1. OBSESSIVE-COMPULSIVE DISORDER IN CHILDREN AND ADOLESCENTS: FAMILY BASED STRATEGIES AND INTERVENTIONS James A. Gall, Ph.D., PLLC 1

2. Overview 2  Family dysfunction does not cause OCD, however family members affect and are affected by a child with OCD  OCD disrupts the psychosocial and academic performance of roughly 1 in 200 children/adolescents ( Academy of Child and Adolescent Psychiatry )  Treatment tailored to a child’s developmental needs and family context may reduce chronic nature of OCD

3. Objectives  Understand the epidemiology of OCD, diagnostic criteria, symptoms, developmental factors, and comorbidity  Understand the importance of parental involvement in all phases of treatment for children experiencing OCD  Understand the importance of treatment tailored to a child’s developmental characteristics 3

4. Objectives  Understand the family/parental role as co- therapists in helping a child learn to manage their symptoms  Understand how the family context and parental reactions affect a child with OCD  Learn strategies for working with the school as well as strategies for improving the overall family functioning 4

5. Definition (DSM-IV) 5 Obsessions as defined by:  Recurrent and persistent thoughts, impulses, or images which are intrusive and cause marked anxiety or distress  Thoughts, images, or impulses are not simply excessive worries about real problems  The person attempts to suppress the thoughts, images, or impulses, with some other thought or action

6. Definition 6 The person recognizes that he obsessions are a product of his/her own mind Compulsions as defined by:  Repetitive behaviors that the person is driven to perform in response to an obsession  The behaviors of mental acts are aimed at reducing or preventing distress or some dreaded event

7. Definition 7  The person recognizes that the obsessions or compulsions are excessive and unreasonable Note: This does not apply to children The obsessions or compulsions cause marked distress or significantly interfere with normal routine (school, social activities, relationships)

8. Children at Risk 8  OCD affects as many as 1% of children (as common as childhood asthma; 3-5 youngsters with OCD per average-sized elementary school)  50% of adult cases of OCD are diagnosed before age 15  2% of children are diagnosed between ages of 7- 12  OCD is more prevalent in boys (2:1 ratio)  20% of children with OCD have a family member with OCD

9. Children and Rituals 9  Some compulsive and ritualistic behaviors in childhood are part of normal development – most common between the ages of 4-8; an attempt to master fears and anxieties  Many children collect objects, engage in ritualized play, avoid imaginary contaminants

10. Children and Rituals 10  Many childhood rituals advance development, enhance socialization, assist with separation anxiety, and help define their environment  Childhood rituals disappear on their own – rituals of a child with OCD persist well into adulthood

11. Symptoms at Home 11  May be worse at home than at school  Repeated thoughts they find unpleasant – not realistic  Repeated actions to prevent a feared consequence  Consuming obsessions and compulsions  Distress if ritual is interrupted  Difficulty explaining unusual behavior  Attempts to hide obsessions or compulsions

12. Symptoms at Home 12  Resistance to stopping the obsessions of compulsions  Concern that they are “crazy” because of their thoughts

13. Symptoms at School 13  Families often seek treatment once symptoms affect school performance  Difficulty concentrating – problem finishing or initiating school work  Social Isolation  Low self-esteem

14. Symptoms at School 14  Other conditions – ADHD  Learning disorders/cognitive problems which are often overlooked  Daydreaming – the child may be obsessing  Repetitive need for reassurance

15. Symptoms at School 15  Rereading and re-writing, repetitively erasing – look for neatness, holes in paper  Repetitive behaviors – touching, checking, tracing letters  Fear of doing wrong or having done wrong

16. Symptoms at School 16  Avoid touching certain “unclean” things  Withdrawal from activities or friends

17. Treatment 17 “There is nothing that is wrong with me that what's right with me can’t fix”

18. Treatment: Psychological Interventions 18  Family-based cognitive behavioral therapy is uniquely tailored to the child’s developmental needs and family context (Bradley Hasbro Children’s research Center, 2008).  Family based CBT provides the child and parents with a set of tools to help manage and reduce the OCD symptoms  Young children require parental guidance and have less emotional awareness

19. Treatment: Psychological Interventions 19  The need for education – not their fault  Differentiate between the child and OCD  Explain OCD in understandable language  Listen to and observe your child  Personifying the obsessions – give it a name  Stop blaming yourself – bad parenting does not cause OCD  Instill hope, learn to fight back, engage in exposure therapy – parents are co-therapists

20. Interventions at Home 20  Therapist must work with the school- NO EXCEPTIONS!  Provide a sympathetic and tolerant environment  Understand the disorder  Listen to your child’s feelings  Plan for transitions

21. Interventions at Home 21  Adjust expectations until the symptoms improve  Praise your child’s efforts to resist symptoms  Plan for what to say to people outside the family  Understand parental limits  “It’s the OCD talking.”

22. Interventions at Home 22  Celebrate accomplishments  Foster hope and normalized developmental behavior  Understand parental role in supporting therapy interventions at home – help child commit to exposure therapy and boss back OCD

23. Interventions at School: Modifications, Accommodations, and Strategies 23  Develop a collaborative relationship with the school, especially the teacher and counselor.  Most school officials want to help the child and work with the therapist – they want help too!  Allow more time to complete certain type of assignments

24. Interventions at School: Modifications, Accommodations, and Strategies 24  Accommodate late arrival due to symptoms at home  Give the child a choice of projects  Adjust the homework load  Anticipate issues such as school avoidance  Assist with peer interactions

25. Interventions at School: Modifications, Accommodations, and Strategies 25  Monitor transition periods  Support and reinforce behavioral strategies developed by the clinician  Encourage the child to problem-solve  Allow alternative ways to complete work or take tests – be creative!

26. Interventions at School: Modifications, Accommodations, and Strategies 26  Eliminate undesirable options, e.g., use a pencil without an eraser  Have the student identify and substitute less disruptive compulsive behaviors  Find solutions for restroom problems

27. Interventions at School: Modifications, Accommodations, and Strategies 27  Do not punish the child for behavior they have no control over  Never tolerate teasing directed towards a child with OCD  Monitor for special educational services/resources

28. Interventions at School: Modifications, Accommodations, and Strategies 28  Flexibility and a supportive environment are essential for a student to achieve success in school “There is nothing that is wrong with me that what's right with me can’t fix”

29. We are Done! 29 Questions & Answers

30. References and Resources 30  The OCD Foundation of Michigan – 313.438.3293 www.ocdmich.org  The International OCD Foundation: www.ocfoundation.org  Anxiety Disorders Association of America www.adaa.org

31. James A. Gall, Ph.D., PLLC 31  Office phone: 810. 543. 1050