A School-Based Treatment Model for Pediatric Obsessive-Compulsive Disorder

Transcription

1 Child Psychiatry Hum Dev (2007) 38: DOI /s ORIGINAL PAPER A School-Based Treatment Model for Pediatric Obsessive-Compulsive Disorder Glenn M. Sloman Æ Jason Gallant Æ Eric A. Storch Received: 1 January 2007 / Accepted: 14 May 2007 / Published online: 15 June 2007 Ó Springer Science+Business Media, LLC 2007 Abstract School psychologists have expertise in the realm of school-based assessment and intervention for behavioral, educational, and psychological difficulties. Recent evidence indicates that many school psychologists lack evidenced based knowledge about assessment and treatment of pediatric Obsessive-Compulsive Disorder (OCD). Pediatric OCD is a relatively common disorder that contributes to substantial impairment in educational and psychosocial domains. Evidence based treatment of pediatric OCD, particularly cognitive-behavioral therapy, has shown to be efficacious. Therefore, the aims of this paper are to provide a review of empirically established treatments for pediatric OCD, and present a school-based problem-solving model that school psychologists can utilize to conceptualize, assess, and treat OCD. Keywords Treatment Obsessive-compulsive disorder Children Schools School psychologist Obsessive-Compulsive Disorder (OCD) is characterized by reoccurring obsessions and/or compulsions, which are distressing, time consuming, or cause significant impairment [1]. Once considered rare, [2, 3] current estimates suggest that pediatric OCD is relatively common affecting approximately 1 4% of the population at any given point [4 6]. As many as 80% of OCD sufferers have an onset during childhood [7, 8], making it the fourth most common childhood psychiatric condition. Pediatric OCD is linked to considerable impairment across psychosocial domains, including peer problems [9 12], substance abuse G. M. Sloman J. Gallant Department of Educational Psychology, University of Florida, Gainesville, FL, USA E. A. Storch (&) Department of Psychiatry, University of Florida, Gainesville, FL, USA estorch@psychiatry.ufl.edu E. A. Storch Department of Pediatrics, University of Florida, Gainesville, FL, USA

2 304 Child Psychiatry Hum Dev (2007) 38: [4, 13], school impairment [9 14], and increased risk of suicidal ideation [15]. Comorbidity is common with up to 75% of cases meeting criteria for a comorbid disorder. Those disorders most frequently co-occurring include other anxiety disorders, tics disorders, depression, and attention-deficit hyperactivity disorder [16]. Within the past 10 years, significant progress has been made in the assessment [17] and treatment [18] of pediatric OCD. Although limited data exist on school professionals experiences with the assessment, treatment, and outcomes of pediatric OCD patients (Gallant et al. 2006, unpublished), very little has been written on treatment and assessment that is tailored for the practicing school psychologist. Such an issue is important as Gallant and colleagues (Gallant et al. 2006, unpublished) found that only 7.1% of school psychologists were using exposure-based treatment much or very much of the time in their treatment of youth with OCD. In addition, nearly half (46.3%) of the respondents reported minimal improvement to no change in the symptoms of their OCD cases after treatment, which is lower than findings from clinical trials [19 21]. Regarding assessment, school psychologists used OCD specific checklists only 30.8% of the time. Overall, the vast majority of respondents (89.2%) felt a need for further training in the assessment and treatment of pediatric OCD (Gallant et al. 2006, unpublished). In light of these findings, the present paper serves as a guide to the identification, assessment, and treatment of OCD, concluding with a model of school-based treatment for pediatric OCD. Identification In order to successfully identify children and adolescents with OCD within the school system, school personnel must be knowledgeable about the disorder. School psychologists are uniquely positioned to facilitate the identification of children with OCD and provide appropriate services by facilitating early identification and formulating healthy consultative relationships with school staff in efforts to inform and train teachers, counselors, and parents about OCD symptoms [9]. Through a combination of school psychologists awareness of the literature in accordance with best practice and continuing educational opportunities, the utility of school psychologists in facilitating the identification of OCD within the schools could be enhanced (Gallant et al. 2006, unpublished). Among children and adolescents, common obsessions involve fears of contamination, worry about harm to self or others, the need for exactness and order, and religious/ moralistic worries [16, 22, 23]. Common compulsions consist of decontamination rituals, excessive counting, checking, and straightening, excessive praying, and reassurance seeking [16, 22, 23]. It is relatively common to see the presentation of compulsions in the absence of obsessions [24, 25]. For instance, Storch et al. [25] found that 19.6% of children and adolescents exhibited primarily obsessions or compulsions. Assessment Teachers and parents serve as vital informants during the assessment process given their familiarity with the child. Considering the secrecy often present in pediatric OCD, [26] teachers and parents are often likely to identify the initial presenting symptoms of their children. The heterogeneity of OCD requires adherence to a comprehensive assessment

3 Child Psychiatry Hum Dev (2007) 38: regimen to insure a complete understanding of the clinical presentation. The first piece of assessment should include obtaining a Social Developmental History (SDH) from the parent(s). This information can provide a detailed account of the child s background enabling insight into the child s medical history, psychology and family medical history. Information from the SDH should be used to guide teacher and parent interviews. When suspecting an emotional, social, or behavioral disorder, there are several symptom tools that can be used to guide assessment. Included are parent, teacher and child interviews, behavioral observations, administered inventories, and self-and parent-report measures. A review of these procedures along with several commonly used, OCD specific indices are included below. Clinical Interviews In accordance with best practice, interviews should be conducted with parents, teachers, and the child [27]. Interviews range from structured to semi-structured to unstructured. Busse and Beaver [28] suggest that semi-structured interviews have distinct strengths as they provide opportunities to compare information across informants with minimal time consumption. The parent interview should include a focus on the presenting problem, detailing the history of the problem and specific concerns. Assessing the family environment is advised, particularly with regards to other stressors and family accommodation of symptoms. Teacher interviews should also include accounts of the presenting problem. With the teacher, identifying willingness to implement possible interventions is important [27]. Furthermore, developing goals for the student may also help facilitate future intervention compliance. Child interviews offer unique data on the child s perception of the presenting problem. Best practice dictates that semi-structured interviews are best for school-based child interviews [27]. The interview should target the child s self-perceptions and feelings of current clinical presentation, assess perceptions of school, family, and friends, and perceived strengths and weaknesses. If the child has insight into his/her problems, assessing motivations and goals to overcome the disorder may help guide intervention development. Behavioral Observations Behavioral observations are a potentially important method of data collection to understand factors that maintain symptoms in the natural environment [29, 30]. Behavioral observation methods can be conceptualized into two categories: naturalistic and systematic. Naturalistic behavior observation refers to situations where the observer enters a situation without awareness of specific aberrant behaviors. For instance, teachers and parents make naturalistic observations of child behavior on an informal basis. When a teacher or parent deems a behavior inappropriate or excessive, school service personnel will follow up with systematic observations. According to Salvia and Ysseldyke [31], systematic observation can be conceptualized by the following characteristics. First, the objective of systematic observation is to evaluate predetermined, operationally defined, target behavior. Behavior should be observed in a standardized manner, with a focus on the function of the behavior. Additionally, behavior should be monitored across multiple time periods and settings (e.g., classroom, cafeteria, and physical education). The following example represents a hypothetical situation detailing these observation principles.

4 306 Child Psychiatry Hum Dev (2007) 38: Ms. Smith, a third grade teacher, is concerned with one of her student s behavior over the past month. She indicates that nine-year old Johnny has had a considerable decline in his academic performance. Furthermore, she reports that recent poor attendance, and hyper vigilance to his surroundings. Also, Ms. Smith states that Johnny s frequent requests to use the restroom have become a nuisance. She indicates that failure to administer a bathroom pass typically results in aberrant externalizing behavior (e.g., yelling, tantrums, and disrespectful comments). A school psychologist was consulted to perform a systematic observation of Johnny s behavior. Four thirty-minute observations were performed using the Functional Assessment Observation (FAO) tool [29]. Dr. Jones noted that Johnny was distracted in morning reading class and had difficulty following the text. In arts and crafts, Johnny refused to finger-paint. He told the art teacher that he did not want to get his hands dirty with the paint. Before lunch, Dr. Jones observed Johnny repeatedly requesting to use the restroom so he could wash his hands. When this request was denied, Johnny became visually anxious. He returned to his seat, began rubbing his hands together quickly while spitting on his hands. After physical education, Ms. Smith took the class to the restroom. Approximately 5 min after returning from the restroom, Johnny requested a restroom pass. When denied again, he presented with hand rubbing and spitting. Ms. Smith s initial observations and Dr. Jones s systematic observations provided fruitful information regarding Johnny s behavioral problems. Dr. Jones may deduce that Johnny has a fear of dirt or contamination as evidence by Johnny s resistance to participate in art, and repeated requests to use the restroom before eating lunch and after contact with dirty items in physical education class. Thereafter, future assessment should be tailored to probe these OCD-like symptoms. A brief review of possible OCD specific measures follows. Clinician Administered Inventories Utilizing clinician-administered interviews allows trained professionals to rate a child s impairment relative to other patients. The most widely administered clinician interview is the Children s Yale-Brown Obsessive-Compulsive Scale (CY-BOCS) [32]. The CY-BOCS is a semi-structured inventory targeting the child s OCD symptom severity over the previous week. The scale is compromised of two subscales: Obsessions Severity and Compulsions Severity. Each scale consists of five items: distress, frequency, interference, resistance, and symptom control. The items are clinician-rated on a 5-point likert scale. Rating adjustments are made if clinical judgments and behavioral observations deem it necessary. After completion, the scores are calculated to elicit an Obsessions Severity score (range = 0 20), Compulsions Severity score (range = 0 20), and a Total score (range = 0 40). The CY-BOCS displays a relatively high internal consistency with Total score alphas (range ). Alphas for the Obsession Severity, Compulsion Severity, and Total score are 0.80, 0.82 [25], and 0.87 [32], respectively. Inter-rater agreement has been shown adequate to high for the CY-BOCS Total Score (0.84), Obsession Severity Score (0.91) and Compulsion Severity Score (0.66). The CY-BOCS also demonstrates treatment sensitivity [21, 33], and convergent and divergent validity vis-à-vis stronger associations to indices of obsessions and compulsive symptoms than to scales of ADHD, anxiety, tic disorders, depression, and aggression [25].

5 Child Psychiatry Hum Dev (2007) 38: The factor structure of the CY-BOCS has received recent attention. The apparent two-factor structure with a third factor representing a total score may not fully gauge the true essence of presenting symptoms. For illustration, approximately 20% of children present with obsession or compulsions only [34]. Therefore, a child presenting with severe obsessions only and no compulsions will present with a total score of 20. However a child with moderate obsessions (score = 11) and moderate compulsions (score = 11) will present with a total score of 22, which is a similar score to one with only obsessions, yet may under-represent symptom severity. Self-report and Parent-report Measures Child-self report and parent report measures allow professionals to obtain a concise screening for possible pathology. Generally, these measures are used in research to obtain pre- and post-treatment data. Unlike the clinician-administered inventories, the client might feel more comfortable by independently completing measures. Disadvantages of self-report measures are that the client may have difficulty in understanding the format and/ or wording of questions. The Leyton Obsessional Inventory-Child Version (LOI-CV) [35] is an individually administered, child-completed, 44-item measure targeting the following categories: persistent thoughts, checking, fear of dirt and/or dangerous objects, cleanliness, order, repetition, and indecision. There are three distinct constructs of the LOI-CV: yes, resistance, and interference. The yes construct focuses on the child s symptoms, resistance identifies if the child has tried to repress the aberrant thoughts or actions, and interference targets how much the obsessive or compulsions hamper their daily routine. Each of these constructs is measured on a Likert scale from 0 non-impairing to 3 impairing. The LOI-CV can be quite time consuming, but unlike most measures, it is interactive and affords the clinician an excellent opportunity to obtain behavioral observations. Studies suggest that the LOI-CV has sound psychometric properties. For example, five-week test retest scores reveal excellent reliability for the yes (ICC = 0.96), the resistance (ICC = 0.97), and the interference (ICC = 0.94) [35]. One major limitation of the LOI-CV is its inability to capture obsessions and compulsions with a relatively low base rate (e.g., sexual obsessions, horrific images) [11], thus being vulnerable to false negatives [36] In addition, the LOI-CV has limited predictive validity in sub-clinical populations [37]. The LOI-CV survey form [5, 37] is a 20-item adaptation to the LOI-CV. The survey form eliminates the resistance construct from the original inventory. Thus, the survey form s focus is on symptom presentation and interference of symptoms. Normative information for this measure was obtained from a high school sample of 5108 students. The sample was evenly distributed among gender and was predominantly Caucasian (94%). Reliability estimates from this data suggest good internal consistency (a = 0.81) [5, 37]. Furthermore, King et al. [38] examined the test retest reliability of the LOI-CV survey form in 106 children over a two-week period. Results indicated that this instrument demonstrates adequate reliability for populations 8- to 10-year-olds (r = 0.51) and good reliability for populations 11- to 13-year-olds (r = 0.75) and 14- to 16-year-olds (r = 0.83) [38]. While the LOI-CV has some positive attributes, this instrument has limited treatment sensitivity [39] and a tendency to produce high false negatives [36]. The Child Behavior Checklist (CBCL) is a widely used measure to assess internalizing and externalizing problems in children 4 18 years of age [40 Recently, Nelson et al. [41]

6 308 Child Psychiatry Hum Dev (2007) 38: introduced an obsessive compulsive scale (OCS) within the CBCL. The sample consisted of 219 participants equally divided into three categories: youth with OCD, youth with a non-ocd psychiatric condition, and a control group. The OCS demonstrated good discriminate validity (i.e., differentiates between non-ocd psychiatric patients, OCD youth, and healthy controls). Furthermore, the measure demonstrated good internal consistency (a = 0.84). Originally consisting of eight items, the OCS was recently revised using factor analytic methods (OCS-R) [11]. Storch et al. [11] administered the CBCL to 190 youth. Forty-eight presented with OCD, 41 with a non-ocd internalizing disorder, and 101 with an externalizing disorder. Results from a confirmatory factor analysis (CFA) revealed a poor fit, thus an exploratory factor analysis (EFA) was conducted. Results from the EFA identified six of the eight items as adequately fitting the new model. The six items are: worries, feels he/she might think or do something bad, feels too guilty, has strange ideas, can t get his/her mind off certain thoughts; obsessions, and repeats certain acts over and over; compulsions. The OCS-R demonstrates adequate reliability (Cronbach s a = 0.75) and construct validity. Youth with OCD (M = 6.48) scored higher on the OCS than did youth with other internalizing (M = 4.75) or externalizing disorders (M = 3.69) [11]. Considering that the CBCL is commonly used in school-based practice, the OCS-R provides practitioners with an easy to use screening tool that is more uniform and accessibility than symptom specific measures. The Children s Obsessional Compulsive Inventory (CHOCI) [42] was designed to be an efficient (15 min) pediatric OCD self-report and parent-report screener. A total of 42 clinical patients and 46 non-clinical patients participated in the initial psychometric study. The CHOCI contained the following subscales: symptoms of compulsions, impairment associated with compulsions, obsessional symptoms, and impairment associated with obsessions. Each of these items was rated on a 1 3 Likert scale translating to not at all, somewhat, and a lot. The CHOCI demonstrates high levels of internal consistency across subscales (a > 0.80). Furthermore, there was a strong item-total correlation (r = ) across children and parents. Results also suggest adequate levels of concurrent and discriminant validity. The final instrument summarized focuses on the family s role in maintaining OCD symptoms. The Family Accommodation Scale (FAS) is a clinician-administered parentreport measure compromised of 12 items that assess the degree that the family accommodates their child s OCD symptoms. The FAS is divided into two sections. The first section asks relatives to identify the patient s current symptoms. The focus of the second section is to identify a relative s accommodating. The FAS has adequate psychometric properties. Internal consistency is adequate (a = 0.76) [43] Furthermore, in a sample of 36 patient/relative pairs, Calvocoressiet al. [44] identified a range of intraclass correlations from average to excellent (ICC = ). Treatment Over the past two decades, systematic research into effective OCD treatments has delineated two forms of effective treatment: cognitive-behavioral therapy (CBT) with exposure and response prevention (E/RP), and pharmacological treatments such as selective serotonin reuptake inhibitor (SSRI) medications (see Lewin et al., [18] for a review).

7 Child Psychiatry Hum Dev (2007) 38: Cognitive Behavioral Therapy Cognitive behavioral therapy for individuals with OCD is comprised of three central features: exposure (exposing the individual to anxiety inducing situations that evoke rituals); response prevention (refraining from ritual engagement or avoidance that leads to diminished anxiety); and cognitive therapy (educating the patient on how to become aware and correct aberrant thought patterns). The use of CBT as an efficacious treatment option for OCD has strong empirical support [19 21, 33], and is considered the first line treatment for pediatric OCD [45]. A recent meta-analysis of 18 pediatric OCD treatment studies further demonstrated the effectiveness of CBT with exposure response prevention (ER/P), finding that CBT with ER/P was superior to SRI medication [45]. Behaviorally, OCD involves a cycle of continuous negative reinforcement. The individual experiences distress from an obsession or just right urge, and therefore, performs a compulsion to reduce their anxiety. Unfortunately, this process prevents the behavior from naturally extinguishing and increases the chance of future ritual engagement [23]. With the therapist s assistance, the client restricts compulsion performance, resulting in habituation to the stimulus. The following is a brief description of the sequence of therapy with a child with OCD. A more thorough depiction related to the schools will be covered later in the paper. Cognitive behavioral therapy begins with psychoeducation about OCD directed to the child and parent(s). For younger children, this is generally achieved through stories about an antagonist who makes people do actions they do not wish to do. In most instances, therapists will tell the child to think of the OCD as being external to the child. For example, if the child has an urge to perform a compulsion, the child would be prompted to recognize that those urges are the OCD talking. This process helps the client realize that they are a separate entity from the OCD. After learning to identify OCD based thoughts, children are taught to fight their thoughts using OCD fighting statements. Examples of such statements include, Leave me alone OCD or I am not going to let OCD control my life. These statements are often considered empowering and give patients the perception of control over their symptoms. A fear hierarchy is the cornerstone of exposure-based CBT. The construction of the fear hierarchy affords the opportunity for the patient to describe anxiety-provoking events, and allows the therapist to better understand the heterogeneity of the symptoms. The hierarchy targets situations that provoke rituals or avoidance. Subsequently, the child, with assistance from others (e.g., parents), begins exposures to the feared stimuli or situation starting with the least distressing situation. For example, if a child has contamination fears, then beginning with touching a doorknob would be advised over starting with the child placing their hand in a garbage can. Prior to the exposures, as mentioned above, the child can be taught cognitive restructuring (e.g., challenging irrational thoughts) to help cope with their anxiety. Furthermore, providing reinforcement for refraining from compulsions may assist in treatment progress. Setting up point-reward systems may facilitate exposure participation. For instance, if the patient completes an in-session exposure they will receive one point, and each point earns the child 10 min of computer or video game time. Complying with homework exposures can earn the child additional points. On an appropriate basis (i.e., daily), the child can cash out their earnings for backup reinforcers. Family involvement is extremely important to the therapeutic process [23, 46, 47]. As previously mentioned, family members may accommodate a client s OCD. For example, families may wash towels and clothing more than necessary or buy an excessive amount of soap, thus giving access to items associated with a child s washing compulsions.

8 310 Child Psychiatry Hum Dev (2007) 38: Therefore, educating family members about the disorder and its treatment, as well as addressing accommodation, can facilitate the treatment course. Teaching parents tools to combat OCD is a critical component of treatment. Guiding parents on how to implement exposures in the home environment can enhance treatment gains and may facilitate the maintenance. In essence, it would be ideal for parents to assume a co-therapist role. To date, relatively little is known about clinical and sociodemographic characteristics that predict treatment response. Among adults, baseline symptom severity and impairment, presence of significant depression, limited motivation, symptom typology (e.g., predominance of obsessions) and phenomenology (e.g., sexual/religious obsessions, hoarding) have all been linked to negative outcome in CBT and SSRI medication trials [48 51]. In addition, lack of insight may impact treatment effects [52]. For example, Foa et al. [52] measured the degree of insight in twenty adult OCD sufferers. Posttest analyses revealed that patients who demonstrated low insight had a mean YBOCS two times greater than those who demonstrated mild to moderate insight. In the limited data on children, poor outcomes have been related to more severe obsessions and greater baseline academic impairment [53], as well as the presence of disruptive behavior disorders [39]. Pharmacological Treatment Recent research has demonstrated positive data with the use of SSRI treatment with symptom reductions of approximately 30% 40% [39]. The most common SSRIs administered to children and adolescents with OCD are clomipramine (Anafrinil), fluoxetine (Prozac), fluvoxamine (Luvox), sertraline (Zoloft), paroxetine (Paxil), and citalopram (Celexa). Of those listed, only clomipramine, fluoxetine, fluvoxamine, and paroxetine are approved by the Food and Drug Administration (FDA) for treating pediatric OCD. In a recent treatment study, POTS [33] evaluated the efficacy of CBT, sertraline, and their combination relative to placebo over 12 weeks. Results indicated that combined treatment was the most efficacious, as evidenced by an average decline in CY-BOCS score from 23.8 to 11.2 (change = 12.6). After treatment, the CY-BOCS score for those receiving CBT decreased from 26.0 to 14.0 (change = 12); the CY-BOCS score for youth treated with sertraline declined from 23.5 to 16.5 (change = 7). There was no significant drop in CY-BOCS score for the placebo group. Thus, the authors concluded that pediatric OCD should be initially treated with CBT alone or CBT with SSRI medications [33]. In a metaanalysis evaluating twelve studies and 1044 children and adolescents, clomipramine had the greatest effect in reducing OCD symptoms relative to other medications [39]. Unfortunately, recent warnings (e.g., FDA) along with adverse side effects [53, 54] cause concern for the administration of SSRIs to children and adolescents with OCD. Therefore, it is suggested that medication be used when the client is experiencing severe symptoms, comorbid disorders, or when first rate CBT is not available [11]. Model Introduction A model for the accurate identification and treatment of pediatric OCD within the school setting requires a paradigm which is both broad in scope in order to capture presenting problems, yet specific enough to guide implementation. Following the problem-solving model with integrated CBT adheres with school psychology s alignment with evidencedbased practices and fulfills both of these criteria [55, 56]. The proposed treatment model

9 Child Psychiatry Hum Dev (2007) 38: borrows from the problem-solving framework summarized by Schwanz and Barbour [57]. As suggested by Schwanz and Barbour [57], the following are best practice components to school-based treatments: define the problem (step one), develop an assessment plan (step two), analyze the assessment results and set goals (step three), develop and implement the intervention plan (step four), and analyze the intervention plan (step five). Durability of treatment services directed at the child are hinged upon a coordinated and collaborative service delivery using a problem solving team consisting of parents, teachers, a school psychologist, and any other school personnel with a legitimate and direct interest in the child educational welfare (i.e., building principles, behavior resource professionals, classroom aides) [58]. Step One: Define the Problem Defining the problem is the first component of a consultation based problem-solving model [57, 59, 60]. Specifically, the problem-defining step involves operationally defining the presenting symptoms in clear and objectively definable terms. For example, the symptom of hand-washing may be defined as, Child is within proximity to a sink, with the faucet turned on, and his/her hands beneath the water. In addition to defining symptoms, this step allows for the identification of symptoms. Identifying OCD symptoms links the components triggering the compulsions and obsessions to guide treatment plan formulation in a collaborative manner. Gathering information from teachers and parents provides a holistic definition of OCD. Parent information on home behavior occurring covertly at school may clarify the topography of the compulsion, in addition to linked antecedent events. For example, a common compulsion experienced by elementary school age children involves a ritualized decontamination repertoire of repeated hand-washing with such frequency and duration as to cause eczematous damage [61], social withdrawal, and missing or incomplete assignments [62, 63]. A teacher may attribute the frequent requests for restroom visits to bladder or bowel fullness rather than OCD or another psychiatric illness. In actuality, the child may be repeatedly escaping situations where evocative stimuli are present, such as hand-washing in the school restroom. Thus, the teacher has information on frequency and duration of restroom breaks by collecting bathroom passes which are matched to parental report of hand-washing, along with observing the presence of dry, red, chapped, cracked, and/or bleeding hands, accompanied by strong cleaning agent odor [64]. Step Two: Develop an Assessment Plan School psychologists have a variety of subjective and objective assessment options using both idiosyncratic and normative comparisons to evaluate pediatric OCD. A well conceptualized plan guides assessment with the reasons why particular measures are administered over others, and justifies the purpose of collecting such information for treatment. Administering assessments helps to determine the conditions under which symptoms occur, how those symptoms are felt by the child, how those symptoms affect social and academic functioning, and what types of structural supports may be necessary for treatment. Utilizing the current behavioral/emotional assessment methodologies, a school psychologist, equipped with teacher and parent information, are in a prime position to both clearly identify and implement an effective intervention. Unsurprisingly, Piacentini et al.

10 312 Child Psychiatry Hum Dev (2007) 38: [14] found functional impairments associated with a pediatric OCD diagnosis significantly disrupt the social, academic, and home domains. For example, the authors administered a battery of clinician and parent-rated measures and found that cognitive and behavioral disturbances concentration on academic assignments were linked to OCD in the school and home setting. Furthermore, impairments were endorsed by children and parents, suggesting that the behavior interfering with academics is salient enough to be detected by teachers in the school setting, and will show in the academic record and behavioral functioning of the child. In order to demonstrate the social and academic significance of the problem, and the effectiveness of the employed treatment, recording baseline data of the defined behavior allows a graphic comparison of pre-, peri-, and post-treatment implementation [65]. Due to the complex nature of pediatric OCD presentation, adhering to the operationally defined presenting problem when developing an assessment plan is critical for data collection and treatment purposes. Dimension options for selecting the appropriate measure for documenting the behavior are available. Depending upon the nature of the OCD symptoms and the targeted compulsion, one may measure frequency, duration, intensity, latency, or a combination of the dimensions. Considerations ought to be made for selecting the dimension measure with priority to the dimension that is most sensitive to change and reflects the most accurate depiction of the defined symptom in order to validate treatment effectiveness for formative and summative outcomes [65]. Critically, the dimension(s) measured must be easily recordable by the child, teacher, or parent (to validate generalization into the home) as to assure the accurate and continuous use of the data recording method [66, 67]. For example, if the child engages in hand-washing in the classroom, the teacher records the frequency of hand-washing by putting a coin in a jar, making a tick mark on a piece of paper, or incrementing a golf stroke counter. At the end of the day, the teacher totals and records the number of these events occurring. Miltenberger [65] provides a cogent description of various behavioral recording methods and how to decide the appropriate behavioral measure for a particular dimension and circumstance. Another method of documenting environmental variables affecting the child s idiosyncratic OCD expression is a functional behavioral assessment (FBA). FBAs assist in identifying contextual setting events, antecedents, and consequences contributing to compulsion emission. For example, the FBA manual of O Neill et al. [29] facilitates describing environmental stimuli evoking a behavior, such as checking, and permits hypothesis generation for the function of the behavior. For instance, results from the FBA may indicate that the child often engages in checking to minimize the chance of errors on an exam, but rarely engages in checking to escape from difficult assignments. Once the conditions under which the behavior occurs are identified, another assessment could be conducted to measure physiological responses related to OCD. A subjective method for tapping a child s experience of somatic complaints associated with OCD is a fear hierarchy. Adapting a fear hierarchy using a 100-point subjective unit of discomfort scale (SUDS) with pictures, verbal descriptions, and/or physical presentation of stimuli evoking discomfort [68], explicates the beginning of the treatment focus. To complete the SUDS rating procedure, the child is asked to rate each situation evoking hand-washing by the level of anxiety elicited up to a terminal outcome exposure (e.g., physically holding/ manipulating dirt with bare hands for a duration of time without engaging in the corresponding compulsion; a SUDS score of 100) [68]. As noted above, compulsions may not be associated with a clear obsession due to the child s limited insight or describing symptoms as nonsensical and crazy [24, 69]. However, by creating a ritual hierarchy, a school psychologist gathers information

11 Child Psychiatry Hum Dev (2007) 38: regarding perceived discomfort in relation to stimuli, and facilitates insight of the problem to the child. Furthermore, one can inform others on the social significance of treating the presenting problem from the child s point of view. For example, it may be helpful to present data on how distressful OCD is to the child using the SUDS to gather teacher and parent support for treatment need and implementation. Administering normative assessments may qualify a child for services under Section 504 of the Rehabilitation Act of To attain a Section 504 plan, one must document evidence of a significant impairment in a major life activity (e.g., learning) to implement environmental accommodations and modifications. On many occasions, after identifying the presence and assessing OCD symptoms, a child study team in collaboration with the school psychologist, drafts a 504 plan to provide targeted environmental modifications and accommodations. By including a 504 plan, classroom support provisions must be adhered to as required by federal regulations [70]. Suggested general education classroom supports are discussed later in relation to step four. However, as Adams et al. [26] note, regardless of whether a child qualifies for Section 504, appropriate behavioral programming will likely be necessary to ameliorate OCD-related symptoms (p. 285). As noted by Storch et al. [71], the amount of time the child is occupied with OCDrelated symptoms may further hinder academic performance, exacerbate academic problems, and have deleterious affects on peer relationships. Therefore, a 504 plan may temporarily help to scaffold achievement and retain social relationships, so that the child can gain access to treatment without further harm to his/her social world and academic performance. Furthermore, Storch and colleagues [71] suggest that even if the child waits to engage in the compulsions until arriving at home, the short-term gains of maintaining peer relationships may lessen the impact of long-term complicating factors such as loneliness, depression, and externalizing behavior when OCD treatment begins. Nevertheless, a 504 plan aligns with the movement in school psychology to provide services to treat problems in the general education classroom environment first. Step Three: Analyze Assessment Results and Set Goal(s) The third step in the problem-solving model is to analyze assessment results and set treatment goals. The notion behind this step is to evaluate the current intensity of the symptom manifestation as well as determine the goal of the intervention, (e.g., the acceptable levels of the target behavior). Continuing with the example of compulsive handwashing, a criterion for acceptable hand-washing is quantified by the number of times other children engage in hand-washing and appropriate instances for hand-washing (e.g., after using the toilet). For instance, a count of the times during the day that hand washing is acceptable is generated. This count is then compared to the number of times the child engages in hand washing. Once again, one must give consideration for selecting the dimension of behavior recorded; a frequency measure may not fully describe the impairing compulsion causes when the frequency of engaging in the behavior is low while the time spent hand washing extends min in duration. Furthermore, when using a normative measure as a baseline, one may compare intervention effectiveness by observing a change in child s initial standard score. Clinical judgment and the assessment manual ought to guide the selection of this score and significance of change. The third step also guides the intensity of the intervention by examining the discrepancy between baseline and the desired decrease. Generally, the greater discrepancy necessitates a more intensive intervention through more classroom supports and a longer duration of

12 314 Child Psychiatry Hum Dev (2007) 38: treatment. Determining intervention intensity primarily affects the next step in the problem-solving process. Step Four: Develop and Implement the Intervention Plan Step four concerns the development and implementation of the intervention plan. Outcome studies demonstrate that CBT with E/RP is the most efficacious and effective treatment of pediatric OCD within clinical settings; although investigations within school settings have yet to be conducted, our clinical experiences working with teachers suggests that this extrapolates to school settings. During exposures, the child gradually contacts the anxiety provoking stimuli, beginning with the least anxiety-evoking situation [71]. Based the 504 plan, classroom support services may include trained personnel to administer the CBT exercises during a classroom related activity [70]. For example, in collaboration with the school psychologist, the teacher can design a series of science lessons on soil including how animals, plants, and people use it. Matching the activity with the identified least anxiety provoking stimuli of touching dirt, the problem-solving team devises an activity of drawing a plant in soil and discussing how plants absorb nutrients/water from the ground. Gradually working through the ritual hierarchy from least to most anxiety-evoking stimuli, the child is presented and remains in contact with the respective hierarchy step stimuli without engaging in the ritual. For instance, a child with concerns about germs might touch the bathroom sinks without washing. To generalize the treatment effects to the home setting, the teacher and parents collaborate on homework activities designed to expose the child to the compulsion [72]. When engaging in an assigned homework activity designed to expose the child to evocative stimuli, the parent prevents the child from engaging in the compulsion. When necessary, the parent prompts, models, and guides the child s use of compensatory strategies taught in the classroom. In addition to compensatory strategies, teaching the child to identify when socially acceptable hand-washing should occur to prevent punishing of appropriate handwashing. Setting a timer or singing happy birthday to monitor duration of hand-washing, after adult/peer modeling of acceptable hand-washing, allows the child to come in contact with the natural contingencies of engaging in acceptable handing-washing practices. During treatment, data are gathered on the dimension selected from step two to measure the intervention progress at school and home [57]. Not only does data collection monitor the change on the child s behavior, it also serves as a method to demonstrate treatment integrity. For example, when treatment implementation begins, so does the monitoring of treatment effectiveness through data collection. By inference, if treatment monitoring is not taking place, either the treatment may not be implemented or the monitoring procedure is not acceptable from the teacher s standpoint. Therefore, it will be necessary to reconvene the problem-solving team to address obstacles interfering with recording and possibly the implementation of treatment with integrity. Step Five: Analyze the Intervention Plan Use of the above measures provides ample evidence for the intervention plan s effectiveness. To assess the programmed intervention progress, the school psychologist can initially collect data sheets two or three times a week, then fading to once per week, to

13 Child Psychiatry Hum Dev (2007) 38: determine treatment efficacy. Further, collecting data sheets from both home and school allows for the evaluation of treatment generalization. Summative treatment outcome comparisons can be drawn between the child s behavior compared to him/herself (before and after treatment), other pupils in the same class, and a national normative sample. Baseline data on the compulsive behavior targeted and completing another SUDS provides objective and subjective idiosyncratic outcomes indicative of treatment success or a need for further intervention modification. Moreover, by comparing opportunities to appropriately wash hands and the number of times engaging in hand-washing, a local normative comparison can be made. Re-administering a standardized assessment documents treatment efficacy in comparison to the client s previous score and simultaneously to children within the individual s own age group as compared to clinical and at-risk populations on an OCD measure. Furthermore, maintenance probes can be administered to assess the durability of treatment and whether reintroducing intervention is warranted. Implementation Challenges A variety of factors may inhibit the treatment model from being implemented, or if implemented, being implemented with integrity. Resource availability, acceptability of intervention, the underlying consultation model used (i.e., thus determining the focus of the intervention), rapport between various professionals involved, systemic issues, interference of OCD symptoms in comparison with academic performance (although arguments support that symptoms interfere greatly with academic achievement and social functioning), failure to establish a coordinated effort among all professionals and parents (maintenance and generalization issues) involved, co-morbid diagnoses, and peer social support system for the child exhibiting these OCD symptoms are all relevant concerns that may impact treatment effects. Among these issues are logistical factors in treating OCD in the schools. Allocating school hours to conduct exposures may be necessary due to student transportation barriers and limited availability of professional personnel to intervene. Similarly, professional time must be appropriated to treat students on an individual basis, as opposed to group therapy, as evidenced by the idiosyncratic presentation of OCD symptoms, and the special considerations that confidentiality demands. In light of these considerations, school psychologists in some districts have time specified in their contracts to provide group and individual therapy. Although currently limited in scope, a school-based health clinic movement in school psychology is gaining strength to support these types of activities [73]. Decidedly, if unable or untrained, school professionals have an ethical obligation to refer or consult with a child psychologist or psychiatrist in providing evidence-based care for the child. As one can imagine, the accumulative impact of each of these variables and issues may not have the equal relevance in all cases. However, findings from Masia et al. s [74] social phobia intervention study indicate that school-based behavioral interventions have strong promise, and are a viable option to treat pediatric anxiety disorders. Therefore, through utilizing problem-solving procedures, one may moderate or overcome these variables to best serve the needs of the child. By viewing problem-solving as process based rather than product focused, implementing these procedures provides a systematic method for adapting the model to surpass obstacles, and incorporate and coordinate available resources.

14 316 Child Psychiatry Hum Dev (2007) 38: Summary The model presented above provides an avenue reliant on current research and best practices within school psychology. Consistent with March and Muelle s [75] OCD treatment manual, the intervention utilizes empirically derived intervention technologies in a systematic treatment procedure for the school age population. The specification of how practitioners may operate to implement and enhance the treatment of OCD in the school system is the crux of the model offered. In addition, the research components are evidenced based approaches when implemented in contexts, which serve pediatric populations. However, little is know about the external validity of these approaches and how the components interact in the model when applied in the school system, thus the model lacks empirical validity since it has not been tested under the particular conditions and challenges extant in schools. Therefore, research is still needed on the components of the model and their effectiveness. Currently, we are formulating future investigations on the necessary components and sufficient conditions needed to support the intervention within the school context. Once piloted, preliminary results will be disseminated to field scientistpractitioners encouraging model implementation among larger samples. We see this as a necessary step to test and demonstrate if the methods are effective, analytical (a convincing demonstration that the treatment as the cause for child improvement), and socially valid [76]. When such an analysis is conducted, scientist-practitioners are justified in advocating use of this model at IEP meetings to treat the debilitating effects of OCD on school and social functioning, which in-turn hampers school success. References 1. American Psychiatric Association (1994) Diagnostic and statistical manual of mental disorders, 4th edn. American Psychiatric Association, Washington, DC 2. Milby JB, Meredith RL, Wendorf D (1983) Obsessive compulsive disorders. In: Morris RJ, Kratochwill TR (eds) Practice of child therapy: a textbook of methods, Pergamon Press, New York, pp Rachman SJ, Hodgson RJ (1980) Obsessions and compulsions. Englewwod Cliffs, New Jersey: Prentice-Hall 4. Douglass HM, Moffitt TE, Dar R, McGee R et al (1995) Obsessive-compulsive disorder in a birth cohort of 18-year-olds: prevalence and predictors. J Am Acad Child Adolesc Psychiatry 34: Flament MF, Whitaker A, Rapoport JL, Davies M et al (1988) Obsessive compulsive disorder in adolescence: An epidemiological study. J Am Acad Child Adolesc Psychiatry 27: Rapoport JL, Inoff-Germain G, Weissman MM et al (2000) Childhood obsessive-compulsive disorder in the NIMH MECA study: parent versus child identification of cases. J Anx Disord 14: Riddle M (1998) Obsessive-compulsive disorder in children and adolescent. Br J Psychiatry 73: Pauls DL, Alsobrook JP, Goodman W et al (1995) A family study of obsessive-compulsive disorder. Am J Psychiatry 152: Clarizo FH (1991) Obsessive compulsive disorder: the secretive syndrome. Psychol Sch 28: Flament MF, Koby E, Rapoport JL et al (1990) Childhood obsessive compulsive disorder: A prospective follow-up study. J Child Psychol Psychiatry 31: Storch EA, Murphy TK, Bagner DM et al (2006) Reliability and validity of the Child Behavior Checklist Obsessive-Compulsive Scale. J Anx Disord 20: Valderhaug R, Ivarsson T (2005) Functional impairment in clinical samples of Norwegian and Swedish children and adolescents with obsessive-compulsive disorder. Eur Child Adolesc Psychiatry 14: Friedman AS, Utada AT, Glickman NW (1987) Psychopathology as an antecedent to, and as a consequence of, substance use, in adolescence. J Drug Educ 17: Piacentini J, Bergman RL, Keller M, McCracken J (2003) Functional impairment in children and adolescents with obsessive-compulsive disorder. J Child Adolesc Psychopharmacol 13: Goodwin R, Koenen KC, Hellman F, Guardino M, Struening E (2002) Helpseeking and access to mental health treatment for obsessive-compulsive disorder. Acta Psychiatr Scand 106: