Slide 1 OCD and Teens/Young Adults: How to

Keep Them Engaged in Their Own Treatment, Symptoms, and Lives

Martin E. Franklin, Ph.D.

Associate Professor of Clinical Psychology in Psychiatry

University of Pennsylvania School of Medicine

& Director, COTTAGe

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Adolescence: A Visual Summary

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8 Developmental Considerations in CBT

Younger children

• More directive approach

• Use age-appropriate language and metaphors

• Greater use of goal-setting and reinforcement

• Greater family involvement

Adolescents

• More collaboration in exposure selection

• More realistic discussion of risk

• More identification of feared consequence, and greater use of disconfirmatory evidence

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9 Meta-Analysis: A Forest Level View

Type: JPG

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10 CBT Age Effects: Individual Patient Meta-analysis (Bennett et al., 2013)

• Examined whether age moderated CBT response in anxiety disorder RCTs (excluding OCD & PTSD)

• 1,171 cases from 17 studies

• No age effects – adolescents do just fine!

• Why not? CBT modifications carried out by expert therapists and supervisors in clinical trials (flexibility within fidelity)

• Might see effects in effectiveness context

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11 CBT for Pediatric OCD: Summary

• CBT is efficacious relative to various comparison conditions

• Symptom reduction typically robust (40% - 65% in RCTs)

• Studies that have included follow-up (e.g., Barrett et al., 2005; Franklin et al., 2011; Piacentini et al., 2010; Storch et al., 2007) attest to durability of TX gains

• Lack of availability in community settings is at issue

• RCTs recruited across a broad age range (6 – 17), which presents challenge to delivery of developmentally sensitive TX

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But What About Age Effects in OCD?

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13 OCD Treatment Outcome x Age

• POTS I: Age was neither a predictor or a moderator of outcome

• POTS II: A hint at an age effect: Kids < 13 tended to do better

• NORDLOTS: Older kids didn’t do as well

• Literature more broadly speaking: Inconsistent…some studies have found age associated with outcome and others have not, so we must form an educated guess based on what is known

• So what do we make of it? We should be mindful of the possibility that age could affect outcome, and we have to be thoughtful about how those effects could be realized…

• Developmental sensitivity is the key!

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14 Adolescents: What Do They Bring to the CBT Context?

• Strong desire to develop their independence

• Increased importance of peer group

• Ability and desire to think for themselves

• Risk assessments sometimes inaccurate, though OCD could mitigate against this to an extent

• Mistrust of adults, especially those who try to make them do things that they don’t want to do

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15 LEAP: Launching Emerging Adults Program (Albano, Columbia U)

Expected developmental milestones for end of adolescence:

• Emotional independence from parents

• Develop self-identity

• Behavioral independence from parents

• Manage money properly & develop

• Make & keep long-term relationships

• Take control of personal care

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16 Adolescents: Potential Risk Factors for Suboptimal Response

“Every moderator of outcome reflects a mediator you haven’t discovered yet.” – Steve Hollon, Vanderbilt University

• Longer duration of symptoms – development of overlearned habits, pessimism about treatment outcome?

• Psychiatric comorbidity?

• Motivational issues/readiness for change?

• Parent-teen conflict about symptoms (or other stuff)?

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17 CBT Interventions for OCD Typically Include:

• 12 – 20 sessions delivered by trained/supervised therapists

• Psychoeducation re: nature of anxiety/OCD

• Identifying & dealing with anxiety-relevant cognitions

• Hierarchy development & selection of treatment targets

• Some form of behavioral exposure to feared thoughts/situations

• Relapse prevention

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18 Goals of Individual Tx Components

Cognitive interventions: Correcting erroneous cognitions (e.g., anxiety

won’t w/o ritualizing; externalize OCD)

Exposure in vivo: Prolonged confrontation with anxiety-evoking

stimuli (e.g., contact with contaminants)

Imaginal exposure: Prolonged imaginal confrontation with feared

disasters (e.g., hitting a pedestrian while

driving)

Ritual prevention: Blocking of compulsions (e.g., leaving the

kitchen w/o checking the stove); eliminating

neutralizing function of compulsions

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19 A Simplified

Theoretical Approach

“Blah, blah, blah, do the thing you’re afraid of,

Blah, blah, blah, the more you do it, the easier it gets.”

Gwen Franklin, age 6, to her father, 2001

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20 Lessons To Be Learned

• Anxiety is transient

• Avoidance strengthens fear; exposure weakens it

• Exposure is necessary for extinction

• Anxiety in anticipation of exposure may be higher than

anxiety during actual exposure

• Feared consequences do not materialize

• “Ceiling Fan” Analogy – letting your anxiety make noise

while you go about your business

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21 PRINCIPLES OF TREATMENT

• Voluntary• Collaborative• Hierarchy-driven• Focus on accomplishments, not failures• Promotes mastery of anxiety • Manage and face fears/urges rather than running away

or giving into them

• Based on assessment of behaviors

Parents may need to learn to accept a less active role…

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Setting Up Treatment:CBT for Pediatric OCD

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• Mapping OCD

Includes the identification of areas of life, activities, thoughts, etc. that the OCD influences

Over time, the goal is to decrease the influence of OCD in as many areas as possible (similar to gaining control of territory in battle)

• Acknowledge current position

• Maintain focus on the treatment goals

• Always attempt a new step toward that goal

Dynamic Process of CBT

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“Flexibility within Fidelity”

Phil Kendall’s CBT Motto

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25 “OCD is Like Hawaii…”

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26 “OCD Is Like My Dog…”

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27 “OCD Treatment is Like…Learning to Play the Violin”

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28 “OCD Treatment is Like…Peyton Manning at the Line of Scrimmage”

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“OCD is Like…Whatever It Is That You Like to Think & Talk About”

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The Heart of the Matter:Conducting ERP in

CBT for OCD

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31 Climbing the Exposure Hierarchy

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• In vivo exposures (during sessions and for homework)

• Homework assignments are logically connected to “in-session” work

• Imaginal exposures

• Exposures are done in a graded manner

• Therapists models exposures for patients

• Exposures should occur “where the OCD lives” (e.g., home, school, etc.)

Two Kinds of Exposures

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33 Imaginal Exposure

Courtesy of John S. March, M.D.

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34 Exposure in Vivo

Courtesy of John S. March, M.D.

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35 Response Prevention

Courtesy of John S. March, M.D.

Nope, I'm

not goingto wash

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36 Extinction

Courtesy of John S. March, M.D.

Will Iget sick?

Honey,

we agreed

I wouldn'tanswer

that question

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37 Early CBT Treatment Sessions

• Begin with only moderately distressing stimuli and intrusions

• Coach and encourage the child to abstain from rituals

• Trouble-shoot and plan for future exposure exercises together

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38 Moving Up the Hierarchy

• Build on past successes from earlier sessions

• Encourage the child to choose from among equivalent stimuli for exposures

• Manage negative family affect

• Note changes in impairment and decreased symptoms to highlight improvement

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• Encouragement and praise for efforts

• Modeling

• Discussion of acceptable vs. unacceptable risk

• Repeated and prolonged exposure

• Confront fears in multiple contexts

Confronting the Greatest Fears

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40 Adolescents: Potential Risk Factors for Suboptimal Response

• Longer duration of symptoms – development of overlearned habits, pessimism about treatment outcome?

• Psychiatric comorbidity?

• Motivational issues/readiness for change?

• Parent-teen conflict about symptoms (or other stuff)?

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41 Adolescents: Potential Risk Factors for Suboptimal Response

• Longer duration of symptoms – development of overlearned habits, pessimism about treatment outcome?

• Psychiatric comorbidity?

• Motivational issues/readiness for change?

• Parent-teen conflict about symptoms (or other stuff)?

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42 Adolescents: Potential Risk Factors for Suboptimal Response

• Longer duration of symptoms – development of overlearned habits, pessimism about treatment outcome?

• Psychiatric comorbidity?

• Motivational issues/readiness for change?

• Parent-teen conflict about symptoms (or other stuff)?

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43 Adolescents: Potential Risk Factors for Suboptimal Response

• Longer duration of symptoms – development of overlearned habits, pessimism about treatment outcome?

• Psychiatric comorbidity?

• Motivational issues/readiness for change?

• Parent-teen conflict about symptoms (or other stuff)?

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44 LEAP Treatment Goals(Albano, Columbia U)

Goals of family intervention:

• Reduce level of conflict & feelings of anger, blame

• Enhance family problem solving

• Facilitate disengagement from child’s OCD symptoms

• Rebuild “OCD free” family interaction patters

• Foster an environment conductive to maintenance of gains

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46 Working within School Settings

• Some anxiety problems can be managed successfully in the school environment without referral for specific outpatient treatment

• Other anxiety problems require referral but the school staff can still play an important role

• In either case, the goals in school are to reduce avoidance and facilitate use of more adaptive coping strategies

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47 Treating Adolescents: What Can You Bring to the CBT Context?

• Respect their independence & work within that frame

• Reinforce their ability and desire to think for themselves

• Stay positive, even when it’s difficult to do so

• Make effort to “get” their world but fess up when you don’t

• Ignore tone, but call them out when they cross the line

• Don’t be one of those adults they mistrust…”My only job here is to make you aware of the consequences of your choices, not to make those choices for you…”

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