relapse prevention the capacity
    to decrease structure while increasing demands to
    optimally challenge students coping resources
    and providing a natural exposure/response
    prevention vehicle
  • March Mulles manualized E/RP treatment
    protocol CBT package was well-suited it was for
    such a milieu, and vice versa.
  • Rather than relying on one or two clinicians to
    conduct treatment, it was the program itself, and
    its highly coordinated components, that became
    the vehicle for therapeutic change.
  • In-residence E/RP or cognitive strategies that
    began with Mary during the day could be continued
    and practiced with the help of residential staff
    in the evening, with full confidence that the
    procedure and follow-through would be consistent
    and well-documented.
  • Thus, such strategies could be supported by any
    number of staff in a variety of on-campus and
    community settings.

47
Notions of Prevention orMaximizing Resiliency
  • The notion of prevention per se of pediatric OCD
    is grandiose and unrealistic, however, minimizing
    risk factors while enhancing resiliency is
    crucial in managing the functional impact of this
    disorder.
  • Multisystemic coordination between parents,
    school counselors and staff, and possibly
    community mental health professionals is crucial
    at all junctures.
  • Proactive attunement of a youngsters adult
    advocates is crucial, is identifying social and
    community risk factors such as insensitive or
    inadequately supported or trained school staff,
    peer rejection or bullying, self-isolation,
    academic struggle, and a generally hostile and/or
    competitive school environment.
  • The challenge here is that compared to classic
    high risk behaviors such as drug abuse, sexual
    acting out, and antisocial behavior, pediatric
    OCD and other anxiety disorders are less visible,
    may be seen as less problematic, and thus fall
    low on priority list when it comes to mobilizing
    school resources.

48
Notions of Prevention orMaximizing Resiliency
(contd)
  • Nevertheless, this condition is still very
    disruptive, stigmatizing, and debilitating, and
    can have functional impairment and subsequent
    socioemotional consequences that we have not yet
    begun to appreciate.
  • Minimizing risk factors educating parents
    (especially in relation to family aggregation
    issues), school and community leaders, and
    students themselves about anxiety disorders and
    OCD in particular, and the very visible
    functional impairment implications, is a logical
    first step.
  • Education professionals need to build more
    tolerant school and social environments for those
    with the condition and other more silent or
    internalizing disorders.
  • Enhancing resiliency and as socially-mediated
    stress Help youngsters cope more flexibly with
    such challenges is crucial. Supportive exposure
    to moderately stressful situations, and a
    systematic titration of external supports, such
    that these children can eventually manage
    increasing demands without perceiving them as
    threatening or overwhelming.

49
  • The case of Mary illustrates the benefit of
    certain resiliency or protective factors in
    contributing to tertiary prevention, and likely
    reducing the functional impact of her OCD.
  • Mary arrived at the Learning Clinic with some
    very strong personal, family, and community
    protective resources already in place.
  • She demonstrated a talent for vocal music and
    drama, which was a great source of pride and
    motivation for her and which were strong
    incentives during her first few months.
  • Family-wise and despite some maternal anxiety,
    over-protectiveness, and accommodation of Marys
    rituals, she benefited from a warm, cohesive and
    supportive home and a close relationship with her
    parents, brother, and relatives.
  • Moreover her parents have been supportive of our
    work with Mary, healthily involved in it, and
    motivated to make the necessary changes in the
    family to support her progress.
  • Finally Mary had a strong social support network
    made up of friends, family acquaintances,
    mentors, and former teachers, with all of whom
    she has remained in contact throughout her stay
    at TLC. In addition, she was able to learn the
    interpersonal skills to build a new community
    within and beyond her school environment.
  • Mary has been able to readily access these
    resources during our work, and this has had a
    profound impact on her motivation to progress and
    thus on her ability to benefit from the
    therapeutic milieu.
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