Empowering Families in the
Treatment of Children with OCD
Katherine Yost, PhD, LMFT
Introduction
• Topic: Empowering Families in the Treatment of
Children with OCD
• This experiential workshop will show how to
include family members in the treatment of
Obsessive-Compulsive Disorder (OCD) for
children. There will be a review of the most
common forms and causes of OCD in children.
The current research on the enhanced
effectiveness of using family therapy will be
presented and then four specific strategies will be
demonstrated, using audience participation.
4 Learning Objectives
• Participants will know the most common
presenting forms of OCD in children
• Participants will know the prevalence and
causes of OCD in children
• Participants will learn about the current
research on pediatric OCD and family therapy
• Participants will learn 4 strategies for involving
the family in the treatment of children with
OCD
Introductions
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Katherine Yost, PhD, LMFT, has over 30 years of experience and maintains a private
practice in Bellevue, WA. She is a Clinical Fellow and Approved Supervisor for the
American Association for Marriage and Family Therapy. She is a past-President for
the New Jersey Division of AAMFT and is currently serving on the board for the
Washington Association for Marriage and Family Therapy. Dr. Yost has taught at
Antioch University in Seattle, Rutgers University in NJ, and several other colleges
and universities. Currently she is excited to be forming the Eastside Anxiety
Center.
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Alternatively:
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Over 30 years of exp as LMFT; AAMFT Clinical Fellow and Approved Supervisor
Past President of NJ-AAMFT and currently on Board for WAMFT
Formerly a prof at Rutgers and currently adjunct for Antioch Univ Seattle
15 years treating OCD
Currently forming the Eastside Anxiety Center with 5 other colleagues
Introductions (cont)
• Audience
– Experience with OCD?
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Treat clients with OCD?
Children with OCD and their families?
Familiarity with CBT/ERP?
Know someone with OCD?
– Attended the IOCDFoundation conf?
• Summer 2014 it will be in LA
• Great experience because it includes clients, their
families, researchers, and clinicians
Format
• Format
– Lecture/disc with audios and videos
– Experiential
– Feel free to ask questions as we go
• Handouts
– Download from AAMFT conference site
– I will have the handouts posted on my website at
ksyost.com until the end of this year
– Include: PowerPoint, sample assessment instruments,
suggested readings for lay people and adults, and
references referred to in this workshop
Preview
• Pediatric OCD
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DSM 5
Prevalence
Etiology
Common Forms
Assessment Instruments
• Current Research on the Systemic Impact of OCD
and the family (see handouts)
• 4 Strategies for empowering the family in the
treatment of children with OCD
Pediatric OCD
• Metaphors for OCD
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French call it the “malady of doubt”
Schwartz (1996) calls it trouble with the gear shift
Often referred to as brain “hiccups”
Like an iPod that won’t stop playing awful rap music
Children love metaphors
• But my current favorite is when the
GPS/smartphone keeps giving the wrong
instructions
• *** in Calif, driving a rental car in the dark canyon
no street lights . . .
Japanese Tourist in Australia
GPS metaphor
• Clients come to you hoping you can help them
turn the *dang* thing off
• More accurate to say that you will help them
to learn how to control the volume
• The therapist empowers child and the family
with toolboxes so that they can learn to be the
boss of OCD
OCD Screener for Children
• Does the child repeatedly wash her hands, use
hand sanitizers, or take long showers?
• Does he have to apologize repeatedly or say
goodbye or goodnight in a certain sequence and
is very distressed when the sequence is
interrupted?
• Does she erase her printing or writing excessively
and insist that it must be perfect or "just right"?
• See handout for complete list or
http://www.austinocd.com/childtest.shtml
DSM 5
• How many of you have had a chance to read
the new chapter on OCD and related
disorders?
• Review the changes together
– What is important
– What is new
• See the handout
DSM 5
• New: OCD comes right after Anxiety (to show
they are related) but now has it’s own chapter.
The code is the same: 300.3
• The chapter also includes hoarding, skin
picking, body dismorphic disorder, and
trichotillamania
Obsessions
• Presence of Obsessions defined by 1 and 2
1. Recurrent and persistent thoughts, urges
[replaces “impulses”] or images that are
experienced . . .as intrusive and unwanted. . .and
that cause marked anxiety and distress
2. The individual attempts to ignore, suppress, or
neutralize with some other thought or action
(compulsion)
Obsessions (cont)
• n.b. Young children may not be able to
articulate the aims of these behaviors or
mental acts.
• *** Listen to woman describing her
experience as a young girl (all audios are from
NPR and in the public domain)
• Not as important to get children to articulate
obsessions because the tx is more likely to be
behavioral (ERP)
Obsessions (cont)
• Note how obsessions wrap themselves around
what is important to a person:
– Accountants are checkers
– Adolescent boys worry about sexual deviation
– What do children care about? *** aud
• Listen to another audio from Mark Sommers,
the host for Double Dare ***
Compulsions (Rituals)
• Repetitive behaviors or mental acts that the
individual feels driven to performs in response
to an obsession or according to rules that
must be applied rigidly.
• These behaviors or mental acts are aimed at
preventing or reducing anxiety or distress or
preventing some dreaded event or situation;
however they are excessive and not realistic.
[underlines added]
Compulsions
• Children may not be able to articulate the
aims of behaviors or mental acts
• Children often insist on AVOIDANCE
• ***Scat mat demo
– Sam and his friends
– Aud participation
More on DSM 5
• Specify insight [new]. Young children usually
don’t have it, improves with age, maybe it can be
taught (Adelman & Lebowitz, 2012). Egodystonic
for adults generally but can vary
• Specify tic disorder (common for young males)
• Must take at least one hour daily
• Must significantly interfere with daily life at
school or at home
• Frequently comorbid with anxiety, depression,
behavioral problems, ADHD, tics, and TS
Differential Dx with Normal
Developmental Quirks
– Children have developmentally appropriate rules and
rituals that are not necessarily OCD. (Freeman, 2009)
• Age 2: children can be rigid about eating, bathing, and
bedtime routines
• Between 3 and 5, children like to repeat activities (building a
tower and knocking it down)
• 5-6 yo, attuned to rules in games, distressed if changed
• 6-11 yo superstitious behavior to prevent bad things from
happening; interest in collections
• 12 and older may become very absorbed in a particular
activity (eg, video games) or person (Bieber); superstitious
behavior to make good things happen (sports performance)
– Indv evaluate each child
Prevalence
• Roughly 1-2% of children, 2%-4% of adults
• 25% of cases start by age 14
• Under 10 yrs, more often males with tic disorder
(esp. symmetry and forbidden thoughts)
• If tic disorder is present, habit reversal may be
more effective than ERP
• Females at puberty or pg (esp. contamination /
cleaning)
• Statistics on remission vary from 6% to 40%
Etiology
• Freud was wrong; this has nothing to do with
toilet training
• Clear neurobiological basis: orbitofrontal
cortex, anterior cingulate cortex, and striatum
(esp basal ganglia)
• Schwartz *** fMRI or PET demonstrate that
certain areas of the brain light up and stay lit
up –the off switch doesn’t seem to work right
Schwartz and Beyette (1996)
Common and Rare Causes
• Heritability (epigenitc? endophenotypic?) (Taylor, 2012)
– No gene identified yet, probably an environmentally triggered
predisposition
– 2x with first degree relative
– 10x young male with tic
– 80% with identical twins
– ***Colas / parents
• Head trauma
• PTSD (think rape + showers)
• PANDAS (Pediatric Autoimmune Neuropsychiatric Disorder
Associated with Strep) or PANS –sudden onset. Might improve and
disappear with timely and massive treatment of antibiotics
• Hx of child abuse
Common Forms of OCD in Children
Research: (Storch, et. al. 2009)
• Concerns with contamination (dirt or pollution) or
getting sick
• Just so (counting, arranging, evening up)
• Repeating routine actions (putting on shoes) a
certain number of times or until it feels just right
• Need to confess or ask for reassurance
• ***youtube teenager who runs CX
Assessment Tools
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See handouts
CY-BOCS – administered by professional
– Gold standard for research
– http://www.permanente.net/homepage/kaiser/pdf/62542.pdf
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Self report/Include versions for parents and teachers
– Children:
– http://cehs.unl.edu/schoolpsych/Forms/OCDforms/Self%20checkilist%20for%20OCD%201-1701.pdf
– Parents:
http://cehs.unl.edu/schoolpsych/Forms/OCDforms/Parent%20checklist%20for%20OCD%20117-01.pdf
– Teachers:
http://cehs.unl.edu/schoolpsych/Forms/OCDforms/Teacher%20checklist%20for%20OCD%201
-17-01.pdf
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Child Florida OCI:
http://ocfoundation.org/btti/Pediatric%20BTTI%20Assessment%20Materials%20a
nd%20Other%20Useful%20Documents/Assessment%20Tools/C-FOCI.pdf
COIS http://www.pgepsychiatry.com/images/9/90/CHILDOCDIMPACTSCALE.pdf
Family Accommodation Scale: http://www.dmertlich.com/assets/FAS.pdf
Using Assessment Tools
in Clinical Practice
• Don’t focus on the score, focus on the issues
• Use for ERP to establish hierarchy for
treatment
• Very useful to have input from client and
family members –who is right?
• Retest at intervals
• SUDS thermometer
• Severity Pizza
SUDS Thermometer
Severity Pizza
school
home
OCD
Sample of Current Research
on Family Therapy for Pediatric OCD
• Accommodation (= enabling)
– Family Accommodation Scale (Pinto, Van Noppen,
& Calvocoressi, 2013)
– Accommodation is when the family is inducted
into the OCD system
• Forced to humor the OCD
• Forced to participate in ritual
• Assist with avoidance
– Ex: “Goodnight, Mom”
– Ex: Sam closing the cupboard, pouring the milk
Why is Accommodation a problem?
• Worse for the child (Storch et al., 2007)
– Validates and reinforces the OCD ritual
– Reinforces the neural pathway
– Families with higher levels of accommodation have
greater severity and worse prognosis (Geffken, Sajid,
&Macnaughton, 2005)
• Worse for the Family (Storch et al., 2008)
– Higher levels of distress and depression in parents and
siblings
– Poorer family functioning (Steketee & Van Noppen,
2003)
The Reassurance Game
The Reassurance Game
• Very common for children with OCD to seek
reassurance (Koburi et al., 2012)
• Demo with vomit ***
• Temporarily relieves anxiety (but reinforces
OCD)
• Family wants to be helpful, but eventually
feels worn out, irritated or worse
• Confessing is a common variant
Dealing with Reassurance
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Client must agree to or at least understand what is being
changed and why. Don’t start here. It is very hard to
change.
Answer once
Say “maybe”
Say “ yes, buckets”
Reassurance Book or cards
Being supportive without reassuring (Gillihan et al.,
2012)
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I know this is hard, and I know you are strong enough to fight
OCD
You seem to be seeking reassurance, what else can you do?
OCD is really bothering you, what have you learned to do to
fight back?
Treatment
• CBT (75-80% effective)
– ERP
– ACT with ERP
– Strategic CBT
– CTx
• Meds (60%)
– SSRI
– Augment with antipsychotic
Professor Gallagher and his
controversial technique of
simultaneously confronting the fear
of heights, snakes, and the dark.
Empowering the Family in the
Treatment of Childhood OCD
• There is now a common consensus among
researchers and clinicians that the family should
be included in treatment
• 4 Strategies
– (1)Psychoed (everyone in the room at the same time)
• Parents cannot cause OCD, but they can help it to improve
• Neurobiological basis
• Not common sense rules for how to respond
– Distraction
– reassurance
• Kid cannot stop by just trying harder
• ***Metaphor of the Elephant
Strategy 2
• Change the Family Narrative
– Externalize the OCD
• Unwelcome but persistent visitor
• Name the OCD
• ***YoutTube example of naming OCD
– Family no longer POWs in OCDland
• Family as part of the team that fights OCD and its rules
• Family as coach
• Strategize together with child on how to change
accommodation (children tend to resist. . .)
• ***TP example
Strategy 3
• Family CBT (Piacentini et al., 2011)
– Externalize the OCD
– ERP interventions planned with child and family
– Parent empowered to be the ERP coach
– Done weekly to “change family dynamics” vs. little
catch up meetings
– Twice as effective as indv CBT + Relaxation and
Psychoed
– ***YouTube Michelle with her mom as coach
Strategy 4
• Structural Family Therapy to create 2nd order
change
• Ex of Sam and the sock
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Changes family structure
Changes family interaction pattern
Facilitates treatment by increasing motivation
Whole family participates in redefining OCD and
the treatment
• Sam’s permission and genogram
Sam’s Genogram
Conclusion
• We have covered our 4 learning objectives
• We have covered 4 ways to empower families
in the treatment of childhood OCD
• And, the next time you make a wad of TP,
think of me and how OCD inspires our
creativity
• Thanks!