Personalization and Improvement of Patient Care for Pediatric OCD ADAA March 2014 Liza Bonin, Ph.D. Pediatrics
Disclosure • UpToDate clinical decision support resource ‐ Wolters Kluwer Health
• UpToDate contributions within Pediatrics ‐ Depression in children and adolescents ‐ Treatment of adolescent depression ‐ Suicidal behavior in children and adolescents
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Educational Objectives Participants will be able to: 1. 2.
3.
Describe current literature on predictors and moderators of treatment outcome for pediatric OCD Summarize current knowledge base of mechanism underlying exposure based CBT and implications of these current advances for implementation of CBT treatment Apply aforementioned knowledge into clinical decision-making and treatment planning for OCD
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OVERVIEW • Introductions • Pertinent literature ‐Predictors and moderators ‐Exposure & new learning
• Strategies for personalizing / improving care ‐Common comorbidities & challenges
• Practice Implementation - vignettes • Wrap Up
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Introductions
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Pediatric OCD • Chronic and impairing condition • Significant advances in evidence-base ‐POTS I, POTS II, POTS-Jr, Predictors / Moderators ‐Family Focused, Intensive, Technology
• Core Elements CBT Treatment ‐Building Engagement / Readiness (Psychoeducation +) ‐Exposure & Response Prevention / Parent Involvement •Collaborative Fear Ladder •Fading Family Accommodation
•Between Session Practice (ERP Homework) Page 6
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Predictors and Moderators* • Symptoms ‐ Baseline Severity ‐ Insight, functional impairment, symptom presentation
• Family accommodation / dysfunction ‐ Family conflict, blame, cohesion
• Comorbid disruptive behavior/externalizing symptoms • First degree family history OCD* • Tics* • Executive dysfunction / neurocognitive impairment • Therapeutic alliance, treatment expectancies
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Clinical Guidelines • American Academy of Child & Adolescent Psychiatry Practice Parameter for Pediatric OCD (2012) ‐ CBT/ERP first line intervention for mild to moderate pediatric OCD ‐ Consider combined treatment (CBT/ERP + SSRI) •Moderate to severe OCD symptoms (CYBOCS > 23) •Positive 1st Degree Family History OCD
•Situations that could impede successful CBT
• Other Key Resources ‐ JCCAP Evidence-Base Reviews (2008, 2013)
‐ See Reference List
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New Learning • Updates to theory about exposure ‐NEW LEARNING as key mechanism •Not weakening of previous (fear) learning •Habituation not necessary condition •New (safety) learning competes with old (fear) learning ‐Successful treatment is when new learning becomes the dominant association to once feared cued ‐New learning is particularly context dependent •Does not generalize easily to new contexts
•Vulnerable with passage of time (return of fear) Page 9
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Implications for Exposure • Task = Ensure that safety learning dominates ‐Across contexts (external and internal) ‐Across time
• Conduct exposures across broad range of most salient / relevant cues and contexts ‐Vary conditions and contexts for safety learning, additive cues ‐Ensure that new learning is not contingent on context •Monitor attributions for improvement/safety (i.e. “I am only OK because of XYZ”)
• Plan for use of recall and generalization cues Page 10
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Liza’s OCD Donut
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Strategies for Personalizing and Improving Care
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PDSA: Evidence Based Treatment
ACT
PLAN
Refine Treatment Plan as Needed
Case Formulation / Treatment Plan
STUDY
DO
Evaluate Progress Benchmarking / TIB
Implement Plan with Progress Monitoring
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Comorbidities & Clinical Challenges • Disruptive Behavior • Tics
• Neurocognitive / Executive Dysfunction (including ASD) • Mood • Somatic Concerns
• Accommodation / Family Dysfunction • Parental OCD
• Poor Insight / Engagement Page 14
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OCD & Disruptive Behavior 1. What does literature say about this comorbidity? 2. What is the potential impact of this comorbidity on implementation of effective exposure therapy? 3. What are potential strategies to personalize and improve treatment response? • Consider ‐ Monotherapy or Combined treatment ‐ Adjust or augment CBT for OCD ‐ Family-based approach (targeting what?)
‐ Another treatment besides CBT for OCD
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OCD & Disruptive Behavior • Comorbid externalizing symptoms / disruptive behavior associated with poor treatment response and higher rate of relapse ‐ Possible mechanisms? • Role of executive dysfunction / self-control • Coercive family processes
• Clinical Decision-Making ‐ Prioritization / readiness for ERP ‐ Augmentation / additional Treatment
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OCD & Tics 1. What does literature say about this comorbidity? 2. What is the potential impact of this comorbidity on implementation of effective exposure therapy? 3. What are potential strategies to personalize and improve treatment response? • Consider ‐ Monotherapy or Combined treatment ‐ Adjust or augment CBT for OCD ‐ Family-based approach (targeting what?)
‐ Another treatment besides CBT for OCD
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OCD and Tics • Tics moderate treatment outcome (POTS) ‐ Those with tics failed to respond to SSRI alone
• Start with CBT or CBT + SSRI (AACAP) • Non-responder meds: Augmentation SSRI w neuroleptic
• Compulsion or Tic - Tourettic OCD (Mansueto) • CBIT for tics (Piacentini, Woods, et al., 2010) ‐ Whose problem is it? EF Skills?
• Monitor for additional difficulties: ‐ In mathematics and written expression, graphomotor skills, deficits in executive functioning
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Neurocognitive / Executive Dysfunction 1. What does literature say about this comorbidity? 2. What is the potential impact of this comorbidity on implementation of effective exposure therapy? 3. What are potential strategies to personalize and improve treatment response? • Consider
‐ Monotherapy or Combined treatment ‐ Adjust or augment CBT for OCD ‐ Family-based approach (targeting what?) ‐ Another treatment besides CBT for OCD
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Neurocognitive / Executive Dysfunction • Evidence suggests EF predicts attenuated outcome
• Implications of poor EF skills for New Learning: ‐ Attention / organization / self-monitoring ‐ Inhibitory control / self-regulation / distress tolerance ‐ Mental flexibility
• Weakness in Language Skills / Understanding
• Point-of-performance supports ‐ Generalization ‐ Antecedent management
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OCD & Mood 1. What does literature say about this comorbidity? 2. What is the potential impact of this comorbidity on implementation of effective exposure therapy? 3. What are potential strategies to personalize and improve treatment response? • Consider ‐ Monotherapy or Combined treatment ‐ Adjust or augment CBT for OCD ‐ Family-based approach (targeting what?)
‐ Another treatment besides CBT for OCD
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OCD & Mood • Depression (particularly if severe) has potential to interfere with CBT/ERP ‐ Engagement / expectancies ‐ Motivation for between session practice ‐ Relational aspect of depression
• Mood disruption / disorder ‐ Dysregulation = Poor tolerance for ERP ‐ Medication challenges
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OCD & Somatic Concerns 1. What does literature say about this presentation? 2. What is the potential impact of this presentation on implementation of effective exposure therapy? 3. What are potential strategies to personalize and improve treatment response? • Consider ‐ Monotherapy or Combined treatment ‐ Adjust or augment CBT for OCD ‐ Family-based approach (targeting what?)
‐ Another treatment besides CBT for OCD
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OCD & Somatic Concerns • Somatic symptoms very common • Fear of sensations / internal cues ‐ Interoceptive exposure
• Health anxiety / somatic focus ‐ Literature on health anxiety ‐ Shift / differential attention ‐ Avoidance behaviors / communications • Systems of care – medical team, school, family • School attendance
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Accommodation / Family Dysfunction 1. What does literature say about this presentation? 2. What is the potential impact of this presentation on implementation of effective exposure therapy? 3. What are potential strategies to personalize and improve treatment response? • Consider ‐ Monotherapy or Combined treatment ‐ Adjust or augment CBT for OCD ‐ Family-based approach (targeting what?)
‐ Another treatment besides CBT for OCD
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Accommodation / Family Dysfunction • Accommodation ‐ Ubiquitous ‐ Role in Maintenance of OCD
• Family Dysfunction ‐ Family conflict, blame, cohesion* ‐ Treatment interfering behaviors
• Potentially Promising Family Based Approach ‐ Positive Family Interaction Therapy (Peris & Piacentini) • Adjunct personalized intervention for pediatric OCD*
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Parental OCD 1. What does literature say about this presentation? 2. What is the potential impact of this presentation on implementation of effective exposure therapy? 3. What are potential strategies to personalize and improve treatment response? • Consider ‐ Monotherapy or Combined treatment ‐ Adjust or augment CBT for OCD ‐ Family-based approach (targeting what?)
‐ Another treatment besides CBT for OCD
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Parental OCD • Positive first degree family history of OCD moderates treatment outcome (POTS) ‐ Those with 1st degree family history responded far less well to CBT than those without such as history
• Consider combined (CBT + SSRI) treatment • Format for treatment?
• Approach for management of: ‐ Family accommodation ‐ Family “just right” and “just want to be sure” issues
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Poor Insight / Engagement 1. What does literature say about this presentation? 2. What is the potential impact of this presentation on implementation of effective exposure therapy? 3. What are potential strategies to personalize and improve treatment response? • Consider ‐ Monotherapy or Combined treatment ‐ Adjust or augment CBT for OCD ‐ Family-based approach (targeting what?)
‐ Another treatment besides CBT for OCD
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Poor Insight / Engagement • Mixed findings on role of insight in prediction of treatment response ‐ Yet low insight often associated with high severity
• Engagement is key to successful ERP • How achieve engagement when insight is low?
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Vignettes
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Case Formulation Activity • Break into small groups • Based on information provided in vignette 1. Develop possible problem list / diagnoses 2. Identify pertinent evidence base to guide treatment decisions
Literature on predictors / moderators
3. Identify potential challenges to effective CBT/ERP
Factors that might interfere with new learning
4. Organize a preliminary treatment plan
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In Conclusion • Personalization and improvement of care ‐Is possible for pediatric OCD
‐Is priority in current health care climate
• Recommend systematic use of clinical guidelines or algorithms to support decision-making ‐Based on predictors and moderators of outcome ‐Guided by current theory (effective exposure = new learning) ‐Hardwire processes to support quality
•Decision-support •Outcome monitoring Page 33
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Key References • Freeman, J., Garcia, A., Frank, H., Benito, K., Conelea, C., Walther, M., & Edmunds, J. (2013). Evidence-base update for psychosocial treatments for pediatric obsessivecompulsive disorder. Journal of Clinical Child and Adolescent Psychology, 43(1), 7-26. • American Academy of Child and Adolescent Psychiatry (2012). Practice parameter for the assessment and treatment of children and adolescents with obsessive compulsive disorder. Journal of the American Academy of Child and Adolescent Psychiatry, 51(1), 98-113. • Barrett, P.M., Farrell, L., Pina, A., Peris, T.S., & Piacentini, J. (2008). Evidence-based psychosocial treatments for child and adolescent obsessive-compulsive Disorder. Journal of Clinical Child and Adolescent Psychology, 37, 131-155. • POTS Study Team (2004). Cognitive-behavior therapy, sertraline, and their combination for children and adolescents with obsessive-compulsive disorder. Journal of the American Medical Association, 292, 1969-1976. New Learning • Craske, M.G., Kircanski, K., Zelikowsky, M., Mystkowski, J., Chowdhury, N., & Baker, A. (2008). Optimizing inhibitory learning during exposure therapy. Behavior Research and Therapy, 46(1), 5-27.
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Key References - Continued Predictors & Moderators • Flessner, C.A., Allgair, A., Garcia, A., Freeman, J., Sapyta, J., Franklin, M.E., Foa, E., & March, J. (2010). The impact of neuropsychological functioning on treatment outcome in pediatric obsessive-compulsive disorder. Depression and Anxiety, 27, 365-371.
• Flessner, C.A., Freeman, J.B., Sapyta, J., Garcia, A., Franklin, M.E., March, J.S., & Foa, E. (2011). Predictors of parental accommodation in pediatric obsessive-compulsive disorder: Findings from the pediatric obsessive-compulsive disorder treatment study (POTS) trial. Journal of the American Academy of Child and Adolescent Psychiatry, 50(7)), 716-725. • Garcia, A.M., Sapyta, J.J., Moore, P.S., Freeman, J.B., Franklin, M.E., March, J.S., & Foa, E.B. (2010). Predictors and moderators of treatment outcome in the pediatric obsessive compulsive treatment study (POTS I). Journal of the American Academy of Child and Adolescent Psychiatry, 49(10), 1024-1033. • March, J.S., Franklin, M.E., Leonard, H., Garcia, A., Moore, P., Freeman, J., & Foa, E. (2007). Tics moderate treatment outcome with sertraline but not cognitive-behavior therapy in pediatric obsessive-compulsive disorder. Biological Psychiatry, 61, 344-347.
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Thank you! Questions?
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