ELIZABETH DAVIS, L ISA 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 Disorder

Obsessive-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)

Therapy process variables in exposure

Only 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)

Considerations for treatment with young children

Treatment can be taken out of children’s 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

Emotion regulatory strategies and treatment

Treatment 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: Accommodation Negative 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)

Parent & Child Emotion Regulation

Behavioral Approach/Safety-Seeking Behavior used to approach/prevent perceived danger or aversive

condition

Experiential Acceptance/Avoidance Behavior used to approach/prevent aversive private event

Willingness Agreement to participate (saying yes) Experiential acceptance (meaning it)

Study Goals

To develop a coding system to assess Child Behaviors

Behavioral Approach Experiential Acceptance Willingness

Parent Behaviors Behavioral approach/avoidance and Experiential approach/avoidance

Therapist Behaviors Collaboration

To explore the relationship of these variables to treatment outcome

Method

Participants 23 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 protocol Sessions 4 (therapist), 4 & 7 (children) & 7 (parents) were

coded

Measures

Kiddie Schedule for Affective Disorders and Schizophrenia for School Age Children-Present and Lifetime Version (K-SADS-P/L) (Chambers et al., 1985; Kaufman et al., 1997)

Child Yale-Brown Obsessive Compulsive Scale (CY-BOCS) (Scahill et al, 1997)

Coding Manual

The Observational Coding Manual (OCM-R; Coyne, Burke, & Davis, 2007)

Based on the theoretical framework of Acceptance and Commitment Therapy (ACT; Hayes, Strosahl, & Wilson, 1999)

Assesses parent, child, and therapist variables

Used during in session exposure planning, and exposure

Manual Development

A preliminary set of theoretically-driven codes were submitted for expert review, and then revised to accommodate expert feedback

Pilot coding of treatment videos was conducted in order to further refine the code definitions

The OCD Coding Manual (OCM): Parent and Child Versions

Behavioral Approach Adapted from Heidtke (2005) Sequential and global codes

Experiential Acceptance Sequential and global codes

Collaboration Adapted from McLeod and Weisz (2005)

Willingness Task Agreement + Experiential Acceptance

Descriptions of codes

Experiential Acceptance Coded globally on a scale from 1-5 Statements coded as “1” were experientially avoidant, and included

anything suggesting a task was too difficult (“I think it’s too hard for him; I can’t stand touching this sticky stuff!!”)

Behavioral approach Coded globally on a scale from 1-6 Behavioral approach was demonstrated through statements or

behaviors that encouraged approach to the stimulus during exposure (“Wow, look how dirty your hands are getting”; child putting hands in the dirt)

Description of codes

Agreement to participate Coded on a scale from 1-5 This code was comprised of a conglomerate score adding ratings of attentiveness,

responsiveness, adding detail, active interest, and distraction to comprise one overall agreement to participate score

Therapist collaboration Coded globally on a scale from 0-5 This code was designed to measure specific therapist behaviors representative of

collaboration The code was broken down into 5 yes/no questions: 1. Does the therapist use the words “we”, “us”, “let’s” in > 1 instance

2. Does the therapist initially provide at least one opportunity for the child to contribute to exposure planning in a generalized and collaborative way

3. Does the therapist provide the child with options for exposure and/or give the child the opportunity to choose the task

4. Does the therapist communicate verbally and/or behaviorally that the child/parent/therapist will work toward the goals of exposure together as a team

5. Does the therapist praise/encourage the child’s collaborative efforts during exposure planning (i.e. problem solving, generating ideas, participation)

Properties of the OCM: Parent Variables

Intraclass Correlations for OCM__________________________________________________

Exposure Planning EA BA Agreement

to Participate

.64 -- .83

ExposureEA BA Agreement

to Participate

.94 .88a .67 __________________________________________________________ Note. a Percent Agreement

Properties of the OCM: Child Variables

Intraclass Correlations for OCM__________________________________________________

Exposure Planning EA BA Agreement

to Participate .97 -- .96Exposure

EA BA Agreement to Participate

.86 .90 .91 Bond

.83 __________________________________________________________

Parent EA, BA, & Treatment Outcome

Contrary to hypotheses…

Parent modeling of behavioral approach/safety seeking and experiential acceptance/avoidance were not associated with child outcome at end of treatment or 3 month follow-up

Did Child EA During Exposure Planning Affect Treatment Outcome?

___________________________________________________________ CYBOCs ET CYBOCs FU

Session 4 Freq. EA -.39† -.73*Global EA -.33 -.29

Session 7Freq. EA -.33 -.33Global EA -.25 -.16___________________________________________________________Note. * p < .05, †p < .10; N=19 for session 4; N = 11 for

session 7

What About Child BA/EA During Exposure?

______________________________________________________ CYBOCs ET

CYBOCs FU Session 4 Freq. EA -.06

-.39 Global EA -.56* -.33

Freq. BA -.56* -.06

Freq. SS -.61*-.32

Global BA -.13 .17

Session 7 Freq. EA -.16 -.25

Global EA -.47† -.60

Freq. BA -.59* -.47

Freq. SS -.06 .18 Global BA -.12 -.15

______________________________________________________

Note. *p < .05; †p < .10; N=14 for session 4; N = 8 for session 7

What About Therapist Collaboration?

______________________________________________________ CYBOCs ET

CYBOCs FUSession 4

Therapist Collaboration -.13 -.64*

______________________________________________________ Note. *p < .05, N=14 at ET, N=8 at FU

What Was the Role of Child Willingness?

Children who displayed better task agreement during exposure at Session 4 had more symptom reduction post-treatment (r = -.56, p < .05, n = 14)

Task agreement was highly correlated with experiential global experiential avoidance, which suggests they measure similar constructs

Study Strengths

First study to develop an observational coding system to assess experiential avoidance

First study to explicitly examine these variables in the context of specific session components, namely, exposure planning and exposure

First study to find a relationship between therapist collaboration and symptoms at follow-up in a sample of young children with OCD

Looking at late vs. early parent involvement, later in the process of “transfer of control” from therapist to parent

Study Limitations

Descriptive onlyTeeny n, thus very low power to detect effectsLower reliability in parent codes, thus potentially attenuating

relationshipsCannot make any statements about directionalityNature of sequential relationships not fully exploredDid not control for CY-BOCS scores at baseline

That being said, findings may suggest…

Creating child “willingness” early in treatment is important

Child Experiential Acceptance behaviors during exposure are significantly related to treatment outcome

Treatment may work, in part, through: Addressing child emotion regulatory strategies

Behavioral approach/Safety Seeking Experiential approach/Avoidance

Fostering agreement and bond between child and therapist Enduring through difficult exposure tasks Therapist collaboration with child

Future Directions

Need more data! Larger N!Why didn’t it work for parents?Looking at functional (sequential) relationships between

parent, therapist, & child behaviorsAssessing the convergent and divergent validity of the

coding system with additional baseline measures of experiential avoidance, parent accommodation, etc.

Thank you!!

Acknowledgements:Dr. Lisa Coyne Angela Burke

Dr. Jennifer FreemanDr. Abbe Mars GarciaDr. Amy PrzeworskiThe Coyne Family