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Ocd
1. 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.
4. What is OCD?
• OCD is characterized by the presence of
obsessions and/or compulsions.
• Time-consuming.
• Create significant distress or impairment.
5. 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.”
6. 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
11. 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.
12. “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.
13. 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.
14. 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).
15. Video – When did you first
notice symptoms of OCD? Q1
16. Distinguishing OCD from Habits of
Childhood (Chansky, 2000)
•
OCD Behaviors
1. 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 Habits
1. 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
17. 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.
21. Neurotransmitter Issues
• Depressed levels of serotonin in the frontal
cortex.
• Dopaminergic overactivity in the basal
ganglia.
• Areas targeted by pharmacological
treatments.
23. 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.
24. 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.
25. 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.
26. 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.
27. 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.
28. 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.
29. 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.
30. 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.
37. 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
39. Psychoeducation
• Session 1
• Define OCD, obsessions, compulsions,
epidemiology, common treatments
• Focus on OCD as medical condition
• Externalize OCD – nickname
• Explain treatment process
40. 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
46. Video – Did Treatment Help you
Manage your OCD? Q8
47. 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
48. 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
49. 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
51. 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
53. 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
55. 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
56. 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)
57. 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)
58. 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
60. 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
61. 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
63. 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).
64. Video – How does OCD effect
your performance in school? Q5
66. 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
68. 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.
69. 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.
70. 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
71. 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
72. Stages in Behavioral
Consultation/CBC
• Conjoint Problem Identification
• Conjoint Problem Analysis
• Conjoint Treatment Implementation
• Conjoint Treatment Evaluation
Stages are procedurally operationalized
through a series of behavioral interviews
requiring both “process ” and “content ”
expertise.
73. Putting CBC to Work to Address OCD
in the School Setting…
•
Important Key Components
1) 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)
74. 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
75. 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
76. 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
77. 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
78. Conjoint Problem Analysis
• Review baseline data
• Conduct strength & conditions analyses
• Design intervention
79. Case Example: Utility of Data Collection
Student's Class Behavior
% of class time
100%
80%
60%
Sleeping
Lecture
40%
20%
0%
Days
*Sleeping behavior corresponded with
study time or tests
*Participation occurred during lecture or
group activities
80. 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
81. 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
82. 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
83. 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
84. Video – What do you think is the
most misunderstood aspect of
OCD? Q17
85. For More Information
• Contact the Cormorbidity in Youth ObsessiveCompulsive 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.
OR
Visit Web Page
www.unl.edu/schpsych/cacs/cocd.htm
