Obsessive Compulsive Disorder (10 page)

Questionnaire measures

Self-report and parent-report questionnaire measures can be a quick and often less intrusive method for gathering further details on OCD symptomatology and impairment. Furthermore, they can be used throughout treatment to track change and areas still in need of intervention. However, few validated questionnaires for use with children, especially less than ten years of age, exist. Below is a selection of both validated and non-validated (often newer) questionnaire measures that are commonly administered to young people and their parents which assess core symptoms of OCD, OCD-related beliefs and appraisals and impairment of child and family functioning.

Other questionnaire measures such as the
Multidimensional Anxiety Scale
for Children
(MASC; March, 1997), the
Screen for Child Anxiety Related
Emotional Disorders – Revised
(SCARED-R; Muris
et al.
, 1999) and the
Child
Depression Inventory
(CDI; Kovacs, 1992) can also be useful when considering comorbidity and differential diagnosis.

The Child Obsessive Compulsive Inventory
(Child OCI; Salkovskis and Williams, 2004a; see Appendix A) is an adapted version of the adult
Obsessive Compulsive Inventory
(OCI; Foa
et al.
, 1998). The OCI consists of 42 items relating to seven subscales (washing, checking, doubting, ordering, obsessing, hoarding and mental neutralising). Each item is rated on a five-point (0–4) Likert scale of symptom frequency and associated distress. The total score is the sum of all subscale scores. A cut-off of 60 has been found to be clinically significant. The OCI has satisfactory reliability and validity (Foa
et al.
, 1998). The Child OCI is a self-report child questionnaire that has been adapted by simplifying the language used and reducing sentence length. In addition, the young person is only required to give distress ratings. Initial normative data for the Child OCI suggests a total mean score of 32.44 in a non-clinical sample (Griffen, 2000). The Child OCI is a useful tool in identifying prominent areas of difficulty and for tracking change throughout therapy.

The Children’s Obsessional Compulsive Inventory
(ChOCI; Shafran
et al.
, 2003) was adapted from the adult OCD measure, the
Maudsley Obsessional Compulsive Inventory
(MOCI; Hodgson and Rachman, 1977). The ChOCI consists of 43 items that are given to both the child and parent
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47

which assess the presence and impairment caused by common obsessive and compulsive symptoms. Each item is scored on a three-point scale ranging from 1 ‘not at all’ to 3 ‘a lot’. A total impairment score of 17 indicates clinically significant OCD. The ChOCI has been found to have adequate psychometric properties (Shafran
et al.
, 2003) although significant correl-ation between child and parent report on obsessive symptomatology was not found, perhaps owing to the internal and thus non-observable nature of obsessions.

The Leyton Obsessional Inventory – Child Version Survey Form
(Leyton CV; Berg
et al.
, 1988) was the first self-report questionnaire to be developed for paediatric OCD. Based on the Leyton card-sorting task, it uses 20 items from the original 44 questions. If a ‘Yes’ rating is given it is ranked for levels of interference on a four-point scale. A ‘Yes’ score of greater than 15 and an interference score of greater than 25 have been used to indicate clinical levels of OCD. The survey form demonstrated good internal consistency but test-retest reliability ranges from poor to good depending on the child’s age. Furthermore, high false-positive rates and poor concordance with clinical interviews have been found (Allsopp and Williams, 1991; Wolff and Wolff, 1991).

The Child Obsessive Compulsive Impact Scale
(COIS; Piacentini and Jaffer, 1999) is a 56-item measure assessing the level of impairment caused by OCD on the child’s day-to-day functioning over the previous month.

Items relate to potential difficulties in school, home and social activities and are rated on a four-point scale ranging from ‘not at all’ to ‘very much’. The COIS has demonstrated good psychometric properties and is sensitive to treatment effects.

The Child Responsibility Interpretation Questionnaire
and
Child Responsibility Attitude Scale
(CRIQ and CRAS; Salkovskis and Williams, 2004b; see Appendix B) are two companion child-report measures which have been adapted from the adult
Responsibility Interpretation Questionnaire Scale
and
Responsibility Attitude Scale
(RIQ and RAS; Salkovskis
et al.
, 2000). The CRIQ is a 15-item questionnaire that measures the frequency and strength of belief in appraisals of responsibility associated with intrusive thoughts.

The CRAS is a measure of general responsibility attitudes (assumptions) and consists of 20 items that ask the child to rate a series of statements such as ‘I often feel responsible for things that go wrong’ on a seven-point scale.

Initial investigation into these adapted measures has indicated high internal consistency and concurrent validity and initial normative data has suggested overall mean scores of 17.4 (frequency) and 451.7 (belief ) on the CRIQ and 64.17 on the CRAS (Griffen, 2000).

The Family Accommodation Scale
(FAS; Calvacoressi
et al.
, 1995) is a parent-report measure that assesses family involvement in the maintenance of OCD. It consists of nine items relating to the accommodation of the child’s obsessive and compulsive behaviour over the previous month. Each item is rated on a five-point scale. The FAS has demonstrated satisfactory levels of inter-rater reliability. However, more research on its psychometric properties is needed.

48

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Clinician administered and self-report questionnaires provide a useful way of quantifying symptoms and can be used to monitor change.

Idiosyncratic measures

Idiosyncratic measures such as diaries are helpful in targeting specific obsessive compulsive symptoms, including the daily frequency and distress associated with the young person’s primary obsessions and compulsions, details on eliciting stimuli and levels of anxiety experienced. These measures can be a useful way of gaining baseline information but also allow the therapist to track change throughout treatment. This is a vital aspect of treatment, given that factors such as the reduction in young persons’ daily experience of obsessions have been found to be a primary indicator of treatment success with adults (Clark, 2004). The use of diaries to identify and challenge the young person’s interpretation of intrusive thoughts is also crucial in cognitive behavioural therapy for OCD. Appendix C

contains examples of diaries that can be used with young people and their parents.

Specific issues in the assessment of OCD with young people
Clark (2004) notes that obsessive compulsive symptoms and characteristics such as the need for exactness, concern about making mistakes, pathological doubt and indecision can all interfere with the assessment process and make the completion of questionnaires and the clinical interview difficult. Completion of questionnaires and the clinical interview may also elicit obsessions and compulsions which the therapist will have to help the young person manage. It is important that the therapist acknowledges the young person’s anxiety and the fact that OCD can make assessment difficult. It is helpful to be clear about the purpose of assessment, to limit the number of measures and to give the young person plenty of time to respond. It can also be useful to develop a joint plan of how to manage the assessment process with minimal distress and to identify and challenge any faulty assumptions the young person may have about what will happen. For example, if the young person is wary of taking part in the assessment process because they are concerned about their resultant levels of anxiety, the therapist could ask them to consider a previous time when they had been in an anxiety-provoking situation and explore previous coping strategies and whether the outcome was as they had predicted.

Another issue relating to the assessment of OCD is the difficulty some young people have in identifying and discussing primary obsessions and interpretations. It has been suggested that up to 40 per cent of young people
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49

do not have clear obsessions (Carr, 1999). For others, their compulsive behaviour has become so habitual that they have gone past being able to draw a clear link between an intrusion, their interpretation and their resultant neutralising behaviour. In such cases it is best to proceed with acknowledging an urge to perform their compulsion and a sense that it would feel awful if they did not complete it. The therapist can then return to trying to identify the obsession and its interpretation once the compulsion has been explored by asking the young person ‘When you had the urge to do X, what do you think was the worst thing that could happen if you did not put it right?’ Alternatively the therapist can ask the young person to let them know the next time they get an urge to complete a compulsion and before they carry it out ask them what is going through their mind and what would be the worst thing about not performing the compulsion.

The issue of shame or embarrassment can also make it difficult for young people to disclose the content of their obsessions and misinterpretations. Some are reluctant because they are fearful of the potential consequences (e.g. ‘You might phone the police or have me locked up’) or worry what the therapist may think of them (e.g. ‘Some of my thoughts are so bad it will make you think that I’m an awful person and you won’t want to help me.’). In such situations the therapist should acknowledge the young person’s difficulty with discussing their thoughts and should also aim to normalise the content of common intrusive thoughts and fears that many young people have: ‘I can see that it is really hard for you to talk about your OCD worries.

This happens a lot of the time because OCD thoughts tend to be about our worst nightmare; the kinds of things we don’t think should go through our heads. But it’s actually completely normal to have nasty or scary things come into our heads and what’s more we have no control of what comes into our heads. OCD is very clever, as it tends to pick on the people that are sensitive and perhaps even care too much. It likes the fact that you are bothered by the thoughts and it knows they will bother you because they’re actually the complete opposite for what you stand for. Would it be helpful if I gave you some examples of the kinds of thoughts that sometimes go through my head and the young people I have seen?’

Due to phenomenological overlap with other disorders, alternative explanations for symptoms need to be excluded and the core features of obsessions and function of compulsions should be explored. Clark (2004) notes the core features of obsessions, which can be useful in distinguishing obsessions from other types of mental phenomena. These include the fact that the obsessions: • are intrusive (enter the mind against the young person’s will)

• cause distress

• are ego-dystonic (inconsistent with the young person’s core values) 50

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• are uncontrollable

• are associated with a strong urge to suppress or resist.

Compulsions can be distinguished by the fact that they are purposeful acts that the young person feels driven to perform in response to their obsessions or associated distress.

• The therapist should be clear about the purpose of assessment and limit the number of measures.

• Issues such as shame or embarrassment or fearing the consequences of disclosing symptoms can make it difficult for young people to disclose the content of their obsessions and misinterpretations.

4

Planning and carrying out treatment

Polly Waite, Catherine Gallop and Linda J. Atkinson
CBT Model

This treatment approach is based on Salkovskis’ (1985) cognitive model of OCD, but modified in order to work with young people and families. This model proposes that in individuals with OCD the normal phenomena of intrusive thoughts are misinterpreted as meaningful and seen as an indication that they might be responsible for harm to themselves or others unless they take preventative action. As a result, the individual attempts to suppress and neutralise the thought through compulsions, avoidance, seeking reassurance or by attempting to get rid of the thought. The aim of these neutralising behaviours is to reduce perceived responsibility. However, they actually make further intrusive thoughts more meaningful and more likely to occur, evoke more discomfort and lead to further neutralising. The key components of therapy are: • carrying out an individualised formulation

• psychoeducation

• establishing goals

• developing an alternative way of making sense of the problem

• testing this out through behavioural experiments

• relapse prevention.

This approach has similarities with traditional ways of working with young people with OCD (e.g. March and Mulle, 1998) in that it involves techniques such as externalising the OCD in order to separate it from the child and family and the use of metaphors and stories. It also involves a large behavioural component in order to get rid of OCD. In both approaches, treatment is predictable and the young person has explicit control over what they carry out inside and outside sessions. However, there are also key differences: 51

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1

March and Mulle’s (1998) treatment package involves extensive discussion of OCD as a medical illness and compares it to illnesses such as diabetes. Our approach is based on the idea that OCD stems from misunderstanding thoughts and that stressing biological factors can be unhelpful, in that it can lead to children and families feeling that there is something wrong with them and that it may not be treatable.