CBT for children with OCD and autism spectrum disorders

Transcription

1 EABCT 43. Annual Congress September 2013 Marrakech CBT for children with OCD and autism spectrum disorders Bernhard Weidle, St. Olav s University Hospital and University of Science and Technology (NTNU), Trondheim, Norway

2 CBT for children with OCD and ASD: A substudy of NordLOTS Why In which framework How Preliminary result Examples for adjustment of CBT for ASD

3 Why OCD +ASD OCD therapists easily will meet patients with autism spectrum disorder (=ASD) Several researchers have reported elevated levels of ASD comorbidity in OCD Adults: Cath et al, 2008: Symptom overlap between ASD and OCD LaSalle et al, 2004: 3 % Bejerot et al, 2001: 20 % ASD-traits Pediatric OCD: 8.2 % ASD (Ivarsson & Melin, 2008)

4 ASD therapists certainly will meet patients with OCD OCD is prevalent in individuals with ASD Epidemiologic study: OCD in ASD 8 %, (Simionoff et al., 2008) OCD second most frequent DSM IV disorder (37%) in a sample of 109 children with autism (Leyfer et al., 2006) OCD symptoms should be carefully distinguished from repetitive behaviours and special interests in ASD (Russell, 2005) Patients with ASD + OCD may benefit from standard treatments (Alicia Russell et. al., 2005)

5 Successful treatment of OCD in ASD is possible: Case reports of successfull treatment of OCD in youth with ASD (Reaven 2003, Lehmkuhl 2008). Recently published RCT (Russel et al., 2013): 46 adolescents and adults (mean 26.9 years, 35 Males) randomized to CBT or anxiety management : Both treatments significantly reduced OCD symptoms, more responders in CBT group (45 % versus 20 %, not significant). Conclusion: Psychological interventions were effective in treating OCD in young people and adults with ASD.

6 In which framework Nordic Longterm OCD Treatment Study (NordLOTS), pediatric OCD, n = 269 Substudy: Treatment of OCD in children and adolescents with ASD/ Aspergers syndrome Same research protocol For non-responders no randomization, but clinical decision, how to proceed (additional CBT or SSRI) CBT adjusted to needs of young people with ASD

7 In which framework NordLOTS Substudy: Treatment of OCD in children and adolescents with ASD/ Aspergers syndrome Recruitment to the study declined. Recognition might by a problem: OCD therapists' may not see ASD symptoms and ASD therapists may regard OCD as a part of autism

8 Differential diagnosis: OCD ASD Autistic repetitive behaviour is not unpleasant for the child, (but might be for parents, teachers...), while OCD usually is Rigidity rituals are not performed to relieve obsessions (f. ex to avoid catastrophe, infections, death... Rigidity is part of the personality ( has always been this way ), OCD is developing ( onsett ) OCD symptoms cause impairment and interfere with the patient s daily life, also in patients with ASD.

9 CBT is appropriate for children with ASD CBT is highly structured High degree of predictability Well-defined treatment goals and exercises Visual tools and repetitions are widely used CBT demands individual adjustment (age, cognitive level etc.), independent from the group of patients.

10 How NordLOTS OCD + ASD: 3 examples for adjustment of CBT: Motivation Poor insight Explicit exposure

11 CBT for OCD in children with ASD Motivation is difficult In normally developing children, a powerful motivation and reward for fighting OCD is the fact, that OCD does not interfere with social activities any more. Children who are not interested in social contact may not perceive OCD symptoms as dysfunctional Find indirect rewards (from areas of special interest) or other ways to make therapy interesting, f. ex. reframe exposure as scientific experiments

12 CBT for OCD in children with ASD: Poor insight Literally perception (for ex. of health information in media) and poor common sense - judgement might reduce insight that the symptoms are unrealistic. Allow more time for psychoeducation, exploring of cognitions, philosophical thoughts about the nature of OCD, hygiene etc. or

13 CBT for OCD in children with ASD: Emphasis on exposure Put emphasis on concrete exposure exercises, based on real life rather than theoretical discussions Explain exposure exercises explicitly: Make all details perfectly clear to avoid misunderstanding Socialising the child to the exposure method by practising again and again.

14 How CBT for OCD in children with ASD: Adjusted communication Motivation important, use areas of interest for motivation Clear treatment goals Fixed structure for the sessions Training to recognize and describe emotions Visualisation increase structure (use work sheet, written instructions, drawings ) Reward system (social rewards do not work) More parents involvement (as the therapists co-workers)

15 NordLOTS OCD + ASD Preliminary results: Site: CAP outpatient clinic Trondheim Included patients: 11 (10 boys) Baseline C-YBOCS: 23 39, mean: 29,6 (SD 5.3) 6 CBT responder (C-YBOCS < 16) 1 CBT step 2 responder (additional 10 sessions) spontaneous recover before treatment 1 CBT non-responder, partially responder on SSRI 1 CBT non-responder assessment for comorbidity 1 refused treatment

16 Motivation example: Using areas of interest: Bridges Play station exposure: Supermarios OCD course metaphor

17 Visualisation: Conquering the land of OCD

18 Exposure reframed as scientific experiment Homework instructions: Explicit and clear

19 Conclusions: No firm conclusions due to sample size, but CBT for OCD in children with ASD was successful in the majority of cases and seems to reduce impairment and to enhance quality of life

20 Thank you for your attention