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.

Obsessive Compulsive

Disorder:http://www.youtube.com/watch?v=ONK1lR7T9y8

What is OCD?

• OCD is characterized by the presence of obsessions and/or compulsions.

• Time-consuming.

• Create significant distress or impairment.

It’s not just avoiding cracks or washing your hands.

“People think it’s like Jack Nicholson in ‘As Good As It Gets,’ but it’s so much more than that.”

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

Video – Describe your Obsessions Q4

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

Video – Describe and Demonstrate you compulsive

behaviors Q2

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.

“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.

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.

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).

Video – When did you first notice symptoms of OCD? Q1

Distinguishing OCD from Habits of Childhood (Chansky, 2000)

• OCD Behaviors1. Time-consuming

2. Disruptive of normal routine

3. Create distress/frustration

4. Believes has to do them

5. Appear bizarre/unusual

6. Become elaborate and demanding with time

7. Must be executed precisely to prevent adverse consequences

• Non-OCD Habits1. Not overly time-consuming

2. Do not interfere with routine

3. Create enjoyment or sense of mastery

4. Habits child wants to do

5. Appear ordinary

6. Become less important and change over time

7. Can be skipped/changed without consequence

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.

Neuropathological Framework

• Dysfunction of this neuropathological circuitry.

frontal cortex / basal ganglia / thalamus / frontal cortex

OCD – Orbital-Frontal Cortex

OCD – Caudate Nucleus

Neurotransmitter Issues

• Depressed levels of serotonin in the frontal cortex.

• Dopaminergic overactivity in the basal ganglia.

• Areas targeted by pharmacological treatments.

Impact upon academic, behavioral, and social

performance in schools.

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.

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.

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.

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.

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.

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.

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.

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.

Ecological Treatment Package (ETP)

• Ecological Assessment

• Individual Cognitive behavioral therapy

• Family therapy

• Parent training

• School Consultation

• Linking clinic, school and family treatment

Clinical Model

Clinician

Client

Family

Psychiatrist

ETP Model

Clinician Consultant

Client

Family

School

Psychiatrist

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)

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)

Ecological Assessment (continued)

• Pretreatment assessment (Clinician):– NIMH Global O-C Scale– Clinical Global Impairment Scale

• Pretreatment assessment (Teacher – if indicated):– BASC

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

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

Psychoeducation

• Session 1

• Define OCD, obsessions, compulsions, epidemiology, common treatments

• Focus on OCD as medical condition

• Externalize OCD – nickname

• Explain treatment process

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

Venn Diagram

OCD Client

TZ

Washing Hands

Asking for Reassurance

Brushing Teeth

Driving Car

Eating Greasy Foods

Checking Locks

Counting Objects

Opening School Locker

Venn Diagram

OCD Client

TZ

Washing Hands

Asking for Reassurance

Brushing Teeth

Driving Car

Eating Greasy Foods

Checking Locks

Counting ObjectsOpening School

Locker

Venn Diagram

OCD Client

TZ

Washing Hands

Asking for Reassurance

Brushing Teeth

Driving Car

Eating Greasy Foods

Checking Locks

Counting Objects

Opening School Locker

Cognitive Training

• Session 3

• Mapping OCD and review the symptom list

• Constructive Self-talk

• Cognitive Restructuring

• Cultivating Detachment

Rewards

• Introduced in session 4

• Plan for ceremonies, notifications

• Provide certificates

• Lots of verbal praise and a positive attitude

Video – Did Treatment Help you Manage your OCD? Q8

Family Sessions

• Handout at Session 1: “Tips for parents.”• Sessions 7 and 12• Focus on helping parents stay out of their

child’s rituals• Parents are taught to help their child fight

OCD• Therapist works with parents to help

facilitate positive communication

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

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

Video – Describe your exposures Q10b

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

Video E/RP Prevention E/RP

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

Graduation

• Session 20

• Certificate of achievement

• Encourage notifications

• Invite friends, family members, whomever child would like to be invited

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

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)

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)

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

Video – Was CBT Helpful? Q13

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

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

Consultation: An Overview

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).

Video – How does OCD effect your performance in school? Q5

Conjoint BehavioralConsultation

(CBC)(Sheridan & Kratochwill, 1992)

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 child’s 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

CBC Model

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.

Conceptual Bases:Ecological-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 client’s 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.

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

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

Stages in Behavioral Consultation/CBC

• Conjoint Problem Identification

• Conjoint Problem Analysis

• Conjoint Treatment Implementation

• Conjoint Treatment EvaluationStages are procedurally

operationalized through a series of behavioral interviews requiring both “process” and “content” expertise.

Putting CBC to Work to Address OCD in the School Setting…

• Important Key Components1) 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)

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 student’s OCD across home & school settings

• Create a partnership between home & school to set-up optimal environments to help the client “fight back” to OCD

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

Conjoint Problem Identification

• Identify the specific concern

• Discuss, in general, the influences that may be related to client’s difficulties

• Generate a consultation / intervention goal

• Develop baseline data collection procedures

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

Conjoint Problem Analysis

• Review baseline data

• Conduct strength & conditions analyses

• Design intervention

Case Example: Utility of Data Collection

Student's Class Behavior

0%

20%

40%

60%

80%

100%

Days

% o

f cla

ss t

ime

Sleeping

Lecture

*Sleeping behavior corresponded with study time or tests*Participation occurred during lecture or group activities

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

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 client’s progress and make any necessary modifications to treatment plan

Gradual Learning Process…

• Teachers are often frustrated with the student & may think that the student lacks motivation, is non-compliant, or just doesn’t 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

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

Video – What do you think is the most misunderstood aspect of

OCD? Q17

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.

ORVisit Web Pagewww.unl.edu/schpsych/cacs/cocd.htm