Obsessive-Compulsive Disorder

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ACT-Relevant Constructs in Child Therapy Process: The Role of Child Experiential Avoidance, Willingness, and Safety Seeking Behaviors in a Family-Based CBT for Young Children with OCD. Elizabeth Davis, Lisa W. Coyne, Evan R. Martinez, Angela M Burke, Abbe M. Garcia & Jennifer B. Freeman. - PowerPoint PPT Presentation

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ACT-Relevant Constructs in Child Therapy Process: The Role of Child Experiential Avoidance, Willingness, and Safety Seeking Behaviors in a Family-Based CBT for Young Children with OCD

Elizabeth Davis, Lisa W. Coyne, Evan R. Martinez, Angela M Burke, Abbe M. Garcia & Jennifer B. Freeman

ACT-Relevant Constructs in Child Therapy Process:

The Role of Child Experiential Avoidance, Willingness, and Safety Seeking Behaviors in a Family-Based CBT for Young Children with OCD

Obsessive-Compulsive DisorderObsessive-Compulsive Disorder is defined as: a disorder marked by recurrent and persistent obsessions and/or compulsions that cause marked distress. In children, it is not required that the person recognize the excessiveness of the obsessions or compulsions (DSM-IV-TR, American Psychiatric Association)

Approximately 1 in 200 children are diagnosed with OCD

33-50% of adults with OCD experienced a childhood or adolescent onset (Beer et al., 2002)

Up to 71% of children with OCD have a parent who experiences obsessive-compulsive symptoms or is diagnosed with OCD (Riddle et al., 1990)

Obsessive-Compulsive Disorder (OCD) in children is characterized by recurrent intrusive thoughts and repetitive ritualistic behaviors

Childhood OCD results in pervasive disruptions in social, academic, and vocational functioning and predicts adult morbidity (Franklin, Foa & March, 2003)

2Therapy process variables in exposureOnly one other study has examined process variables in exposure-based treatment for children with OCD

Two studies have examined process factors in exposure-based treatments for OCD in adults, and found the following to be related to treatment outcome: Therapeutic alliance, willingness to participate, and client expectancy (de Haan et al., 1997; Vogel, Hanson, Stiles, & Gotestam, 2006).

Process variables that have been found to be significantly related to treatment outcome in treatment for depression and anxiety in children include:Parent and child willingness (Karver, Handelsman, Fields, and Bickman, 2006)Child involvement (Chu and Kendall, 2004) Positive therapist-parent, and child-therapist alliances (McLeod & Weisz, 2005) Therapist collaboration behaviors (Creed & Kendall, 2005)

Recent data from clinical trials suggest that CBT alone or in combination with sertraline is helpful in substantially reducing OCD symptoms in children aged 7 17. An initial clinical trial for young children (aged 5-8) with OCD comparing a family-based CBT to a family-based relaxation active control has also shown promising results. CBT with exposure and response prevention has been shown to be the most effective therapeutic approach for ocd.

To date, only two studies have examined process factors in exposure-based treatments for OCD (de Haan et al., 1997; Vogel, Hanson, Stiles, & Gotestam, 2006). Both of these were adult studies. Therapeutic alliance, client motivation for change, willingness to participate, and expectancy predict outcome for CBT for OCD in adults.

These variables account for 30% of the variance in adult treatment outcome, beyond the 15% accounted for by specific therapeutic techniques.

Only one other study has examined process variables in exposure-based treatment for children with OCD.

3 Considerations for treatment with young childrenTreatment can be taken out of childrens control determined by parents/teachers

Young children may have more difficulty describing gradations in their feelings, making designing an exposure hierarchy more difficult

Children may feel coerced to participate in the exposure

Involvement of parents in management/enabling of OCD rituals (King, Leonard & March, 1998)

Children are often embarrassed or defensive about symptoms (King, Leonard & March, 1998)

Treatment of OCD in young children requires parent participation to guide and reinforce exposures within sessions and between sessions

Many children and adolescents with OCD do not yet have the emotional and cognitive skills to fully address their irrational fears and compulsive behaviors. As such, they may have difficulty identifying and articulating their fears and/or why they feel compelled to do certain behaviors.

They also may not recognize that their fears are exaggerated or unrealistic. Furthermore, children with OCD may be resistant to discussing these problems with anyone, even their parents. Likewise, children and adolescents with OCD may anticipate being very uncomfortable or frightened by the prospect of discussing these issues with a psychotherapist. It is not unusual for children and adolescents with OCD to exhibit "magical thinking" in which they believe that their fears will come true if they talk about them with a therapist (or anyone). Others may deny symptoms, or want to avoid dealing with them in the hope that their OCD will just go away by itself.

Thus, the role of the family in individual therapy for young children is particularly important, and has only recently received empirical attention.

4Emotion regulatory strategies and treatmentTreatment efficacy may be affected by emotion regulation strategies that children and parents use, such as experiential avoidance and safety-seeking behaviors

If children feel coerced, they may be unwilling to participate in exposure, and thus exhibit experiential avoidance and safety seeking behaviors

Parents may inadvertently model experiential avoidance for their children, through statements such as Oh, I think that might be too hard for her.

Parent factors and family environment may also be impacting child symptoms:AccommodationNegative family interactions (criticism and hostility)Cognitive and behavioral avoidance coping strategies (Derisley et al., 2005)Exhibiting less warmth and less encouragement of independent thinking (Moore, Whaley, & Sigman, 2004)

Prevention of rituals/encouragement of exposure can be extremely distressing for children and their parents the degree to which parents are willing to tolerate this distress may be critical to treatment compliance.

Young childrens increased reliance on parents as therapeutic coaches may be complicated by the greater likelihood that parents may engage in frank accommodation of child symptoms (Lenane, 1989, 1991; Leonard et al., 1989; Pollack and Carter, 1999; Rettew et al., 1992; Steketee, 1997)

Frequently, parents participate in rituals in response to their childs requests or distress (e.g., providing reassurances, tying dirty shoelaces) and sometimes overreact to the childs behavior.

5Parent & Child Emotion RegulationBehavioral Approach/Safety-SeekingBehavior used to approach/prevent perceived danger or aversive condition

Experiential Acceptance/AvoidanceBehavior used to approach/prevent aversive private event

WillingnessAgreement to participate (saying yes)Experiential acceptance (meaning it)

6Behavioral Approach/Safety-Seeking

Parents & children may be especially vulnerable to behavioral avoidance if they have difficulty tolerating (or are unwilling to experience) aversive internal states.

Experiential AvoidanceDeliberate attempts to minimize aversive internal psychological eventsRestricts attention/ability to engage in the present momentMay preclude the development of more adaptive behaviorsAssociated with white-knuckling, or going through exposure unwillingly

Child willingness to participate in treatment has been examined in only one child process-outcome treatment study (Adelman et al., 1984).Willingness has often been included as part of therapeutic alliance measures.

Parental willingness to participate in treatment has been studied in two child and adolescent treatment outcome studies (Kadin, 1977; Fields et al., 2004)Behavioral Approach/Safety-Seeking, which refers to behavior used to approach/prevent perceived danger or aversive condition

Parents & children may be especially vulnerable to behavioral avoidance if they have difficulty tolerating (or are unwilling to experience) aversive internal states.

Experiential Avoidance refers to deliberate attempts to minimize aversive internal psychological events. EA has been associated with restricted attention/ability to engage in the present moment, may preclude the development of more adaptive behaviors, and may be associated with white-knuckling, or going through exposure unwillingly

Child willingness refers to saying yes, or implicit task agreement, and meaning it, or acceptance of aversive internal states (EA). Willingness to participate in treatment has been examined in only one child process-outcome treatment study (Adelman et al., 1984), and has often been included as part of therapeutic alliance measures.

Study GoalsTo develop a coding system to assess Child BehaviorsBehavioral ApproachExperiential AcceptanceWillingnessParent Behaviors Behavioral approach/avoidance and Experiential approach/avoidanceTherapist BehaviorsCollaboration

To explore the relationship of these variables to treatment outcome7Overall goal: To examine process variables in exposure-based therapy for young children (ages 4-8) with OCD

MethodParticipants23 children aged 4-8 years (mean age 6.61 years), 60.9% female, with (1) Primary OCD (2) symptom duration of at least 3 months; (3) at least one parent able to attend all sessions

Family-Based CBT: 14 week, 12 session protocolSessions 4 (therapist), 4 & 7 (children) & 7 (parents) were coded

8Participants included 23 children aged 4-8 years (mean age 6.61 years, 39.1% male, 60.9% female) who participated in the CBT arm of a small RCT comparing a family-based cognitive behavioral treatment with a famil