Cognitive Behavior Therapy: A proven treatment for OCD and Anxiety

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An interview with Tamar Chanksy, PhD

Dr. Tamar Chansky is the founder and director of the Children's Center for OCD and Anxiety, and author of Freeing Your Child from Anxiety, and Freeing Your Child from Obsessive-Compulsive Disorder. Dr. Chansky lectures to parents, psychologists and educators on how to make treatment and prevention kid-friendly, effective and easy to implement. She is frequently featured on television, radio, and in print media.

Interview by Sheila Rogers, editor

I appreciate the opportunity to interview you, Dr. Chansky. I know your area of expertise in anxiety and obsessive compulsive disorder (OCD) will interest many of our readers. Perhaps you could start by telling us about your center in Plymouth Meeting, Pennsylvania.

There is a tremendous need for therapists who are competent and understand kids with anxiety and OCD. This was the driving force behind starting the Children's Center for OCD and Anxiety. It is also important to raise the visibility level of these conditions. When you have a child with more typical medical issues such as asthma or diabetes, it is a fairly straightforward effort to locate choices as you seek to help your child. This is not the case for many mental health conditions. I wanted the name of the center to be a sign to people that anxiety and OCD are common, treatable problems.

Now, more than ever, children are faced with stress, worry, and anxieties in their lives. They often suffer needlessly and invisibly. Our staff recognizes that anxiety and OCD can negatively impact a child's health, social growth, and academic performance. We strive to teach methods whereby symptoms can be greatly reduced. Cognitive behavior therapy is our main focus. We also started a website to help the public recognize stressors and find ways to address them: www.worrywisekids.org.

What is cognitive behavior therapy (CBT)?

The word "cognitive" relates to thinking or reasoning. Through this approach, kids are taught to challenge the thoughts that make them anxious. It involves understanding the situation, rather than just accepting intrusive thoughts as the truth. Therapists trained in this field encourage children to develop new coping skills, and together they come up with ways to deal with obsessive or anxious thoughts. With time, children can face the situations that make them fearful and deal with them, getting past the anxiety.

CBT encourages kids to generate more realistic versions of situations and to increase their ability to cope with them. Once they have a new mindset, children then gradually face their fearful situations by breaking the challenges down into small, manageable steps. Over time, children are able to more quickly tap into non-anxious interpretations of situations, and understand that avoidance of feared situations only makes matters worse. Instead, the way to get past anxiety is to face it head on and approach situations until they become used to them.

When you say anxiety and OCD are common, what is the current incidence for this type of problem?

Estimates are that one or two out of a hundred, perhaps more, suffer from these conditions. The incidence does seem to be increasing, and hopefully this is due in part to people knowing there is help now. Rather than suffer in silence, people are seeking help more often. It seems to be going from a hidden condition to one for which people are willing to discuss their problem and look for help.

We do know that there is both a genetic and environmental component to many of these cases. The environment can determine what tips the scales and results in significant symptoms. One area that concerns me is the degree of stress children are under. A study published in 2000 examined the baseline stress levels in kids, studying average (not identified as being at-risk) children in the 1980s. Their stress level was higher than psychiatric patients had in the 1950s--and this was pre-9/11! The stressors for children have increased even further, not decreased, since the 80s. Clearly, children now have to absorb a more stressful culture than many years ago. Of course, adults face the same issues, but we tend to have better coping skills.

If a child has vulnerabilities and hits a stressful time, that can tip the scales. Maybe a grandparent dies, or they are relocated with a parent's job, or there's a divorce--this can trigger a response. This is a real concern of mine.

Sometimes parents assume their child is just shy, or just a "worrier," and the issues are dismissed. Ignoring or minimizing the problem can result in an anxious adolescent or adult. Instead, interventions can be used to avoid that progression.

How do parents know if they need to seek help?

If you look at your child, consider the degree of stress that child seems to be experiencing. I emphasize looking at the child rather than the content of what they are worrying about--i.e., separation, being afraid of the dark, fear of a dog or a social situation. Why? Because the content may seem normal to you. It is typical to fear the dark, for example. Yet, it is the degree of their reaction that is the indicator you need to focus on.

Also consider how well you, as a parent, are able to discuss the situation and move forward. For example, if you can talk it through with your child, and you see that you are making progress--at least with baby steps--this child probably doesn't need treatment because he or she is moving in the right direction. However, if just the mention of the situation creates a meltdown in your child, then you need to get professional help to start making a positive change.

What are some of the red flags for children with anxiety?

When kids are struggling with something, they tend to regress in some way. They may have difficulty coping with regular situations, such as getting up in the morning and getting ready for school. Parents should be aware of the child's condition when they return from school; a lot of parents report that teachers aren't seeing a problem at school, but what happens is that as soon as the child gets off the bus to come home, they start to fall apart. That's a red flag that indicates an overstressed child. This stress or anxiety can continue into the evening, making management of homework and bedtime difficult.

Children with anxiety or OCD may have trouble at bedtime. Perhaps they used to be able to sleep separately at night, but when the symptoms are flaring up, they can no longer be independent at night. There may be periods of crying, angry tantrums, or "freezing"--not being able to respond. These are classic red flags for young children.

Whether it's having a babysitter, going to a location where there will be a costumed character, or any number of triggers that might increase internal stress, these types of kids will react. They may seem more irritable or have trouble sleeping, and grades may begin to suffer.

Avoidance is a cardinal sign of an anxiety disorder. Usually, young children can only freeze; they don't yet have the power to avoid. As they get older they may choose "not to do." They avoid a swim party at a friend's house, avoid going to school on the day of a book report--they won't do it, because they are so anxious about what might happen if they did go.

Do you find that school staff is helpful with children who are dealing with OCD, panic attacks, or anxiety?

It seems that guidance counselors are more aware of how kids struggle with what is happening in their world, especially post-9/11. I see a willingness with most people I work with to learn more about these topics at conferences. They want to know what they can do to help children cope better. School nurses throughout the country have reported to me that an unbelievable number of children now come to the clinic with panic attacks. We have a serious problem on our hands, and educating school staff can go a long way in helping students.

Where can families find a therapist who is trained in cognitive behavior therapy, and what should they expect?

Cognitive-behavioral therapy has a proven track record for the treatment of anxiety disorders, OCD, and Tourette syndrome (TS). We don't talk about curing anything because these tend to be ongoing conditions where the potential to have another episode is there. But symptoms can be reduced. As an example, in the case of TS you may learn habit reversal therapy to eliminate some tics. Then, other tics may surface along the way and you may need to learn new techniques for those. So we don't talk about a cure.

These groups can help provide referral information, and their websites are informative:

• Obsessive Compulsive OC Foundation (OCFoundation.org )

• The Anxiety Disorder Association of America (adaa.org) [Editor's note: a search by zipcode seems to work best at present.]

• Academy of Cognitive Therapy (academyofct.org)

• Association for the Advancement of Behavior Therapy (aabt.org).

Could you differentiate between obsessive compulsive disorder (OCD) and a generalized anxiety disorder (GADS)?

That's a good question, because people tend to think of all worry as just "worry." The important differentiation involves what a child is worried about, and what causes it to occur. The content, or the actual concerns with OCD are usually different from those of a child who is dealing with panic or GAD--generalized anxiety.

GAD is uncontrollable worry about expected things. For example, if a child has general worries, they worry about whether friends like them, how they will do on a test, and/or how they will perform in a soccer game. They have concerns about whether the family is going to get sick, or if they will have enough money. Many of us might worry about the situations just mentioned, but someone with GAD has a more constant, pervasive sense of these types of worries.

In contrast, someone with OCD may have concerns that seem strange or unusual--even to themselves. They might have the thought that because someone coughed near them they will get AIDS, or they will get sick because they touched a door knob, or if they don't tie their shoelaces ten times instead of two times someone will be in an accident and die. Uncomfortable thoughts arise even when the connection between the action and the outcome is nonsensical. Those with OCD often recognize that the connection doesn't make sense. Kids might say, "You may think this is weird, but I'm afraid of such and such."

What is the difference between an obsession and a compulsion?

The term obsession is used to represent the intrusive thoughts a child may have. Let's say a child is getting ready for school and they have a mental picture of their little brother eating poison or sticking a finger in an electrical outlet. The image comes out of nowhere--it barges in, or parachutes into the mind out of nowhere. This would be disturbing for anyone, but kids with OCD also conceive an idea of something to do in order to ward off the feared consequence. Like: If I open and close my book bag for my "lucky number of times" then nothing bad will happen. Or: If I don't make any mistakes at school today, then nothing bad will happen. The action is the compulsion, which is often repetitive, and the purpose of the action is to undo the fear that the obsession has brought on.

Through behavioral therapy, people can learn to recognize that the thoughts they have would make anyone upset. It is totally normal to feel upset with those thoughts. The problem is that the brain is delivering those thoughts when they shouldn't. They have to learn how to ride out that anxiety. They learn how to deal with intrusive thoughts without having to engage in compulsive behaviors. Over time, the brain will learn how to not send them those messages. Further, the anxiety they feel when those types of messages do come through is diminished.

Normally, when they follow through with compulsive actions, do the actions strengthen the OCD?

Yes. It is a case of negative reinforcement. With the example given previously, when a person with OCD believes that opening and closing a book bag for a certain number of times will prevent a bad situation, then when that compulsion is performed there is a feeling of relief. Even though the relief is based on an invalid belief, it reinforces the behavior by removing the awful feelings that were being experienced. The child believes that the only way to get rid of that thought is to do the compulsion--and it works temporarily. It creates an ongoing cycle.

I found your book Freeing Your Child from Obsessive-Compulsive Disorder very reader-friendly. I particularly liked the section describing how to "boss back the OCD." Could you give a brief summary of that therapeutic technique?

When children have an obsessive or anxious thought, the worries bombard and frighten them--they are like foreign thoughts. John March, who developed a treatment of cognitive behavior therapy for OCD, talked about making the OCD a "third party." He suggested redefining it into a concrete entity that the child can boss back, because the thought has been bullying him or her. For example, the thought says: "Oh, you'd better not step on that crack" or "You can't have the birthday treat because someone else touched it." The child is taught to think of OCD as a bully that needs to be bossed back with a response such as: "You are not the boss! You can't make the rules." Or, they might tell the thought: "If this were not safe, my parents would tell me that, not you." They need to look at the worry as coming from an unreliable authority that they are now going to demote in importance.

Can parents help a child develop this skill?

Parents play an important role, and here's an example. Instead of asking a daughter why she washed her hands again since they were just washed, a father could say, "That OCD is really bossing you around. I know you would much rather go play with your friends now. Why don't you boss it back--let's do it together." Parents should have prearranged comments that they are ready to say to a child. This is how we approach other things in our lives--we know how to handle a flat tire under a variety of circumstances. When a parent sits down with a child, or with the therapist, they need to work through what the OCD is about, come up with a name for it, and then talk about a plan. Then, when the bully says, "You have to tap on the sides of the door when you walk through it," you can boss it back. At the same time, you find something else the hands could be doing. You make the plan ahead of time so that in those moments you can be coaching your child instead of fighting with them over what they are doing.

It's a matter of changing the configuration of what is going on between them. When parents reach the clinic they are often broken down. It is heart-wrenching to see what OCD can do to a family. A mother might explain, "We're so tired at night, but I have to say good-night in a certain way, or a certain number of times, or Timmy won't go to sleep." The children have become indoctrinated into what the OCD wants them to do. I turn it around and tell Timmy that he should "hire" his mother to fight the OCD. We work through ideas together that a parent could use to help the child get past the ODC.

How do children respond to this type of approach?

We find that kids love it when they have developed a sense of power over the OCD. Children may be very reluctant at first to make any changes. Therapists can help kids get on board by conveying the following messages:

• It is okay to be afraid;

• This is not your fault;

• There is a way out--and, finally;

• We will do this together at a manageable pace.

Treatment is hard work but it can even be fun, like playing catch with a pair of untouchable shoes and then eating a snack, or finding all the ways in the office to make things uneven.

Do you find that parents overreact to possible signs of anxiety or OCD?

You know, some experts suggest that parents who see mental health symptoms and seek help for their children are just looking for problems and magnifying the issues. This attitude troubles me, because we often see very reasonable parents who are watching their responsible, previously normal child start doing abnormal and troubling actions, or complaining about distressing fears. These parents haven't created this situation. It is very real, and they should be concerned.

What is the status of medications for OCD?

At this point there is not a lot of data for any treatments dealing with kids with OCD, and there hasn't been much funding for related research. To date, anecdotal reports and the studies that have been completed are promising. Consensus guidelines for treating OCD, provided in the Journal of Clinical Psychiatry, suggest that the first line of treatment for children should be CBT. As a general rule, if improvement has not been seen in four to six sessions of CBT, then medication should be considered.

What often occurs is that parents are not aware of CBT and so they see their pediatrician, who may not know much about the condition. That doctor suggests the child may outgrow it, or the family is referred to a psychiatrist, where medication is offered. Unfortunately, despite CBT having been proven useful, doctors often fail to refer patients for it. The use of CBT can often avoid the need for medication.

Now, if the child is depressed, or you are dealing with a teenager, it might work better to start with medication or start both treatments together. Research has shown that medications and CBT have the potential to change different parts of the brain for depression and for OCD. With this in mind, it could make sense to use both approaches. Yet, some studies indicate that using the combination of treatments has not been beneficial beyond that of a single therapy. I would suggest we look at results on a case to case basis. Sometimes there may be evidence for a combined approach. Some kids who go on medication have such difficult cases or compliance issues that it would be impossible to start CBT alone. Many parents are reluctant to use medication, and my concern is they assume it is the only option they have, and CBT isn't properly considered.

As you and I both know well, there are alternative medicine treatments as well. Supplements such as inositol have been clinically shown to reduce OCD symptoms on par with antidepressants. Parents can get more information about vitamins on your website as well as at worrywisekids.org. Anxiety creates a resource drain on the body. Good eating habits and possibly supplements may help reduce anxiety while also helping to restore the body's resilience.

Does insurance cover cognitive behavior therapy?

Mental health coverage is notoriously weak, and this includes treatment for OCD and anxiety. Sometimes if parents request a specialist to write a letter explaining that the child has a need for specialized therapy (CBT) that they cannot get through their regular health network, they receive approval. Insurance companies will usually cover medications. However, there is some concern about the safety of these types of medications for children.

One reason I am so excited about CBT is it has no negative side effects, and it can increase feelings of competency and problem-solving in kids. Children can apply what they learn to other areas of their lives.

At this point there is not a lot of data for any treatments dealing with kids with OCD, and there hasn't been much funding for related research.

Cognitive- behavioral therapy has a proven track record for the treatment of anxiety disorders, OCD, and Tourette syndrome (TS).

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