Parent Coaching Tips
Sessions One - Two:
You and your child are about to embark on a time-limited treatment program for children and adolescents with OCD that has been developed in the Program for Child and Adolescent Anxiety Disorders at Duke University. This treatment package is backed by years of empirical research and has shown itself to be an effective treatment for OCD in young persons.
As the name suggests, Obsessive-Compulsive Disorder (OCD) is characterized by obsessions and compulsions. Obsessions are unwanted, persistent thoughts, images or urges that are accompanied by unpleasant feelings such as anxiety, disgust, or guilt. Common examples include fear of germs or other contamination, fear of harming self or others, aggressive or sexual thoughts, and "just-so" worries. "Just-so" OCD usually involves a felt need for exactness or symmetry rather than idea about perfectionism. Compulsions, which are sometimes termed rituals, are acts that are performed to reduce the uncomfortable feelings, thoughts, and urges involved in obsessions. Compulsions, which include cleaning, washing, checking, ordering/arranging, counting, repeating and hoarding and collecting, are usually performed in a rule-bound manner and are often bizarre. For example, and eight year-old boy with "just so" OCD and counting rituals had to trace and retrace his letters eight times or more, making it hard for him to complete his school work.
OCD in children and adolescents is more common than once thought. Between one in one hundred and one in two hundred young persons is affected at any give time. What does this mean? Three or four youngsters with OCD per average-size elementary school; up to twenty in a large urban school. Since most of us don't know that many children with OCD, researchers believe that a large number must be suffering in silence. Although there is a great deal of overlap between boys and girls with OCD, research has also shown that OCD on average looks a bit different in boys and girls. Boys have more "just so" feelings, and are more likely to have tics and attention-deficit hyperactivity disorder. Boys are also more likely to have their symptoms begin during elementary school years. Girls exhibit more fears and anxiety, are more likely to be depressed, and tend to have their OCD symptoms start during early adolescence.
When OCD in children looks like OCD in adults, and responds to both behavioral psychotherapy and to specific anti-obsessional medications, children pose a unique treatment challenge because they: (1) more often lack the ability to see their obsessions as senseless and their compulsions as excessive; (2) tend to be embarrassed by their obsessions and compulsions, and so try to keep them secret; (3) may have difficulty tolerating anxiety; and (4) more frequently involve other family members with OCD.
Cognitive behavioral psychotherapy (CBT) will help you and your child write OCD out of his or her life story. During these sessions, you and your child will receive: information about OCD; instructions about how to "boss back" OCD; a "tool kit" for coping with anxiety; and an opportunity to practice these strategies with the therapist. In addition, your child will choose a series of homework assignments that facilitate his or her "bossing back" OCD.
Parents often ask, "How can we help?" In answer to this question, the program includes two parent sessions. In addition, we have attached five instruction sheets for your reference. These parent coaching tips offer practical information and suggestions on how you can best participate in your child's treatment process. We have also included a list of recommended readings. Remember, you and your child are in a battle with OCD. The more you know about your common enemy (OCD), the better your chances are of winning.
We begin with a simple definition of Obsessive-Compulsive Disorder. OCD is a neuro- behavioral disorder, that is, a brain problem that affects a child's thoughts, feeling, and behaviors in a very specific fashion. As a neurological problem, OCD cannot, in any way, be viewed as your child's "fault", or as something your child could stop "if only he or she just tried harder." On the contrary, OCD is a "short circuit," "hiccough," and/or "volume control" problem in the brain's "worry computer". This "worry computer" inappropriately sends fear cues which do not deserve such attention. These fear cues are what we call obsessions:
Tip 1. Obsessions are unwanted thoughts, urges, or images that are accompanied by negative feelings. The fear that he might contaminate himself or someone else by touching something "germy" is a common obsession.
When the brain gives these unwanted fear cues, the child must in come way respond. Responses often show up as ritualized behaviors which we call compulsions.
Tip 2. Compulsions are actions designed to make these thoughts go away and to relieve accompanying anxiety. Excessive washing is a common ritual for contamination phobic patients with OCD. Avoiding "contamination" is also common, and can produce considerable distress and dysfunction.
When compulsions are seen as bad behavior, your child can become frustrated and depressed by his or her inability to change. By viewing OCD as a specific brain problem, your child can let go of the notion that he or she is the problem, thereby taking a first step toward making OCD the problem and giving OCD a name.
Tip 3. OCD is the problem. Reinforce this message with your child, calling OCD by the nasty nickname your child chooses in Session Two. In this way, OCD becomes the "bad guy" while you and your child are the "good guys" working to make OCD "get out of the Dodge".
Once OCD is clearly identified and named as the problem the treatment process of "bossing back" OCD begins. The means of "bossing back" or "saying no" to OCD is exposure and response prevention (E/RP). Exposure and response prevention is the heart of the treatment process with the therapist serving as "coach" to facilitate that process. Exposure occurs when the child exposes him or herself to the feared object, action, or thought. Response prevention is the process of blocking the rituals and/or minimizing to avoidance behaviors that result from exposure. With exposure and response prevention, anxiety over the obsession and associated rituals decreases or even disappears. Another form of response prevention is extinction. Extinction occurs by the removal of any positive reinforcement for the targeted behavior. Take, for example, the child with a contamination fear about touching door knobs. In this case, since door knobs trigger the obsession, the exposure task would require the child to hold the "contaminated" door knob. Next, response prevention takes place when the child refuses to perform the usual anxiety-driven compulsion, such as washing hands or using a tissue to grasp the knob. Extinction takes place when the child's parents, siblings or friends either ignore compulsive reassurance seeking, or refuse to grasp the knob for the child. During therapy sessions the therapist and the child together decide on a exposure and response prevention tasks to be practiced daily between the sessions. The parent sessions will further explore extinction as a response prevention technique.
Tip 4. Be a cheerleader for your child. As a cheerleader, you can help motivate your child as he or she begins to boss back OCD. If you exhibit a supportive, and confidently neutral approach you will contribute to anxiety reduction during exposure tasks. Criticism or punishment invariably makes OCD worse by decreasing your child's motivation to resist. Remember that you wouldn't criticize your youngster for having asthma; OCD is not much different. Remember also that the tasks chosen or E/RP may see small and insignificant, but it is important for E/RP to take place at your child's pace.
E/RP is often threatening for the child and therefore an important aspect of the treatment process is the "tool kit". The "tool kit", which is introduced in Session Three, provides coping strategies for your child to use while experiencing anxiety. The next parenting coaching sheet will explain these strategies in detail.
OCD affects not only the sufferer but the whole family. The family often has a difficult time accepting the fact that the person with OCD cannot stop the distressing behaviour. Family members may show their anger and resentment, resulting in an increase in tension and a worsening of the OCD. Or, to keep the peace, they may assist in the rituals or give constant reassurance.
Education about OCD is important to the family. Families can learn specific ways to encourage the person with OCD by supporting the medication regime and the behavior therapy. Self-help books are often a good source of information. Some families seek the help of a family therapist and or join one of the educational or support groups that have been organized throughout the country.