Download ACT-Relevant Constructs in Child Therapy Process

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
ELIZABETH DAVIS, LISA W. COYNE, EVAN R.
MARTINEZ, ANGELA M BURKE, ABBE M.
GARCIA & JENNIFER B. FREEMAN
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-SADSP/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.
2.
3.
4.
5.
Does the therapist use the words “we”, “us”, “let’s” in > 1 instance
Does the therapist initially provide at least one opportunity for the child to contribute to
exposure planning in a generalized and collaborative way
Does the therapist provide the child with options for exposure and/or give the child the
opportunity to choose the task
Does the therapist communicate verbally and/or behaviorally that the
child/parent/therapist will work toward the goals of exposure together as a team
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
Exposure
EA
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
-.96
Exposure
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
Global EA
-.39†
-.33
-.73*
-.29
-.33
-.25
-.33
-.16
Session 7
Freq. EA
Global EA
___________________________________________________________
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
-.06
-.56*
-.56*
-.61*
-.13
-.39
-.33
-.06
-.32
.17
Session 4
Freq. EA
Global EA
Freq. BA
Freq. SS
Global BA
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 FU
Session 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 only
 Teeny n, thus very low power to detect effects
 Lower reliability in parent codes, thus potentially attenuating
relationships
 Cannot make any statements about directionality
 Nature of sequential relationships not fully explored
 Did 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 behaviors
 Assessing 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 Freeman
Dr. Abbe Mars Garcia
Dr. Amy Przeworski
The Coyne Family