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1 AN INVESTIGATION OF TREATMENT HISTORY OF PEDIATRIC O BSESSIVE COMPULSIVE DISORDER AND PREDICTORS OF TREATMENT RECEIVED By CARY JORDAN A DISSERTATION PRESENTED TO THE GRADUATE SCHOOL OF THE UNIVERSITY OF FLORIDA IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF DOCTOR OF PHILOSOPHY UNIVERSITY OF FLORIDA 2011
2 2011 Cary Jordan
3 To my grandmother who sadly passed before seeing me complete my degree, I want to thank her for the constant devotion and belief in me. This manuscript is in your honor.
4 ACKNOWLEDGMENTS I want to recognize my father who never stopped helping me achieve my goals in life and has been there every step of the way. To my wife, who without I would have never made it this far you inspire me everyday I wish to thank my mentors Eric Storch, Gary Geffken, and Steven Pence for all your support and impact on my maturation as a clinician and researcher. I am only great at what I do because I have stood on your shoulders.
5 TABLE OF CONTENTS page ACKNOWLEDGMENTS .................................................................................................. 4 LIST OF TABLES ............................................................................................................ 7 ABSTRACT ..................................................................................................................... 8 CHAPTER 1 REVIEW OF LITERATURE .................................................................................... 10 Overview of Obsessive Compulsive Disorder ( OCD) Characteristics ..................... 10 Symptom Impairment .............................................................................................. 13 Comorbidity ............................................................................................................. 13 Biological Theories of Etiology ................................................................................ 15 Assessment ............................................................................................................ 16 Treatment ............................................................................................................... 18 Cognitive Behavioral Therapy with Exposure and Response Pr evention ......... 19 Medication ........................................................................................................ 20 Medication Side Effects .................................................................................... 24 Family Acco mmodation .................................................................................... 27 Treatment P rotocols ......................................................................................... 28 Barriers to T reatment ....................................................................................... 29 Res earch Questions for Investigation ..................................................................... 32 2 METHODS AND PROCEDURES ........................................................................... 34 Participants ............................................................................................................. 34 Measures ................................................................................................................ 34 Children's YaleBrown Obsessive Compulsive Disorders Scale ...................... 34 Family Accommodation Scale for Obsess ive Compulsive Disorder ................. 35 Barratt Simplified Measure of Social Status ..................................................... 36 Procedure ............................................................................................................... 38 Statistical Analyses ................................................................................................. 39 3 RESULTS ............................................................................................................... 40 Medication .............................................................................................................. 41 Analysis of Independent Variables .......................................................................... 44 Regression A nalyses ........................................................................................ 44 Mediation A nalyses .......................................................................................... 46
6 4 DISCUSSION ......................................................................................................... 54 Treatment History ................................................................................................... 54 Regression and Mediation Analyses ....................................................................... 58 Limitations ............................................................................................................... 59 Conclusions ............................................................................................................ 61 APPENDIX: QUESTIONNAIRE .................................................................................... 64 LIST OF REFERENCES ............................................................................................... 77 BIOGRAPHICAL SKETCH ............................................................................................ 87
7 LIST OF TABLES Table page 3 1 Summary of d escriptive d ata .............................................................................. 48 3 2 Summary of initial treatment provider sought ..................................................... 48 3 3 Summary of t reat ment ultimately received ......................................................... 49 3 4 Summary of t reatment ultimately received when p sychologist was initial provider .............................................................................................................. 49 3 5 Summary of t reatment ultimately received when p sychiatrist was initial provider .............................................................................................................. 50 3 6 Summary of t rea tment ultimately received when primary c are was initial provider .............................................................................................................. 50 3 7 Summary rates of therapy treatment by treatment provider ............................... 50 3 8 Summary rates of medication treatment ............................................................. 51 3 9 Correlation m atrix of independent variables ....................................................... 51 3 10 Correlation of independent variables with treatment latency .............................. 51 3 11 Comparison of means by g ender on dependent v ariables ................................. 52 3 12 Regression of treatment latency on demographics, symptom severity, parental anxiety, functional impairment, and family accommodation .................. 52 3 13 Regress ion of latency of treatment on overall symptom s everity and f amily a ccommodation .................................................................................................. 52 3 14 R egression of l atency of treatment on obsessive symptom severity and f amily a ccommodation ........................................................................................ 53 3 15 Regression of latency of t reatment on o bsessive symptom severity and functional i mpairment ......................................................................................... 53
8 Abstract of Dissertation Presented to the Graduate School of the University of Florida in Partial Fulfillment of the Requirements for the Degree of Doctor of Philosophy AN INVESTIGATION OF TREATMENT HIST ORY OF PEDIATRIC O BSESSIVE C OMPULSIVE D ISORDER AND PREDICTORS OF TREATMENT RECEIVED By Cary Jordan August 2011 Chair(s): John Kranzler Co Chair : Diana Joyce Major: School Psychology C ognitive behavioral therapy (CBT) with Exposure/Response Prevention (ER/P) [ CBT is the broader term and its subsequent use encompasses ERP. ] has been shown to be effective in treating symptoms of Obsessive Compulsive Disorder ( OCD) in pediatric and adult populations ( Abramowitz, 1997; Abramowitz, Whiteside, & Deacon, 2005; Chambless & Hollon, 1998; The Pediatric OCD Treatment Study [ POTS ] 2004) According to the Expert Consensus Guidelines f or children and adolescents with mild to moderate symptoms CBT alone is recommended as the first line treatment and CBT plus medicati on for adolescents with severe symptoms (March, Frances, Carpenter, & Kahn, 1997). However, little information is known about actual treatments received by pediatric patients in the community and factors associated with treatment seeking Considering onset of OCD symptoms typically occurs in adolescents (Kessler et al. 2005), w ithout effective treatment symptoms can worsen over time ( Eisen et al., 2006; Rapoport, Clary, Fayyad, & Endicott, 2005 ; Rasmussen & Tsuang, 1986) I t was important to understand help seeking behaviors in pediatric OCD and any other mediating variables that may predict access to quality treatment T his study examined
9 the treatment history of pediatric OCD and potential factors that may predict treatment seeking once OCD symptoms become problematic. Eighty three parents/caregivers of children with OCD participated R egression analyses were used to examine relationships between SES, gender, age, parental anxiety, functional impairment family accommodation, and symptom severity and t he dependent variable of treatment latency. Child's gender was the only variable that demonstrated a significant relationship. Treatment latency was significantly longer for girls than for boy s. A total of 14 different treatment variations were reported as received. T he most common treatments included 27% receiving CBT alone, 16% for medication and CBT combined, and 13% for talk therapy alone. Medication treatment was reported as a primary component of all treatment providers, with psychiatrists utiliz ing medication the most. Within this vein, medication side effects were numerous with f luoxetine having a total of nine reported side effects. It appears that although strides have been made with regards to dissemination of first line treatments, childr en continue to lack adequate access to CBT. Implications and directions for future research are discussed.
10 CHAPTER 1 REVIEW OF LITERATURE Overview of OCD Characteristics Obsessive compulsive disorder (OCD) is a complex psychiatric disorder. The two prim ary symptoms of OCD are obsessions and compulsions that work together in maintaining and exacerbating the severity of the disorder. Obsessions are intrusive and recurrent thoughts, ideas, impulses, or images that increase anxiety because they are incong ruent with self image and disturbing in nature (American Psychiatric Association, 2000). Compulsions are repetitive behaviors (e.g., checking, hand washing) or mental acts (e.g., counting, praying) that serve to reduce anxiety (American Psychiatric Associa tion, 2000). Patients with OCD are heterogeneous with regards to symptom presentation for both children and adults (McKay et al., 2006; Stewart et al., 2008). The Diagnostic and Statistical Manual of Mental Disorders Fourth Edition Text Revised (DSM IV TR American Psychiatric Association, 2000) defines the five areas of diagnostic criteria for OCD diagnosis : (a ) recurrent obsessions and compulsions; (b ) a t some point during the course of the disorder, the person has recognized that the obsessions or compulsions are excessive or unreasonable, but this does not apply to child diagnosis; (c ) o bsessions and compulsions are severe enough to be time consuming (e.g., more than 1 hour per day) or cause distress or significant impairment; (d ) i f another Axis I disorder is present, the content of the obsessions or compulsions is not restricted to it (e.g., preoccupation with food in the presence of e ating d isorders hair pulling in the presence of t richotillomania concern with appearance in the presence of b ody d ysm orphic d isorder; preoccupation with drugs in the presence of a Substance
11 Use Disorder; preoccupation with having a serious illness in the presence of h ypochondriasis preoccupation with sexual urges or fantasies in the presence of a p araphilia or guilty r uminations in the presence of major d epressive d isorder); (e ) t he disturbance is not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition (American Psychiatric Association, 2000). An im portant note for pediatric diagnosis for clinicians is the omission of insight (e.g., C riteria b ) related to recognizing their symptoms as excessive or unreasonable. Understanding the childs developmental level is important when applying DSM IV TR diagnostic criteria and assessing insight within OCD diagnosis. Many children with OCD may have considerably less insight into their OCD symptoms than adults and may not consider their obsessions and compulsions to be distressing or impairing to their daily liv es (American Academy of Child and Adolescent Psychiatry [AACAP], 1998). Children may internalize their symptoms and make it difficult for teachers and parents to detect signs of OCD or impairment (Storch et al., 2008b). Symptoms of OCD avoid detection of ten due to the potentially compliant and quiet demeanor of childr en with OCD. In light of these obstacles to diagnosis, an unknown number of children are not referred for treatment and remain unidentified (Flament, Koby, Rapoport & Berg, 1990). This is an important consideration related to the chronic nature of OCD and major impairment in childhood and as an adult if left untreated (Eisen et al., 2006). Currently, OCD is the fourth most common mental disorder affecting approximately 69 million Americ ans or 23% of the United States population (Kessler et al., 2005). Symptoms of OCD most often have an onset that occurs in adolescence
12 (Wewetzer et al., 2001). When considering the chronic course and functional impairment of the disorder, it is important for patients to have access to effective treatments early during symptom onset to prevent lifelong impairment. Symptom presentation within OCD is diverse with patients reporting a variety of obsessions and compulsions (McKay et al., 2006; Rasmussen & E isen, 1992). Symptoms in pediatric samples consist of obsessions related to: contamination, fear of harm, unwanted impulses, religious/moral beliefs, and need for symmetry (Storch et al., 2009). Compulsions consist of washing/cleaning rituals to prevent harm, reassurance seeking, ordering arranging, and repetitive routine behaviors (Scahill Riddle, Mc Swiggen Hardin, & Ort 1997). A high percentage of children with OCD have compulsions that are associated with specific obsessions (Masi et al., 2005) F or example, contamination fears are related to cleaning and washing rituals ; fear of harm to self or others is associated with checking and hoarding ; need for symmetry, exactness, or order commonly is related to straightening and counting, concerns with re ligious or moral conduct are related to confessing, praying and seeking reassurance ; and sexual or aggressive thoughts are associated with touching and tapping (Masi et al., 2005). Behavioral theory plays a role in maintaining obsessions through compulsi ons. The use of compulsions to reduce anxiety is a learned behavior through negative reinforcement by relieving anxiety. This cycle continues as intrusive obsessions raise a persons anxiety and compulsions are performed to reduce anxiety, further increas ing the likelihood of ritualistic behavior in the future and exacerbating symptom severity (Storch, 2005).
13 Symptom Impairment The course of OCD is chronic and unremitting without treatment, which can cause significant impairment and distress in a person s social, academic, and professional life (Eisen et al., 2006; Piacentini, Bergman, Keller, & McCracken, 2003; Rapoport et al., 2005; Rasmussen & Tsuang, 1986). Impairment of social functioning within OCD patients occurs in several areas of quality of lif e that encompasses ability to work, perform household duties, subjective sense of wellbeing, social relationships, and ability to enjoy leisure activities (Eisen et al., 2006). Within pediatric samples, quality of life impairment may present in similar ways that includes, difficulty with school work, inability to maintain friendships, and lack of engagement in enjoyable activities (Piacentini et al., 2003). It was shown that OCD patients report their obsessions to be the most debilitating to their emotional wellbeing and enjoyment of leisure activities (Eisen et al., 2006). Further research by others has shown the detrimental effects of OCD on academic, social, and family functioning within pediatric OCD (Flament et al., 1988; Leonard et al. 1993). Bett er understanding of how symptom impairment affects helpseeking behavior is needed for dissemination of efficacious treatment to both mental health and medical professionals. Comorbidity Given the impact of OCD on quality of life it is not uncommon for co morbid disorders to exist within patients diagnosed with OCD. Denys, Tenney, van Megen, de Geus, and Westenberg (2004) showed that in an adult OCD sample major depressive disorder was 10 times and personality disorders were three times more prevalent tha n in the general population. With the impact on daily functioning and overall impairment it is not unexpected to see such a high rate of depression within the OCD population.
14 Pigott, LHeureux, Dubbert, Bernstein, and Murphy, (1994) found that more than 5 0% of OCD patients met the criteria for at least one personality disorder. Denys et al. (2004) showed that 63% of their sample of OCD patients was diagnosed with a comorbid disorder. Within pediatric samples high rates of comorbidity have also been reported for major depression (1073%), anxiety disorders (2670%), tic disorders (1759%), disruptive behavior (1053%), attention deficit hyperactivity disorder (AD/HD; 1050%), and mania (27%) (Geller Biederman, Griffin, Jones, & Lefkowitz 1996; Geller et al. 2001a ; Geller et al., 2003a ; Hanna, Yuwiler, & Coates, 1995; Riddle, Scahill, King, & Hardin, 1990; Swedo, Rapoport, Leonard, Lenane, & Cheslow 1989). Comorbid pediatric OCD has been noted as treatment resistant with less favorable response to eith er CBT or medication treatments (Flament, Geller, Irak, & Blier, 2007; Geller et al., 2003a ; Grados, Scahill, & Riddle, 1999; Storch et al., 2008a; Storch et al., 2008b). Pediatric patients with depression may perceive the potential positive outcomes of t reatment less favorably and not engage as readily with their therapist (Storch et al., 2008a). Furthermore, difficulty maintaining attention in therapeutic session s and lack of completing therapy homework is a concern for comorbid AD/HD patients (Storch e t al., 2008a). Interestingly Storch et al. (2008a) found that children diagnosed with OCD and cormorbid anxiety had similar treatment response to children diagnosed only with OCD. Storch et al. (2008a) stated this result indicates that the diagnosis of multiple anxiety disorders may not adversely impact treatment outcomes when children are administered CBT. Symptoms of pediatric and adult OCD can vary greatly from one patient to the next in conjunction with comorbid conditions. Comorbidity is a salient
15 i ssue within both adult and pediatric OCD populations and requires accurate comprehensive assessment in order to guide effective treatment. Biological Theories of Etiology No specific biological link has been discovered for OCD, but many factors are belie ved to contribute to the disorder. Specific areas of the brain with relation to modified functioning of neurocircuitry include: orbitofrontal cortex, anterior cingulated, thalamus and basal ganglia (Kang, Kim, & Choi, 2004). Research regarding genetic links has shown higher rates of OCD among monozygotic twins when compared to dizygotic twins, with higher rates for immediate relatives who have OCD (Rassmussen, 1993). Additional biological studies have examined the link between onset of pediatric OCD sympt oms and streptococcal infections known as P ediatric A utoimmune N europsychiatric D isorder A ssociated with S treptococcal infections (PANDAS; Murphy & Pichichero, 2002; Swedo et al. 1998). Evidence suggest s that PANDAS infections cause an autoimmune respons e that may inadvertently affect the basal ganglia, causing dysfunctions that manifest as OCD symptoms, chorea, tics, and hyperactivity (Larson, Storch, & Murphy 2005; Snider & Swedo, 2004). Symptoms of PANDAS typically have a rapid onset and episodic course that includes symptoms returning for about 50% of children diagnosed (Murphy & Pichichero, 2002). Current research examining genetic links has shown some candidate genes are associated with OCD, but no specific genes have been identified as a cause for OCD at this time (Samuels, 2009). In sum pediatric OCD is a salient issue affecting many children. Knowing how to properly assess and treat is crucial for early identification and intervention.
16 Assessment Proper identification and assessment of pediatric OCD is important to facilitate early treatment. For those children presenting with anxiety symptoms a broad measure of anxiety may be a logical first step in assessment. The Multidimensional Anxiety Scale for Children (MASC; March & Parker, 1999) produces an overall anxiety score by summing the four individual scales of physical symptoms, harm avoidance, social anxiety, and separation panic. The MASC takes only ten minutes to administer and requires a skilled examiner. When considering broad clinician ad ministered measures of overall anxiety and time constraints on therapists, the MASC may be the superior option due to the reduced time to administer. Clinician administered and narrow measure instruments are designed to examine and rate current symptom s everity. Key elements of symptom severity measures (Keeley, Storch, Dhungana, & Geffken, 2007) include the amount of time consumed by attending to or engaging in obsessions or compulsions, to what extent the distress is associated with symptoms, and the d egree to which OCD symptoms have a functional impairment on important areas of a patients life. When examining narrow measures for pediatric OCD, the most widely used and gold standard for assessing symptom severity is the Children's YaleBrown Obsessive Compulsive Disorders Scale (CY BOCS; Scahill et al., 1997). The CY BOCS contains an OCD symptom checklist as well as symptom severity rating scales. The CY BOCS utilizes a clinician rating with a required trained observer through a semi structured inventory of OCD symptoms. It also measures both symptom severity and frequency and takes 1530 minutes to administer (Keeley et al., 2007).
17 Another important component in assessment of pediatric OCD is measuring the degree of family accommodation. Family accommodation is known to exacerbate symptom severity (Storch et al., 2007a). The Family Accommodation Scale for Obsessive Compulsive Disorder (FAS; Calvocoressi Lewis, Harris, & Trufan, 1995) consists of 13 items that assesses parent/caregivers awareness of childrens OCD symptoms and the degree that they enable compulsive behaviors over the past nine months and related stress among family members. Several areas of accommodation are assessed by the FAS that include the degree of reassurance from family members, items provided for performance of compulsions, reduction in expectations for the child, changes to regular family routines, and assistance with avoiding items, locations, or experiences that may be distressing (Storch et al., 2007a). When working with pediatric populations there are some important considerations with regards to assessment and diagnosis. Between the ages of 28 years, most children demonstrate various rituals (e.g., hoarding toys, superstitions, fear of cooties; Leonard, Swedo, R apoport, & Koby, 1989). Many obsessions and compulsions may relate to need to control environment and manage fears and anxiety. Symptoms are most evident at bedtime in many cases (Hyman & Pedrick, 1999). Further signs of OCD in children includes: frequent cleaning/hand washing resulting in red and chapped hands; long or frequent trips to the bathroom; avoidance of the playground, art supplies sticky substances, untied shoe laces due to fear they are contaminated; checking and redoing activities or behav iors over and over; hoarding of items in school desk; compulsively going over letters and numbers; taking excessive time to perform tasks; withdrawal from usual activities; excessive fears of things
18 happening to self or others; unusual fixations with numbers; excessive fears of making mistakes; persistent lateness; and persistent question asking or reassurance seeking; (McKay et al., 2006). Further consideration should include assessment of recent infections and be aware of the relationship between onset o f OCD symptoms and streptococcal infections (PANDAS). Treatment Currently CBT and medication are the most common treatments for pediatric OCD. Treatment that utilizes CBT will involve exposing an individual to an anxiety provoking stimuli or situations an d then preventing the person from avoiding or engaging in anxiety reducing behaviors (compulsions). The goal of CBT is to break the association between specific stimuli, situations, or thoughts that provoke anxiety, and the experience of ritualistic behavi ors, temporarily reducing anxiety (Kozak & Foa, 1997). The prevention of ritual engagement eliminates the negative reinforcement (e.g., anxiety reduction) that serves to maintain or exacerbate symptoms and allows patients to experience anxiety reduction naturally without the cycle that perpetuates the habitual engagement of rituals (Eisen et al., 2006; Koran, Thienemann, & Davenport, 1996). Exposures are conducted in a hierarchical fashion, beginning with easier/less anxiety producing items first and then progressively becoming more difficult. Cognitive restructuring may be used depending on the level of insight of the child and is typically conducted separately from exposures to avoid the creation of new rituals. Cognitive behavioral therapy is recommended to be used as the first line treatment of choice for both children and adults with mild to moderate symptoms severity (Abramowitz et al., 2005; Chambless & Hollon, 1998; March et al., 1997; POTS, 2004 ). Although CBT is considered a first line treatment, medication may be adjunctive for
19 more severe symptom presentations or treatment refractory patients and prove beneficial at reducing symptom severity (March et al. 1997; POTS, 2004 ). Cognitive Behavioral Therapy with Exposure and Response Prevention Many studies demonstrate the efficacy of CBT for treating pediatric OCD ( Abramowitz et al. 2005; Benazon, Ager, & Rosenberg, 2002; Piacentini, Bergman, Jacobs, McCracken, & Kretchman, 2002 ; POTS, 2004 ). Piacentini et al. (2002) treated a sample of 42 childre n diagnosed with OCD using CBT Results show e d a 79% response rate overall, with 85% for CBT alone and 73% for combined CBT and concurrent medication. Over all symptom reduction was also significant for the CBT and combined groups (44% vs. 46%, respectivel y). In a small sample of 16 pediatric OCD patients Benazon et al. (2002) found similar results with 70% response rate and slightly more than 50% reduction of symptom severity overall. Cognitive behavioral therapy for pediatric OCD also has demonstrated superiority over other psychological treatments for anxiety disorders in very young populations. Freeman et al. (2008) examined the efficacy of CBT versus relaxation training (RT) in a sample of 42 children between the ages of five and eight Eleven out of 16 p articipants (69%) who completed treatment in the CBT group experienced clinical symptom remission compared to only three out of 15 (20%) in the RT group. Participants who were treated with CBT showed a significant mean reduction in Children's Yale Brown Obsessive Compulsive Scale ( CY BOCS ) score of 8. 6 SD = 7.8, versus the RT group (M = 4.6, SD = 6.7). Results of Freeman et al. (2008) demonstrate the effectiveness of CBT for younger children diagnosed with OCD. Overall CBT for pediatric OCD is ef fective for all ages of children. Response rates of CBT with children have been reported as high as 90% (March, Franklin, Nelson, &
20 Foa, 2001), superior to rates for medication monotherapy (Geller et al., 2003b ; POTS, 2004) Additionally, symptom reduction rates generally are in the 25% to 70% range ( Barrett, Farrell, Dadds, & Boulter, 2005; Freemen et al., 2008) exceeding rates for medication alone treatment regimens ( Geller et al., 2003) Children also appear to maintain their treatment gains well with CBT at 12 or 24 months post treatment follow up ( Barrett et al., 2005; March, Mulle, and Herbel, 1994; Piacentini, Gitow, Jaffar, & Graae, 1994). Additionally OLeary Barrett, & Fjermestad (2009) provide support for the long term durability of CBT observ ing significant treatment gains at a seven year follow up. Shalev et al. (2009) showed promising results for the effect of CBT on children and families with reduced OCD symptoms up to 36 months post treatment and continued decrease in parental accommodati o n of OCD symptoms Thus, in addition to demonstrating long term durability, continued effects for the family as whole may be associated with CBT for pediatric OCD. Medication Early research with adult OCD examin ing the effects of the tricyclic antidepress ant clomipramine showed only modest reduction in OCD symptoms when used as a stand alone treatment (See Geller et al., 2003, for review) but it may be more effective than other more selective serotonin reuptake inhibitors ( SSRIs ). Foa et al. (2005) compar ed clomipramine to CBT, placebo (e.g., sugar pill) and combined treatment. Results showed the superiority of CBT over clomipramine with an 86% response rate for CBT, 79% for combined, 48% for clomipramine and 10% for placebo. clomipramine response was modest but more effective than placebo. Currently clomipramine is prescribed typically after lack of response to an SSRI due to a less than favorable side effect profile (Stahl & Stahl, 2000).
21 Currently only three SSRIs are approved by the FDA for treatment of pediatric OCD: fluoxetine, fluvoxamine, and sertraline. Although there are several more SSRIs available, others are not approved at this time for pediatric OCD populations due to the lack of clinical trials conducted with these patients. These unapproved medications are often prescribed to children anyway based on adult research data in what is referred to as off label use or prescribing without guidance for child dosages and side effects Furthermore, childrens rates of metabolism are different and prevent generalization from adult studies. Off label prescription use in children should be done with caution and parents need to be informed when such practices are employed regarding any potential risks or adverse side effects (Stahl & Stahl, 2000). Overall dosages of SSRIs typically are higher with OCD patients for effective response rates (Fineberg & Gale, 2005) when compared to other disorders (e.g., depression). The elimination of serious side effects of previous medications (e.g., tricyclics) has greatly increased the acceptance and widespread use of SSRIs (Fineberg & Gale, 2005). SSRIs primary mechanism of action involves increasing the amount of serotonin (5HT) available through the inhibition of 5HT reuptake (Goodwin, 1996; Stahl, 1998). O ver the past 15 years, several studies have examined the efficacy of SSRIs in reducing symptom severity of pediatric OCD symptoms. One of the earliest of these stu dies was conducted by Riddle, Scahill, King and Hardin (1992) using a relatively small samp le size for both E xperimental ( n = 7 ) and C ontrol ( n = 6). They examined the effects of fluoxetine over an 8 week trial that included recording a baseline and posttreatment CY BOCS score for both groups. At the end of 8 weeks of treatment the CY BOCS total score decreased 44% (n = 7) for the Experimental group, compared to
22 27% (n = 6) for the Control group. In another study on the efficacy of fluoxetine by Geller et al. (2001) included a much larger sample size of E xperimental (n = 71 ) C ontrol (n = 32). T reatment effects were studied over 13 weeks with the same design and relative baseline CY BOCS scores as Riddle et al. (1992). Results showed an overall 9.5 point reduction in CY BOCS scores for the E xperimental group and 5.2 points for the C ontrol. Res ults of these two studies on fluoxetine indicate its efficacy at reducing overall symptom severity and frequency and may highlight therapeutic effects for prolonged treatment (e.g., 8 weeks versus 13 weeks). However, only one of these two stud ies included a modest sample size, and generalizations for the population at large may be limited due to the small number of participants Research on fluvoxamine has shown similar results as fluoxetine (Geller et al., 2001; Riddle et al., 1992) Riddle et al. (200 1) examined the effects of fluvoxamine on 120 children randomly assigned to E xperimental (n = 57) and C ontrol (n = 63) groups for a 10 week treatment period. The baseline mean CY BOCS score s were 24.2, SD = 4.4 for C ontrol and 24.2, SD = 4.8 for E xperimen tal, indicating moderate to severe symptom severity for all participants Results showed an overall 6point reduction in CY BOCS scores for the experimental group and 3.3 points for the control with a significant difference between groups. March et al. ( 1998) examined sertraline with 187 children randomly assigned to E xperimental (n = 92) and C ontrol (n = 95) groups over a 12 week treatment period. The baseline mean CY BOCS score was 23. 4 for the E xperimental group and 22.5 for the C ontrol group, indicating moderate to severe symptom severity. Results showed an overall 6.8 point reduction in CY BOCS scores for the E xperimental grou p and 3.4 points for the C ontrol group with a significant
23 difference between groups. Results of studies on fluvoxamine and se rtraline have yielded similar conclusions and indicated at least modest symptom severity and frequency reduction (e.g., approximately 3045%) when compared to placebo/control groups. Although there are several studies examining SSRIs superiority when comp ared to control groups, results are not as favorable for using them as a first line treatment when they are compared CBT (POTS, 2004) The most comprehensive study of SSRIs and CBT was conducted by The Pediatric OCD Treatment Study (POTS, 2004). They exam ined sertraline through a multisite randomized design with four groups : medication alone, CBT alone, combined CBT and medication, and placebo with 28 pediatric participants per group. Baseline mean CY BOCS scores for all groups fell within the moderate t o severe range. Treatment was conducted for 12 weeks and CY BOCS scores were collected at 4 week intervals throughout the 12 week treatment. At the 12 week follow up the mean CY BOCS point reductions for each group w ere; CBT 12, medication alone 7, combined treatment 12.6, and 3.7 for the placebo group. Remission rates were also calculated if participants scored below 10 points on the CY BOCS. Remission rates for each group were 54% for the combined CBT medication group, 39% for CBT alone, 21% for medication alone, and 4 % for placebo. Effect sizes for the groups were 1.4 for combined, .97 for CBT alone, and .67 for medication alone. POTS results indicate that children and adolescents with OCD should be treated with combined medication and CBT or CBT alone as a first line treatment. However, due to variations in side effects, CBT alone may be the best first line treatment for pediatric OCD. Further support from the OCD Expert Consensus Guidelines (March et al., 1997) recommend CBT as the
24 first line trea tment for OCD as well. One important issue as noted by Thomsen (2000) is how symptoms of OCD typically return to pretreatment levels after medication is discontinued. Medication Side Effects Medication treatment for pediatric OCD has been show n to be modestly effective at reducing symptom severity and frequency. Recently, more attention has been focused on adverse side effects associated with SSRI treatment in children, further cautioning professionals on its use as a first treatment option (Murphy, Segarra, Storch, & Goodman, 2008; Walkup & Labellarte, 2001). Behavioral activation is a common side effect of SSRI treatment in children. It is defined as a worsening of clinical presentation, increase in activity level, poorer impulse control, hyperactivity talking, and meanness (Murphy et al., 2008; Walkup & Labellarte, 2001). Activation usually occurs early in treatment with SSRIs, typically within the first few weeks (Murphy et al., 2008; Walkup & Labellarte, 2001). Akathisia or motor restlessness is also common As Murphy et al. (2008) stated, this symptom should not be misinterpreted as worsening of symptoms. Mania or symptoms of euphoria, grandiosity, and hypersexuality can occur with SSRI treatment and highlight the importance of monitoring behavior during the first few weeks of treatment due to potential danger of harm to self and others by acting on impulsive urges (Goodman, Murphy, & Storch, 2007). Not to be confused with mania are symptoms of "celebration" which when a child will participate in more activities due to OCD symptom reduction (Walkup & Labellarte, 2001). Typically, this is not an issue or concern but may lead a parent to believe that their child may be having a manic episode (Walkup & Labellarte, 2001). Parents should receive adequate psychoeducation related to monitoring their childs behavioral changes. A pathy may also occur with SSRI
25 treatment but is different than an increase in depressive symptoms (Murphy et al., 2008; Walkup & Labellarte, 2001). Murphy et al. (2008) sugg est ed a reduction in dosage and augmentation with another anti depressant may be needed, since the therapeutic range may no longer be achieved with the initial SSRI. The most concerning and severe form of adverse side effects of SSRIs is related to increased suicidal ideation within pediatric populations. The Medicines and Healthcare Products Regulatory Agency (MHRA) in England recently banned the use of antidepressants with the exception of fluoxetine, for use with children in 2003 as a response to concern of increased suicidal ideation (MHRA, 2003) In 2004, the FDA issued a black box warning that was placed on all antidepressant prescription labels regarding risk of suicidality within pediatric patients (Murphy, et al., 2008). In a review by Hammad, Laughren, and Racoosin (2006), 4000 participants were studied in trials of antidepressants including all SSRIs approved for pediatric OCD. Of the sample 4% showed increased suicidal behaviors compared to 2% who were administered only placebo. The risk of suicide was the highest in the first 19 days of treatment with antidepressants. In a metaanalysis Bridge et al. (2007) separated antidepressant treatment and suicidal ideation by presenting condition. With regards to treatment studies of SSRIs and pediatric OCD, there was a 1% rate of suicidal ideation/attempt for treatment groups compared to .3% for the placebo groups. There were no completed suicide attempts in any of the studies reviewed by Bridge et al. (2007). Overall, research examining the ris k of increased suicidal ideation with antidepressant treatment appears to be highe r with Major Depressive Disorder (MDD) than with either nonOCD anxiety disorders or OCD (Bridge et al., 2007; Hammad et al.,
26 2006). An important consideration to note is that although the increased suicidal risk was small, the Food and Drug Administration ( FDA ) has recommended that children starting treatment with antidepressants be monitored closely in order to quickly identify changes in behavior and increased symptom sev erity (Murphy et al., 2008). Data have shown an overall decrease in suicide rates during the period of highest antidepressant prescribing (Olfson, Shaffer, Marcus, & Greenberg, 2003) However, following the FDAs block box warning Gibbons et al. (2007) f ound an increase in suicide rates after a decrease in prescribing of SSRIs. Increased suicide risk is an important consideration for SSRI treatment of pediatric OCD and other psychiatric conditions, but a comprehensive reduction in medication treatment for all children may potentially have harmful consequences and inadvertently increase suicide rates (Gibbons et al., 2007). SSRIs have been demonstrated to be effective in reducing overall symptom severity of pediatric OCD (Geller et al. 2001; March et al. 1998; POTS, 2004; Riddle et al., 2001 ; Riddle et al., 1992). However, rates of reduction have only been as high as 45% (in one study) and fall short of rates demonstrated by CBT alone or combined therapy (>50%). In addition, remission rates of OCD sy mptoms for CBT or combined therapy exceed medication alone (POTS, 2004). Although SSRI treatment is not as efficacious as CBT or combined treatment, it does reduce overall symptom severity and frequency and is safer with fewer side effects than previous m edication alternatives (e.g., non selective reuptake inhibitors). Expert consensus and randomized controlled studies recommend that CBT alone may be the most conservative best first line treatment option with pediatric OCD populations (March et al., 1997; POTS; 2004 ). However, SSRI treatment for pediatric OCD may be the best alternative in situations
27 where access to a qualified CBT therapist is unavailable. Considering this information it is important that we better understand the types of treatments recommended to parents of children with OCD. In addition, it is important to know which professional those recommendations are coming from, in order to better disseminate evidence based treatment information. More broad dissemination of effective treatments c ould increase the time for accessing quality treatment and reduce duration of pediatric OCD symptoms. Family Accommodation With regards to children, there are several studies examining the role the family plays in treatment outcomes and exacerbation or mai ntenance of symptoms (Barrett, Healy Farrell, & March, 2004; Storch et al., 2007b). Family accommodation is related to family members participating in or encouraging rituals, providing reassurance (e.g., answering questions or giving confirmation that ev erything is ok), modification of routines (e.g., changing the way activities are done in order to reduce anxiety), providing objects (e.g., hand sanitizer), and assisting in completion of tasks (Storch et al., 2007b). Results from Storch et al. (2007b) s howed that parents most often offered their child reassurance about unsubstantiated obsessions or fears and participated in rituals. Family accommodation was positively correlated with reports of parents related to child functional impairment at home, wit h slightly higher correlations than those with school or social domains. F amily accommodation was significantly related to both OCD symptom severity and child functional impairment (Storch et al., 2007b) Additionally family accommodation was shown to me diate the relationship between OCD symptoms severity and parent rated child functional impairment. As Steketee and Van Noppen (2003) noted, even though parents do not mean any harm by providing accommodation,
28 their action may cause increased impairment that impacts the family as a whole negatively B y participating in rituals and reinforcing them a child's symptoms can worsen and cause distress to them and their family. Results of these studies underscore the important role family accommodation plays in s ymptom severity and maintenance of symptoms within pediatric OCD. Thorough treatment for pediatric OCD should therefore include family members in order to facilitate treatment and understand the role of family members within the disorder. Currently no d ata exists with regards to how family accommodation may directly affect the length of time between manifestation of problematic symptoms and parents seeking treatment for their child. Treatment protocols Treatment of pediatric OCD using CBT has been conducted in two empirically supported protocols, either weekly for 14 sessions or intensive 3 week 1 4 session programs (Lewin, Storch, Merlo, Murphy & Geffken, 2005; Storch et al., 2007b ). Storch et al. (2007b ) compared CBT administered in daily intensive or weekly sessions and showed both treatment approaches were efficacious The Intensive group had a 63% reduction in overall symptoms and 50% for the Weekly group. There was a slight advantage shown for the I ntensive group versus Weekly group at post treatm ent, but no difference between treatments at follow up. The differences in post treatment and follow up for intensive treatment highlights the need for additional care following t ermination (Storch et al., 2007b). Similar results have been found with Abr amowitz, Foa, and Franklin (2003) who showed that both intensive and weekly approaches have merit and achieve similar results with regards to patient outcomes, but intensive may be a more efficient means of treatment Daily sessions over a three week peri od may be more favorable for patients who are seeking a lower time commitment and are willing to
29 engage in treatment daily Abramowitz et al. (2003) recommend ed that treatment, when conducted weekly could be varied in terms of interval between sessions i n order to enhance generalization and practice of exposure skills. Storch et al. (2007b ) included at least one family member in all CBT sessions. Their results showed reductions in family accommodation and impairment related to OCD within the intensive tr eatm ent group. Storch et al. (2007b) points out that their results are consistent with those of Barrett et al. (2004) with regards to a family based approach for treating pediatric OCD and reinforce the notion that inclusion of family members in treatment may have advantages over individual based treatment. Both intensive and weekly approaches to treating OCD are supported, but involvement of parents and family in treatment appears to be a predictor of greater reduction in symptom severity and maintaining of gains from treatment. Empirical support remains for CBT with E/RP as the first line treatment for pediatric OCD (March et al., 1997; POTS, 2004). Barriers to treatment There is an abundance of research supporting CBT for pediatric OCD, but access t o qualified professionals remains a salient concern (Goodwin, Koenen, Hellman, Guardino & Struening, 2002) This lack of access to qualified therapists is highlighted as one of the main barriers to quality treatment ( American Academy of Child and Adolescent Psychiatry [ AACAP] 1998). Furthermore, in a study by Blanco et al. (2006) United States psychiatrists were surveyed regarding types of first line treatments given to OCD patients. Results showed that most adult patients did not receive CBT and it wa s broadly defined by the survey as "CBT themes" without inquiring about exposure and ritual prevention procedures. The broad definition of CBT may have allowed for an inflated rate of reported CBT use by psychiatrists. This is important considering the
30 data from Blanco et al. (2006), that only 7.5% of U.S. psychiatrists reported using CBT themes in therapy and the actual use of evidencebased CBT may have been far less. Although CBT is the recommended first line treatment for pediatric OCD ( Abramowitz et al. 2005; POTS, 2004; Ch ambless, & Hollon, 1998; March et al. 1997), it remains a concern that often times it is not the initial treatment. This information highlights not only the lack of qualified professionals who can treat pediatric OCD, but the lac k of use by professionals of CBT in the initial phase of treatment. An even greater issue than access to qualified therapists is the large percentage of OCD patients that do not seek treatment or obtain treatment after many years of suffering with the di sorder (Kennedy & Schwab, 1997; Shapiro, 1984). Hollander et al. (1997) discussed the mean time between onset of symptoms and access to efficacious treatm ent is approximately 17 years. Shapiro (1984) showed that only 35% of OCD patients received speciali zed mental health treatment. Only 40% of adults in Goodwin et al. (2002) ever received treatment. More important ly a majority of the patients experienced significant impairment in daily functioning and onefourth reported suicidal ideation with three ou t of four reporting major depression or another anxiety disorder. The most significant results of Goodwin et al. (2002) was 40% of the sample reported that the reason for not seeking treatment in the past was lack of knowledge of where to find help. Othe r mitigating factors for seeking treatment were level of symptom severity and insurance coverage. Additionally Goodwin et al. (2002) found that strength of family relationships and financial resources are considered crucial factors related to pursuing treatment. They further found that only 6% of participants reported that they did not feel treatment would help. These findings are important because they show
31 that OCD patients want and believe treatment will help, but may lack the knowledge of how to acc ess it. More concerning are results of Freiheit Vye, Swan & Cady (2004) showing that nearly 10 years after APAs Division 12 (Clinical Psychology) Task Force on Promotion and Dissemination of Psychological Procedures ( Chambless & Hollon 199 8 ) relative ly little ha d changed with regards to increased utilization of CBT amongst psychologists. Only little more than onethird of psychologists reported using CBT for OCD. Freiheit et al. (2004) point out that even though the effectiveness of CBT is well established, adoption within the psychology field remains a major concern. Considering that 80% of adults with OCD have symptoms onset in childhood, it is important to examine all potential barriers to accessing effective treatment, but little is known about p ediatric populations at this time. Dissemination of evidencebased treatments for OCD remains an issue within the mental profession and community. Kettlewell (2004) stated that evidencebased treatments provide guidance to better serve patients and we hav e a moral obligation to select the most effective treatments based on research. Furthermore treatments that have been demonstrated through research to be effective are not employed by most practitioners. Kettlewell (2004) recommended that practitioners need to stay informed about evidencebased treatments, to collaborate with researchers or conduct and support effective research, and form partnerships with other practitioners and applied programs. Cognitive behavioral therapy alone or combined with SSR Is as a first line treatment for pediatric OCD is widely supported in the literature (Abramowitz et al., 2005; Geller et al., 2003b ; POTS, 2004). Although CBT is the first line treatment many
32 patients do not have access or do not receive such treatment ( Blanco et al., 2006; Goodwin et al., 2002) When deciding on treatment, access to qualified professionals can assist in deciding to utilize intensive or weekly approaches (Storch, 2007b ). After selection of a treatment approach is completed it is important to involve the family in therapy to improve outcomes, address accommodation, and improve generalization (Storch, 2007a ). Developmental level of pediatric patients is another careful consideration w hen tailoring treatment (Keeley, Storch, Merlo, & Geffken 2008). Further addressing the barrier of lack of knowledge of how to access qualified professionals to treat pediatric OCD should be a primary concern and focus of future research (Goodwin et al., 2002). Dissemination of evidencebased treatments for OCD remains a crucial issue within professional practice and warrants continued development and research (Kettlewell, 2004). In summary pediatric OCD is a disorder that has significant impairment on all aspects of a childs life. Without treatment, symptoms only continue to worsen through repeated negative reinforcement of ritualistic behavior. Pediatric OCD not only impairs the life of the child, but has major impact in the family unit through accommodation, and parents suffering through seeing their c hild deal with debilitating symptoms. An average of 17 years to receive treatment (Hollander et al., 199 7) is a situation within the mental health profession that deserves immediate attention and remediation. Research Questions for Investigation While su pport for treatment options for OCD in children and adults has been established, the literature has several gaps within the understanding of treatment seeking behaviors and factors related to this in pediatric OCD. Currently only one study has examined the types of treatment received by adults diagnosed with OCD who
33 were seen by a United States psychiatrist (Blanco et al., 2006). At this time there are no known studies examining the treatment history of pediatric OCD patients or predictors of treatment s eeking The primary goal of this study was to examine factors associated with treatment seeking behaviors in parents of children with OCD, types of treatment received, and variables affecting when treatment is sought by parents. Secondary goals include gathering information on how treatment was delivered (e.g., how often seen) and specifics of medication treatment such as type, dosage, and side effects. The pr i mary hypotheses are as follows: 1. What professionals do parents receive treatment from and w hat treatments are delivered most often by each professional? 2. What are the specific data regarding the treatment provided? 3. What variables predict latency between problematic OCD symptoms and seeking treatment? 4. How does the degree of family ac commodation and symptom severity relate to latency between problematic symptoms and seeking treatment? 5. How does the degree of functional impairment and obsessivecompulsive symptom severity relate to latency between problematic symptoms and seeking tr eatment? 6. How does the degree of functional impairment and compulsion severity relate to latency between problematic symptoms and seeking treatment? 7. How does the degree of functional impairment and obsession severity relate to latency between probl ematic symptoms and seeking treatment?
34 CHAPTER 2 METHODS AND PROCEDURES Participants During the fall of 2009 and spring 2010 semesters a community sample of 83 parents who self report having a child diagnosed with Obsessive Compulsive Disorder ( OCD) and have either sought treatment in the past or are currently engaged in treatment were solicited through the use of a notice on parents of children with OCD Yahoo group, International Obsessive Compulsive Foundation and OCD Chicago websites, and referrals fr om clinic staff at two OCD clinics in Florida. Parents of existing and new pediatric OCD patients seen at Shands Behavioral Health Unit in Gainesville, Florida and The Rothman Center for Neuropsychiatry in Saint Petersburg Florida were solicited through a flier asking them to complete a brief online survey regarding their childs OCD symptoms and treatment. Staff at the clinics provided a link to the survey at the request of the participant. Participants then completed a brief onli ne questionnaire through SURVEYMONKEY.com. Of the parents who participated, 79 were the mother of the child, 2 father, 1 grandmother, and 1 listed as other. Ninety two percent of participants identified as White/non Hispanic, 4 White/Hispanic, 1 Hispanic, 1 Black/African Am erican, 1 Asian, and 1 Other. Child's gender was reported as 38 male (46%) and 45 female (54%) respectively. Measures Children's Yale Brown Obsessive Compulsive Disorders Scale Children's YaleBrown Obsessive Compulsive Disorders Scale (CY BOCS; Scahill et al., 1997) contains an OCD symptom checklist as well as symptom severity rating
35 scales. The CY BOCS utilizes a clinician rating with a required trained observer through a semi structured inventory of OCD symptoms. It also measures both symptom severit y and frequency and takes only 1530 minutes to administer (Keeley et al., 2007). Scahill et al. (1997) reported high internal consistency for CY 0.87). Interrater agreement ranged from good to excellent with interclass correlations coefficients ranging from .66.91 (Scahill et al., 1997). Convergent and divergent validity of the CY BOCS has been established through stronger association with obsessional measures than measures of overall anxiety (e.g., Revised Children's Manifest Anxiety Scale [ RCMAS ] ) or depression ( e.g., Child Depression Inventory [ CDI ] ) (Scahill et al., 1997). Research conducted by Storch et al. (2004) has further confirmed that the CY BOCS is both a reliable and valid measure for assessing OCD symptomatology in pediatric populations with internal consistency of parental report for total score and obsession severity at 86 and .83 respectively. In addition, Storch et al. (2004) found internal consistency scores for the compulsion severity scale in the The CY BOCS demonstrated excellent convergent and divergent validity (Storch et al., 2004). Results of Storch et al. (2004) showed that the CY BOCS was significantly correlated with the similar measures of Multidimensional Anxiety Scale for Children Total Score (MASC) and Tourettes Disorder ScaleParent Rated (TODS) OCD factor and only mo derately with scores on the Child Depression Inventory and clinician ratings of aggression and AD/HD symptoms. Only the 10 items that yield a global score were used in the current study. Family Accommodation Scale for Obsessive Compulsive Disorder Family Accommodation Scale for Obsessive Compulsive Disorder (FAS; Calvocoressi et al., 1995) assesses parent/caregivers awareness of childrens OCD
36 symptoms and the degree that they enable compulsive behaviors. This measure contains good psychometric properties with inte Interrater agreement was excellent with interclass correlations coefficients ranging from .75.95. The FAS also has demonstrated excellent convergent and discriminate validity Calvocoressi et al. (1995) found that, t he FAS w as significantly correlated with the similar measures of Patient Rejection S cale and McMaster Family Assessment Device subscales and not correlated with scores on the behavioral control sub scales of the McMaster Family Assessment scale. Furthermore, the FAS correlated significantly with similar sub scales on the Questionnaire on Resources and Stress for Families With Chronically Ill or Handicapped members (Calvocoressi et al., 1995). Beck Anxiety Inventory Beck Anxiety Inventory (BAI; Beck, Epstein, Brow n, & Steer, 1988; Beck & Steer, 1990) assesses severity of anxiety in adult populations. The BAI consists of 21 items representing common anxiety symptoms (e.g., numbness, fear of bad events, hands trembling) inquiring about how the person has been feeling during the past week. This measure contains good psychometric properties with internal .92 .94. Testretest reliability was excellent at 30 days with coefficients ranging from .67 .75. The BAI has also demonstrated excellent convergent and discriminate validity (Beck et al., 198 8; Fydrich, Dowdall & Chambless, 19 92). The BAI was shown to significantly correlate with the Diary Anxiety measure and not with Diary Depression measure (Fydrich et al. 1992) Barratt Simplified Measure of Social Status Barratt Simplified Measure of Social Status ( BSMSS ; Barratt, 2006) is a broad measure of Social Economic Status ( SES ). Hollingshead ( 1975) initially constructed a
37 simple measure of social status upon which this measure is modeled. The BSMSS measures SES based on marital status, employment status, highest educational attainment, and occupational prestige. The list of occupations was updated in response to r esults of Davis, Smith, Hodge, N akao, and Treas (1991). The BSMSS yields a singular score ranging from 866 by adding t he educ at i o n and occupati on scores. Reliability and validity data were not reported in the development of the BSMSS by the authors. However recent studies using this scale have found SES to be a significant covariate with participants reports of symptoms decreasing as their SES scores increased ( Cur rier, Hermes, & Phipps, 2009). In addition the BSMSS also identified significant differences between groups based on SES scores ( Currier et al. 2009; Jurbergs, Long, Ticona, & Phipps, 2009). Child Sheehan Disability Scale Parent report form Child Sheehan Disability Scale Parent report form (CSDS P ; Whiteside (2009) is adapted from the Shee han Disability Scale (SDS; Shee han, 1986) for assessing child anxiety impairment is a six item scale measuring the degree to which parents perceive their childs anxiet y symptoms interfere with school, social, and family functioning (e.g., functional impairment) Items on the scale are measured using an 11 point Likert type scale with scores ranging from 0 = not at all to 10 = extremely. The original version of the SDS d emonstrated good internant cons truct validity (Leon, Olfson, Portera, Farber & Sheehan, 1997). Analyses by Whiteside (2009) showed the adapted measure contains good convergent and divergent validity when compared to other child impairment measures (Whiteside, 2009). The CSDS P significantly correlates with the Family Assessment Device (FAD), Spence Childrens
38 Anxiety Scale (SCAS) Spence Childrens Anxiety Scale Parent Report (SCAS P) and Behavior Assessment System for Children parent rati ng scales ( BASC ) internalizing scales. Divergent validity of the CSDS P was demonstrated by non significant correlations with the BASC externalizing scales and behavioral symptom s index (Whiteside, 2009). Procedure Each participant filled out an online survey at the website SURVEYMONKEY.com, which they accessed through a link on the parents of children with OCD Yahoo group, Obsessive Compulsive Foundation (OCF) or OCD Chicago websites, or using a link provided by their treatment clinic. Participants reported information regarding their childs treatment history, OCD symptoms and severity, family accommodation, functional impairment, parental anxiety, and SES. Participants initially had to read and complete an informed consent before being able to proceed to filling out the questionnaire. The completion of the questionnaire was estimated to be approximately 10 to 15 minutes in duration. They were asked to complete a brief demographic section that inquires about information regarding which parent was com pleting the form, age, gender, and race of child. Participants reported information regarding OCD treatment history regarding latency between onset of problematic symptoms and seeking treatment, what type of professional sought for treatment, what treatmen t ultimately received (e.g., CBT with exposures, CBT without exposures, Talk therapy, medication alone or in combination with other treatments), and specific information regarding medication if prescribed (e.g., type, dosage, and side effects) and how often seen for treatment. The following questionnaires were also completed: The Barratt Simplified Measure of Social Status (BSMSS), Children's YaleBrown Obsessive
39 Compulsive Disorders Scale (CY BOCS; Scahill et al., 1997), Family Accommodation Scale for Obs essive Compulsive Disorder (FAS; Calvocoressi et al., 1995), Child Sheehan Disability Scale (CSDS P ; Whiteside, 2009), and Bec k Anxiety Inventory (BAI; Beck et al. 1988; Beck & Steer, 1990). The entire questionnaire is included in A ppendix A. Statistica l Analyses Before evaluating study hypotheses, preliminary analyses were conducted to screen d ata for normality and potential outliers D escriptive statistics were calculated to report means of independent and dependent variables, examine sample characteri stics, and i nternal consistency of all included measures were examined using Cronbachs alpha. If assumptions of statistical procedures were violated, the corrective procedures were applied where indicated (e.g., transformations for nonnormality). In order to assess if patients differed in the type of initial treatment provider sought, a chi square test for goodness of fit was performed. Multiple linear regression was used as an analytic framework with all variables entered into the model simultaneously. Me diation models based on Baron and Kenny (1986) were used to identify potential ly significant mediating relationships between independent and dependent variables. The Sobel test (Sobel, 1982) was utilized to assess reliability of mediations.
40 CHAPTER 3 RES ULTS Primary variables yielded the following results of treatment latency days (M = 579.74, SD = 777.1 0 ), obsessive compulsive symptom severity ( Children's YaleBrown Obsessive Compulsive Disorders Scale [ CY BOCS ; ] M = 24.84, SD = 7.48), functional impairm ent ( Child Sheehan Disability Scale [ CSDS P ] ; M = 32.95, SD = 11.8), family accommodation ( Family Accommodation Scale [ FAS ] ; M = 24.83, SD = 12.58), parental anxiety ( Beck Anxiety Inventory [ BAI ] ; M = 13.95, SD = 12.81) and Social Economic Status ( SES) ( Barratt Simplified Measure of Social Status [ BDMMS ] ; M = 48.86, SD = 9.81) D escriptive data are presented in Table 3 1 With regards to init ial treatment provider sought, participants reported 52% psychologist, 33% psychiatrist, 14% primary care/pediatrici an, and 1% nurse practitioner ; the se results are presented in Table 3 2 Participants reported a total of 14 different combinations of treatment ultimately received f rom practitioners Three treatment variations accounted for slightly more than half of all combinations reported. Twenty seven percent of participants reported ultimately receiving CBT alone, 16% for medication and Cognitive Behavioral Therapy ( CBT ) combined and 13% for talk therapy alone C omplete results are presented in T able 3 3 Diffe rences were found in the type of initial type of treatment provider sought, 2(3) = 48.23, p < .001. Psychologists were reported as initial treatment provider 52% of the time with a total of 11 different combinations of treatment ultimately provided. Of the treatments given by psychologist s the primary types were CBT alone (37%), medication and CBT combined (19%), and talk therapy alone (12%) ; complete results are presented in T able 3 12 Psychiatrists were reported as the initial treatment provider 33% o f the time with a total of nine different combinations of treatment ultimately
41 provided. Slightly more that 60% of all treatments provided by psychiatrists utilized medication either alone or combined with another form of treatment, complete results are pr esented in T able 3 5 Primary care physicians were reported as the initial treatment provider 15% of the time with a total of seven different combinations of treatment ultimately provided. Primary care physicians were more likely to provide CBT alone (27% ), medicatio n and CBT combined (16%), talk therapy alone (13%) and medication, talk therapy, and CBT combined (11%) than other treatments, complete results are presented in T able 3 6 Nurse practitioners were reported as the initial treatment provider 1% of the time and provided CBT alone as the treatment. Participants also reported how often their child was seen for either therapy or medication treatment. Psychologists provided therapy at rates of 67% weekly, 19% bi weekly, 9% daily with 5% not receivi ng treatment. Psychiatrists rates of therapy treatment were 67% weekly, 11% bi weekly, and 7% for monthly, daily, or no treatment. Primary care physicians provided therapy at rates of 36% for weekly and bi weekly and 9% for monthly, daily, and no treatme nt. C omplete results for all treatment providers rates of th erapy and medication treatment are presented in Table 3 7 Rates of medication treatment were 38% no medication given, 2% daily, 5% weekly, 6% bi weekly, and 49% monthly, results are presented in Table 3 8 Medication Participants reported a variety of prescription medication history for their children with specific medications, respective dosages, and side effects per prescription. Serotonin r euptake inhibitors (SRIs) were reported most often. O ne person reported clomipramine with a dosage of 100mg and no side effects disclosed. Fifteen participants used citalopram with dosage of 15mg and side effect frequencies of mania
42 (n = 1), behavioral activation (n = 1), and hyperactivity (n = 1). One pers on reported v enlafaxine with no dosages or side effects disclosed. Two people used d uloxetine with dosages of 20mg and 60mg, and side effect frequencies of worsening of symptoms (n = 1). Fifteen participants used e scitalopram with only one dosage of 20mg r eported and side effect frequencies of more talkative (n=1), increased participation in activities ( n = 3), worsening of symptoms (n = 1), behavioral activation (n = 1), and poor impulse control (n = 1). Eleven participants reported f luvoxamine with dosage of 200mg and side effect frequencies of motor restlessness (n = 1), poor impulse control (n = 2), worsening of symptoms (n = 1), more talkative (n = 1), and increased participation in activities (n = 1). Three people used p aroxetine with no dosage levels reported and side effect frequencies of worsening of symptoms (n = 1), mania (n = 1), behavioral activation (n = 1), and hyperactivity (n = 1). Twenty seven people used f luoxetine with dosage ranges of 40 80mg and side effect frequencies of motor restlessness (n = 2), worsening of symptoms (n = 4), increased meanness (n = 3), behavioral activation (n = 4), poor impulse control (n = 2), mania (n = 1), more talkative (n = 1), increased activity (n = 1), and akathisia (n = 1). Thirty eight people used sertrali ne with dosage ranges of 25200mg and side effect frequencies of akathisia (n = 1), hyperactivity (n = 3), increased activity (n = 2), more talkative (n = 4), grandiosity (n = 1), worsening of symptoms (n = 4), celebration (n = 1), euphoria (n = 1), behavi oral activation (n = 2), poor impulse control (n = 1), and mania (n = 1). Attention Deficit Hyperactivity Disorder (AD/HD) medications (i.e., methylphenidate, atomoxetine) were reported with second most frequency. Three people used dextroamphetamine and am phetamine with dosage ranges of 2.510mg
43 and side effect frequencies of behavioral activation (n = 1), hyperactivity (n = 1), and mania (n = 1). Seven participants reported Methylphenidate with dosage ranges of 518mg and side effect frequencies of worsening of symptoms (n = 1) and behavioral activation (n = 2). Three people used d exmethylphenidate with dosage ranges of 2.510mg and side effect frequency of increased meanness (n = 1). A tomoxetine was reported by two people with no dosage amount disclosed a nd side effect frequency of sadness (n = 1). Lisdexamfetamine was used by one participant with dosage of 50mg and no side effects disclosed. Three separate atypical anti psychotic medications were reported. Five people used a ripiprazole with dosage of 5m g and side effect frequencies of increased participation in activities (n = 1), worsening of symptoms (n = 1), and motor restlessness (n = 1). Twelve people used r isperidone with dosage ranges of .252.5mg and side effect frequencies of hyperactivity (n = 1), increased activity (n = 1), more talkative (n = 1), euphoria (n = 1), and worsening of symptoms (n = 2). Three participants reported q uetiapine with dosage ranges of 25175mg and no side effects disclosed. Three total benzodiazepines were reported. Three people used l orazepam with dosage of .50mg and no side effects disclosed. Three participants reported clonazepam with dosage of 1mg and no side effects disclosed. One person used a lprazolam with no dosage or side effect information disclosed. Three miscellaneous medications were reported. Gabapentin and o xcarbazepine were reported once each and no dosage or side effect information was disclosed for either one. Three participants reported b upropion with dosage of 200mg and no side effects disclosed.
44 Analysis of Independent Variables To explore inter relationships among independent variables a correlation matrix among variables is shown in Table 3 9 As can be seen some notable relationships were observed. Total obsessive compulsive symptom severity (e.g., CY BOCS) was significantly related to family accommodation. Functional impairment (e.g., CSDS P ) was significantly related to parental anxiety (e.g., BAI) family accommodation, and overall obsession severity. Parental anxiety was significantly related to SES and family accommodation. Family accommodation was also related to overall obsession severity. Regression analyses B ivariate c orrelations between ind ependent variables and treatment latency are presented in Table 3 10 Only child 's gender was significantly related with treatment latency, with treatment latency being longer for girls than for boys Table 3 11 contains data comparing means by gender for dependent variables and treatment latency. To assess the unique contributions of the indep endent variables, all measures were entered simultaneously into a regression model to predict treatment latency. As shown in Table 3 12, only g ender made a significant unique contribution to the prediction of treatment latency in the model ( = .235; t = 2.015; squared semipartial correlation = .05 3 ; p < .05). Additional analyses were conducted to examine the pos sibility that the distribution o f study measures were skewed, thereby violating the assumption of normality for parametric corre lational analyses. These analyses revealed that t he measure of treatment latency demonstrated positive skew (1.98) and kurtosis (3.68), and the measure of parental anxiety (i.e., the Beck Anxiety Inventory) also displayed kurtosis (2.79), which are outside the recommended range of 2 (Cameron, 2004) To adjust for
45 these undesirable properties a square root transformation was applied to these measures, as indicated by Tabachnick and Fidell (2009), and any correlation and regression analyses were rerun wit h these transformed variables However, while the transformations yielded acceptable skewness and kurtosis values for these variables (i.e., within the 2 range), no changes in statistical significance were observed when analyses were rerun. Given this lac k of change in results after transformation, to aid in interpretability, all results are reported in the original (untransformed) metrics. Since gender was found to be associated with treatment latency, additional analyses examined the possibility that tre atment latency might be associated with obsessive compulsive symptom severity and the predictors after controlling for childrens gender Pearson correlations between treatment latency, obsessive compulsive symptom severity family accommodation, functional impairment and parental anxiety were computed separately for boys and girls. In addition, interaction terms were entered into the multiple regression equation to assess for moderation, where the moderating effect of gender on obsessivecompulsive sympt om severity, family accommodations, functional impairment, and parental anxiety in predicting treatment latency was evaluated. N either of these analyses revealed a significant association between treatment latency and measures of obsessive compulsive sympt om severity, family accommodation, functional impairment or parental anxiety Cumulatively, the results of these analyses support the following conclusions with regard to the primary research questions of the present study. Hypothesis 3 asked: What va riables predict latency between problematic OCD symptoms and seeking treatment? The results of the bivariate correlational analyses, and the multiple
46 regression analyses, indicate that the child's gender is a significant predictor of treatment latency wh ich was longer for girls than for boys. However, gender did not affect the relationship of the variables of obsessive compulsive symptom severity, functional impairment, family accommodation, and parental anxiety with treatment latency. Regardless of a par ticipant s gender scores on these variables did not differ significantly. Mediation analyses Initial analyses were conducted to determine whether specific combinations of predictor variables and potential mediators met certain minimal criteria for inclusi on in the proposed mediational model s, as stated by Baron and Kenny (1986). In order to claim that a variable mediates the relationship between a predictor and an outcome, it is necessary (but not sufficient) to establish that the predictor variable is related to the outcome of interest ( e.g ., treatment latency ), that the potential mediator is associated with the outcome of interest, and that the potential mediator is related with the predictor variable. These three conditions can be established by examining the pattern of correlations among predictor variables, potential mediators, and outcome measures. Hypotheses 4 through 7 proposed specific mediating pathways between obsessive compulsive symptom severity and treatment latency. Specifically, Hypothesis 4 suggested that family accommodation might mediate the relationship between obsessive compulsive symptom severity and treatment latency. Hypothesis 5 proposed that functional impairment might mediate the relationship between obsessive compulsive symptom severity and treatment latency. Hypothesis 6 suggested that the relationship between compulsion severity and treatment latency might be mediated by functional impairment. Hypothesis 7 suggested that the relationship between obsession
47 severity and treatm ent latency might be mediated by functional impairment. R elationships between obsessive compulsive symptom severity and treatment latency were not detected. Thus, under the Baron and Kenny (1986) mediation framework, there is no observed meditational ef f e ct. Multiple approaches were employed to ascertain that this effect was not observed, including a logarithmic transformation for treatment latency to address skewness, and the moderating effects of gender were probed to see if effects of interest were rest ricted to girls or boys. Despite these efforts, the predictors of interest were not associated significantly with treatment latency even when the effects of other predictors were controlled statistically. Moreover, the proposed mediators (functional impair ment and family accommodation) were not observed to have a direct effect on the DV, thus also rendering the meditational model as nonexplanatory. Further investigation is merited to validate the model underlying these original hypotheses, given these incongruent data. Given that the predictor variables were associated significantly with one of the mediators (family accommodation), a further possible mediational model should be considered. It is possible that obsessive compulsive symptom severity and famil y accommodation, individually, do not have a significant bivariate relationship with treatment latency, yet family accommodation may have a significant association with treatment latency in the context of a regression equation containing both obsessive com pulsive symptom severity and family accommodation. To test this possibility, regression analyses were conducted in which overall obsessive compulsive symptom severity and family accommodation were employed to predict treatment latency. The results of thi s analysis are shown in Table 3 13 Neither overall obsessivecompulsive
48 symptom severity nor family accommodation made a significant unique contribution to the prediction of treatment latency. Additional analyses considered the possibility that family accommodation or functional impairment made a significant contribution to the prediction of treatment latency after controlling statistically for levels of obsessive symptom severity. To examine this possibility, regression analyses were conducted in whic h obsessive symptom severity and either family accommodation or functional impairment were entered into the equation. As shown in Table 3 1 4 neither obsessive symptom severity nor family accommodation made a significant contribution to the prediction of treatment latency. Similarly, as shown in Table 3 15 neither obsessive symptom severity nor functional impairment made a significant contribution to the prediction of latency. Table 3 1. Summary of descriptive d ata Variable Mean SD Total Latency 579.7 777.1 N=80 CY BOCS 24.84 7.48 N=83 Sheehan 32.95 11.83 N=83 BAI 13.95 12.81 N=83 BSMMS 48.86 9.81 N=83 FAS 4.83 12.58 N=81 Table 3 2. Summary of initial treatment provider sought Treatment Provider % of all respondents N=83 Psychologist 51.8 43 P sychiatrist 32.5 27 Primary Care 14.5 12 Nurse Practitioner 1.2 1
49 Table 3 3. Summary of t reatment ultimately received Treatment Type % of all respondents N=83 Medication Alone 4.8 4 Talk Therapy Alone 13.2 11 CBT/ERP Alone 26.5 22 CBT W/O ERP Alo ne 2.4 2 CBT/ERP & CBT W/O ERP 2.4 2 Medication & Talk Therapy 4.8 4 Medication & CBT/ERP 15.6 13 Medication & CBT W/O ERP 1 1 Medication, Talk Therapy & CBT/ERP 10.8 9 Medication, Talk Therapy & CBT W/O ERP 7.2 6 Medication, Talk Therapy CBT/ERP & CBT W/O ERP 7.2 6 Talk Therapy & CBT/ERP 1 1 Talk Therapy & CBT W/O ERP 1 1 Talk Therapy, CBT/ERP & CBT W/O ERP 1 1 Table 3 4. Summary of t reatment ultimately received when p sychologist was initial provider Treatment Type % of all respondents N=43 T alk Therapy Alone 11.6 5 CBT/ERP Alone 37.2 16 CBT/ERP & CBT W/O ERP 4.7 2 Medication & Talk Therapy 2.3 1 Medication & CBT/ERP 18.6 8 Medication, Talk Therapy & CBT/ERP 7.0 3 Medication, Talk Therapy, & CBT W/O ERP 2.3 1 Medication, Talk Therapy, C BT/ERP & CBT W/O ERP 9.3 4 Talk & CBT/ERP 2.3 1 Talk & CBT W/O ERP 2.3 1 Talk Therapy, CBT/ERP & CBT W/O ERP 2.3 1
50 Table 3 5. Summary of t reatment ultimately received when p sychiatrist was initial provider Treatment Type % of all respondents N=27 M edication Alone 11.1 3 Talk Therapy Alone 14.8 4 CBT/ERP Alone 18.5 5 CBT W/O ERP Alone 3.7 1 Medication & CBT/ERP 11.1 3 Medication & Talk Therapy 3.7 1 Medication, Talk Therapy & CBT/ERP 11.1 3 Medication, Talk Therapy, & CBT W/O ERP 11.1 3 Medic ation, Talk Therapy, CBT/ERP & CBT W/O ERP 14.8 4 Table 36. Summary of t reatment ultimately received when p rimary Care was initial provider Treatment Type % of all respondents N=12 Talk Therapy Alone 13.2 2 CBT/ERP Alone 26.5 1 Medication Alone 4.8 1 Medication & Talk Therapy 4.8 1 Medication & CBT/ERP 15.6 3 Medication, Talk Therapy & CBT/ERP 10.8 2 Medication, Talk Therapy & CBT W/O ERP 7.2 2 Table 37 Summary rates of therapy treatment by treatment provider Treatment Provider Total Weekly Bi Weekly Monthly Daily No Treatment Psychologist N=43 67.4% (29) 18.6% (8) 0 9.3% (4) 4.7% Psychiatrist N=27 66.6% (18) 11.1% (3) 7.4% (2) 7.4% (2) 7.4% (2) Primary Care N=11 36.3% (4) 3 6.3 % (4) 9.1% (1) 9.1% (1) 9.1% (1) Nurse Practitioner N=1 100% (1)
51 Table 3 8 Summary rates of medication treatment Daily Total Weekly Bi Weekly Monthly No Medication 2.4% (2) 4.9% (4) 6.0% (5) 49% (40) N=82 Table 39 Correlation Matrix of independent variables (1) (2) (3) (4) (5) (6) (7) (8) (9) (1)CY BOCS 1.00 (2)Sheehan .205 (3)BAI .001 .302** (4)SES .032 .40 .440** (5)Family .253* .559** .314** .094 Accommodation (6)Gender .156 .035 .003 .122 .098 (7)Age .157 .066 .148 .106 .196 .046 (8)CYBOCS Compulsions .938** .123 .017 .054 .211 .164 .142 .680** (9)CYBOCS Obsessions .892** .273* .019 .003 .261* .117 .146 ** P<.01 P <.05 Table 310. Correlation of independent variables with treatment latency Variable Latency Age .014 Gend er .259* SES .161 Parental Anxiety .027 Functional Impairment .068 Family Accommodation .002 Overall Symptom Severity .106 Obsessive Symptom Severity .114 Compulsive Symptom Severity .076 p < .05
52 Table 311. Comparison of m eans by g ender on d ependent v ariables Variable Males Females Statistic Latency M = 364.16 SD = 575.99 M = 765.18* SD = 880.55 t (78) = 2.367, p = .02 CY BOCS M = 23.58 SD = 7.56 M = 25.91 SD = 7.32 t (81) = 1.424, p = .15 Sheehan M = 32.50 SD = 12.93 M = 33.33 SD = 10.94 t (81) = .318, p = .75 FAS M = 23.52 SD = 12.60 M = 25.97 SD = 12.60 t (79) = .874, p = .39 BAI M = 14.00 SD = 14.84 M = 13.91 SD = 10.97 t (81) = .031, p = .98 BSMMS M = 50.13 SD = 10.38 M = 47.77 SD = 9.81 t (81) = 1.104, p = .27 p < .05 Overall Model R2 = .315 Table 312. Regression of treatment latency on demographics, symptom severity, parental anxiety, functional impairmen t, and family accommodation Unstandardized Beta Standard Error Standardized t p Gender 369.436 183.324 .235 2.015 .048* Age 7.420 24.207 .037 .300 .765 SES 12.105 11.006 .145 1.100 .275 Symptom Severity 6.165 12.634 .060 .488 .627 Parental Anxie ty .037 9.221 .001 .004 .997 Functional Impairment 6.766 9.546 .103 .709 .481 Family Accommodation 2.290 9.787 .037 .234 .816 p < .05 Table 3 1 3 Regression of l atency of t reatment on o verall symptom s everity and family a ccommodation Predictor Standardized Coefficient t Probability Symptom Severity .107 .911 .365 Family Accommodation .026 .216 .830
53 Table 3 14. Regression of l atency of t reatment on o bsessive symptom s everity and f amily a ccommodation Predictor Standardized Coefficient t Probability Obsessive Symptom Severity .122 1.033 .305 Family Accommodation .030 .254 .800 Table 3 15. Regression of l atency of t reatment on o bsessive symptom s everity and f unctional i mpairment Predictor Standardized Coefficient t Probability O bsessive Symptom Severity .145 1.217 .227 Functional Impairment .103 .864 .390
54 CHAPTER 4 DISCUSSION The current study examine d areas of treatment history of pediatric Obsessive Compulsive Disorder ( OCD) regarding provider initially seen for treatment type of treatment received, medication history with dosages and side effects, and assessed areas of pediatric OCD (e.g., obsessivecompulsive severity, family accommodation, functional impairment, and parental anxiety. The primary goals of the study were to better understand the treatment seeking behaviors of parents/caregivers of children with OCD, characteristics of treatment and uncover any potential variables that may predict when treatment is initially sought. Furthermore, relationships between obsessive compulsive symptom severity and treatment latency were examined with regards to the potential mediating variable of family accommodation and functional impairment Treatment History Half of participants reported psychologists as the initial treatme nt provider, with another third reporting psychiatrists. Participants were recruited from a variety of sources including OCD related websites, online parent groups and two OCD clinics in Florida. Interestingly, primary care physicians were reported as the initial treatment provider 15% of the time. This finding may highlight a potential area for psychoeducation of physicians and development of materials to be delivered to parents of children with OCD, to address any potential barriers to locating a quali fied therapist. More concerning is the huge diversity of treatments reported being delivered. A total of 14 different treatment approaches were reported with slightly more than half involving medication. It was unclear if medication was added as an adjunc tive component or at the outset of treatment. When considering the current literature support for Cognitive
55 Behavioral Therapy ( CBT ) alone as the first line treatment (March et al., 1997; POTS, 2004), it is concerning to find such numerous types of treatm ent s being delivered. Furthermore, medication being reported as a major theme of pediatric treatment highlights the need for more qualified therapists and continued training on best practices of pediatric OCD treatment. Several trends appeared with regards to specific treatment provider. Psychologists were reported to have a fairly large degree of variation of treatments with 11 different combinations offered. However, CBT alone or with medication was delivered to slightly more than half of participants a t some point in the childs treatment history With a large percentage of treatment from psychologists including CBT, this may be an indication that evidence based treatments are being adopted by these providers. Similar to results in Blanco et al. (2006) psychiatrists in this study administered medication as a component to approximately two thirds of clients One of the primary goals of the current study was to replicate Blanco et al. (2006) with a pediatric population to examine treatments delivered by all professionals and examine any similarities or differences in results. It appears that psychiatrists have similar rates of medication use in both adults and children. Contrary to Blanco et al. (2006) this study found rates of CBT use to be much hig her by psychiatrists (7.5% vs. 14.8%) Several factors may have had a role in this finding. First, many participants came from clinics that specialized in CBT treatment or through websites that likely state the importance of CBT as a first line treatment Secondly, CBT was more clearly defined in the current study as compared to the description in Blanco et al. (2006) of "CBT themes" with several treatment options to select. This modification in the current study could have allowed for a more detailed
56 re port of treatment history Furthermore, the current study asked parents to report on treatment history instead of surveying just psychiatrists as in Blanco et al. (2006), thus allowing for a more diverse sample to examine treatment variation on a whole for the pediatric OCD population. Regardless of differences between studies, it appears that the current sample received treatment using CBT more frequently than in Blanco et al. (2006). Rates of therapy and medication treatment for children with OCD were another issue for investigation to gauge alignment with best practices. Currently therapy treatment of pediatric OCD can be conducted in two empirically supported protocols, either weekly for 14 sessions or intensive 3 week 14 session programs (Lewin et al ., 2005; Storch et al., 2007b). A positive finding for psychologists showed that rates of therapy consisted primarily of weekly and bi weekly with large gaps in treatment not reported. This finding is in direct alignment with the extant literature for best practices of therapy treatment for OCD (Storch et al, 200 7b) Psychiatrists showed similar rates for therapy treatment with most being weekly or bi weekly as well, with a small number being monthly. With regards to medication treatment frequency, part icipants reported this information regardless of treatment provider initially sought. It was assumed that those participants reporting psychologists as the initial provider were receiving medication treatment from a physician, psychiatrists, or possibly f rom psychologists who w ere practicing in a state that has prescribing privileges (e.g., New Mexico or Louisiana). Rates of medication treatment were similar for both psychologists and psychiatrists, with monthly treatment being the most common delivered. Eric Storch Ph.D. discussed how m onthly medication is commonplace for most mental health
57 conditions from clinical experience (personal communication, September 12, 2010) However, with regards to children, more frequent medication treatment may be a more effective alternative. Children have different rates of metabolism and side effects may vary greatly when compared to adults (Stahl & Stahl, 2000) In addition, results from this study demonstrated many side effects reports. More frequent medication tr eatment follow up may identify problematic side effects and help professionals target the most therapeutic dosage. This may be an important issue facing pediatric OCD treatment utilizing medication, considering that dosage rates are typically higher for O CD than other mental health conditions (Fineberg & Gale, 2005). Currently the four Serotonin Reuptake Inhibitors ( SRIs ) that are approved by the Food and Drug Administration ( FDA ) for treatment of pediatric OCD include clomipramine f luoxetine, f luvoxamine, and sertraline. However, a total of 10 different SRIs were reported being prescribed for children in this study with a variety of dosages. Parents also reported on average two different side effects per SRI medication with as many as nine on some (e. g., f luoxetine). Murphy et al. (2008) discuss ed adverse side effects of SRIs and the need for careful monitoring and titration of dosages when initially beginning treatment However, it was unclear how well monitored were children in this study consideri ng most were only seen on a monthly basis for medication treatment When considering this common practice of off label use of medication, the numerous side effects reported and lack of regular monitoring on a weekly or bi weekly basis a conservative approach to treatment utilizing CBT alone at the outset is supported by these findings.
58 A total of eight Attention Deficit Hyperactivity Disorder (AD/HD) medications across 16 different participants were reported as being prescribed in this study. Comorbidity data was not gathered in this study and it is unclear if those reporting AD/HD medication use were actually diagnosed with AD/HD, receiving concurrent treatment for AD/HD and OCD, or only had only an OCD diagnosis. Another explanation for reported A D/HD medication use could be misdiagnosis, because OCD symptoms in children may often times present similar to AD/HD through inattention and impulsivity related to anxiety. Interestingly AD/HD medications, particularly stimulants are not efficacious for r educing OCD symptoms. Stimulant medication actually exacerbate symptoms and may triggering obsessions and compulsions (Rapoport & Inoff Germain, 2000). Regression and Mediation Analyses A primary aim of the current study was to investigate any possible variables that predict the time to treatment once a child's OCD symptoms became problematic. Several possible variables (e.g., gender, age, Social Economic Status [ SES ] symptom severity, family accommodation, functional impairment, and parental anxiety) were included in a regression analysis to examine their predicted relationship to treatment latency. Child's gender emerged as the only significant predictor of treatment latency. Treatment latency was significantly longer for girls than boys. A possible explanation for this finding might be the potentially higher degree externalizing behaviors of boys compared to girls with potentially lower degrees of family accommodation. Further analysis revealed that boys and girls did not differ significantly on any in dependent variable in this study ( Table 4 4) Although other variables did not significantly explain treatment latency, several possible factors may have contributed to the lack of a
59 significant finding. Overall the symptom severity of participants was in the moderate to severe range with little difference between individuals based on degree of treatment latency For example, participants who waited two years to seek treatment did not differ significantly from someone who waited only 90 days with regar ds to overall symptom severity. Similar results were observed with regards to family accommodation and functional impairment in that regardless of treatment latency they did not differ on these variables significantly. Other relationships were explored to determine if family accommodation and functional impairment acted as a significant mediator of the relationship between symptom severity and treatment latency. No significant relationships were found between symptom severity and treatment latency were di scovered. Furthermore, when treatment latency was transformed to resemble a normal distribution, no significant relationships were found. The overall findings did not support the proposed mediations models in the current study. Limitations Although sev eral interesting and potentially beneficial findings were discovered, this study is not without some important limitations. As expected the sample of participants reported relatively high overall SES. This result is not surprising considering clinical experience, which has revealed a higher SES associated with both adults and children seeking treatment of OCD. In addition, this study was conducted online and required computer access and understanding of websites that offer support or information on pediat ric OCD. Requiring computer access to participate may have favored a higher SES sample. Race and ethnicity was not diverse in this sample with a majority of participants identifying as White/Caucasian. Generalizability of these
60 findings for lower SES m inorities or both may be limited. Psychologists were reported as the primary treatment provider, but this could have been related to the recruitment of participants in clinics and from websites that featured psychologists as primary treatment providers. Generalizability of results regarding types of treatments delivered and protocols could be limited to the population at large. The overall symptom severity of participants was relatively high and may have hindered detection of significant differences. How ever, the mean symptom severity in this study at 24.8 was nearly identical to other studies using the same measure (Storch et al., 2007a; Storch et al., 2007b). Average symptom severity in those studies was 25.7 and 25.1, respectively. Replication with a larger sample may increase the probability of detecting significant differences of symptom severity and its relationship with treatment latency but these could be clinically meaningless Related to symptom severity the Children's YaleBrown Obsessive Co mpulsive Disorders Scal e ( CY BOCS ) was modified for online parental report. In clinical settings this measure is administered by a trained therapist with a second rater (Scahill et al., 1997). For this study it is unclear the potential impact and effect on accuracy of having parents anonymously report on their child's OCD symptoms. The modification of the CY BOCS may have accounted for the relatively high average report of symptom severity in this sample. Although no predictor of treatment latency was discover other than gender, that does not necessarily mean that a significant predictor does not exist. Further research on pediatric OCD with larger samples may explain factors that can accurately predict when a parent of a child with OCD will seek treatm ent. In addition, more research with larger sample sizes may
61 reveal potential mediators of the relationship between symptom severity and treatment latency. Conclusions Despite these limitations many areas within pediatric OCD were explored with potentiall y important results for professional practice. Contrary to Blanco et al. (2006) rates of CBT use amongst psychiatrists was much higher and maybe an indication of a shift in professional practice. However, medication remains a central component of their treatment regimens and this may be an area for continued professional development and dissemination of evidencebased practices. Additionally, physicians emerged as a prominent treatment provider behind psychologists and psychiatrists highlighting primar y care as a potential area for increased psychoeducation and collaboration for effective treatment Adoption of CBT as a first line treatment for children with OCD by psychologists may be increasing, but improvement remains considering the large variety of treatments reported being delivered. Psychologists primarily provided CBT or CBT with medication, but many other treatment types were utilized as well. Results of this study may indicate a positive shift of CBT to the forefront of treatments delivered by all professionals and the need for continued adoption of evidencebased practices. However, it appears that although strides have been made with regards to dissemination of first line treatments, these results show children continue to lack adequate access to CBT. Another interesting but previously documented finding, was the overall impairing nature of OCD in children. Symptom severity averaged in the moderate to severe range. In addition, family accommodation and functional impairment was relati vely high as well. As expected total symptom severity was significantly related to family
62 accommodation. Family accommodation is known to be an exacerbating factor in pediatric OCD ( Barrett et al. 2004; Storch et al., 2007 a ). Furthermore parental anxi ety was significantly related to obsessional severity and family accommodation, highlighting the impact of pediatric OCD on parents as well. In a similar vein parental anxiety was also significantly related to SES and family accommodation. Lower SES is k nown to be related to more family stress (Baum, Garofalo, & Yali, 1999). The relation of SES to family accommodation makes clinical sense, in that a stressed parent may be more likely to accommodate a child's OCD symptoms in order to avoid more household stress. However, parents may be unintentionally exacerbating their child's overall symptom severity with this practice. When examining functional impairment, school and social impairment was reported at the markedly level on average. This finding highl ights the need for early identification and treatment in order to reduce potential impact on academic and social functioning. In addition, participants did not differ on symptom severity regardless of treatment latency, which highlights the chronic and unremitting nature of OCD. Most participants were at a moderate to severe level of symptom severity when seeking treatment. A goal of this study was to discover any variables that may assist professional practice in understanding what could predict treatm ent seeking by parents. Unfortunately, these results were unable to identify any potential predictors of treatment latency However, the vast amount of information regarding the high degree of symptom severity, functional impairment, and family accommoda tion highlights the need for more research and continued investigation of ways to better understand pediatric
63 OCD. Continued research to identify variables that may predict treatment latency need to be examined. Results of this study show the impairing nature of pediatric OCD and impact in parents, thus highlighting the need for early treatment and remediation.
64 APPENDIX QUESTIONNAIRE Demographic Information Fill in the following information, keeping in mind that all information given is strictly confiden tial according to your informed consent document Relationship to Child: Father Grandmother Grandfather Aunt Uncle Childs Age______ Childs Gender: Male Female Race/Ethnicity : /Non Hispanic panic merican
65 The Barratt Simplified Measure of Social Status (BSMSS) Mark the appropriate box for your Mother's, your Father's, your Spouse / Partner's, and your level of school completed and occupation. If you grew up in a single parent home, mark only the box from your one parent. If you are neither married nor partnered leave the spouse column blank. If you are a full time student mark only the box for your parents. Level of school Completed Mother Father Spouse Self Less than 7 th grade Junior high/middle school (9 th grade) Partial High School (10 th or 11 th grade) High School Graduate Partial College (at least one year) College graduate Graduate degree (Masters, Ph.D., J.D., etc) Mark the appropriate box for your Mother's, your Father's your Spouse / Partner's, and your occupation. If you grew up in a single parent home, use only the box for your one parent. If you are not married or partnered leave the spouse column blank. If you are a full time student only mark the box for your parents. If you are retired use your most recent occupation. Occupation Mother Father Spouse Self Day laborer, janitor, house cleaner, farm worker, food counter sales, food preparation worker, bus boy. Garbage collector, short order cook, cab driver, shoe sales, assembly line workers, masons, baggage porter. Painter, skilled construction trade, sales clerk, truck driver, cook, sales counter or general office clerk. Automobile mechanic typist, locksmith, farmer, carpenter, receptionist, construction laborer, hairdresser. Machinist, musician, bookkeeper, secretary, insurance sales, cabinet maker, personnel specialist, welder. Supervisor, librarian, aircraft mechanic, artist an d artisan, electrician, administrator, military enlisted personnel, buyer. Nurse, skilled technician, medical technician, counselor, manager, police and fire personnel, financial manager, physical, occupational, speech therapist.
66 Mechanical, nucl ear, and electrical engineer, educational administrator, veterinarian, military officer, elementary, high school and special education teacher, Physician, attorney, professor, chemical and aerospace engineer, judge, CEO, senior manager, public officia l, psychologist, pharmacist, accountant. Did you grow up with both parents? If you grew up with one parent, which one was your primary caretaker? Mother Father Other Are you married or partnered? Are you a full time student? Do you live alone?
67 O bsessive C ompulsive D isorder (OCD) Treatment History 1. How long between when your childs OCD symptoms became problematic and you began treatment? __Years __Months __Weeks 2. Where did you initially receive treatment, for your childs OCD symptoms? A) Primary Care physician/Pediatrician; B) Psychiatrist; C) Psychologist; D) Nurse Practitioner; G) Other: Please Specify ____________ When answering question 3 please use the following definitions to guide your selections: Psychot herapy or Talk Therapy : is broadly defined as any of a group of therapies, used to treat psychological disorders, that focus on changing undesirable behaviors, thoughts, perceptions, and emotions that may be associated with specific disorders. Cognitive Behavioral Therapy (CBT) with Exposure s : Treatment that utilizes CBT with exposures will involve exposing an individual to an anxiety provoking stimuli or situations and then preventing the person from avoiding or engaging in anxiety reducing behaviors ( rituals ). The goal of CBT is to break the association between specific stimuli, situations, or thoughts that provokes anxiety, and the experience of ritualistic behaviors, temporarily reducing anxiety. Cognitive Behavioral Therapy (CBT) without Exposures: Treatment that will not involve exposing an individual to an anxiety provoking stimuli or situations and then preventing the person from avoiding or engaging in anxiety reducing behaviors, but may include discussion regarding a persons thoughts and changing the way a person thinks about or perceives their uncomfortable thoughts.
68 3. What was the treatment you ultimately recommended? Check Yes or No for any treatment received Medication Talk Therapy Cognitive Behavioral Therapy with exposures Cognitive Behavioral Therapy without Exposures 4. Please list any medications with dosages and side effects for each below: Medi cation Dosage Side Effects Medication and Side effects columns will have a drop down list of all potential options under each category. 5. How often was your child seen for treatment (e.g., daily, weekly, bi weekly, monthly)? _____
69 C hildren's Yale Brown Obsessive Compulsive Disorders Scale (CY BOCS) QUESTIONS ON OBSESSIONS (ITEMS 1 5) Please answer the following questions regarding your childs obsessional thoughts. Circle the one best answer that best describes your childs symptoms 1. TIME OCCUPIED BY OBSESSIVE THOUGHTS How much time does your child spend thinking about these things? (When obsessions occur as brief, intermittent intrusions, it may be impossible to assess time occupied by them in terms of total hours. In such cases, estimate time by determining how frequently they occur. Consider both the number of times the intrusions occur and how many hours of the day are affected). How frequently do these thoughts occur? 0 NONE 1 MILD less than 1 hr/day or occasional in trusion 2 MODERATE 1 to 3 hrs/day or frequent intrusion 3 SEVERE greater than 3 and up to 8 hrs/day or very frequent Intrusion 4 EXTREME greater than 8 hrs/day or near constant intrusion 2. INTERFERENCE DUE TO OBSESSIVE THOUGHTS How much do these thoughts get in the way of school or doing things with friends? (If currently not in school determine how much performance would be affected if your child were in school.) 0 NONE 1 MILD slight interference with social or school activities, but overa ll performance not impaired 2 MODERATE definite interference with social or school performance, but still manageable 3 SEVERE causes substantial impairment in social or school performance 4 EXTREME incapacitating
70 3. DISTRESS ASSOCIATED WITH O BSESSIVE THOUGHTS How much do these thoughts bother or upset your child? (Only rate anxiety/frustration that seems triggered by obsessions, not generalized anxiety or anxiety associated with other symptoms.) 0 NONE 1 MILD infrequent, and not too dist urbing 2 MODERATE frequent, and disturbing, but still manageable 3 SEVERE very frequent, and very disturbing 4 EXTREME near constant, and disabling distress/frustration 4. RESISTANCE AGAINST OBSESSIONS How hard does your child try to stop the thoughts or ignore them? Only rate effort made to resist, not success or failure in actually controlling the obsessions 0 NONE makes an effort to always resist or symptoms so minimal doesn't need to actively resist. l MILD tries to resist most of the ti me 2 MODERATE makes some effort to resist 3 SEVERE yields to all obsessions without attempting to control them, but does so with some reluctance 4 EXTREME completely and willingly yields to all obsessions 5. DEGREE OF CONTROL OVER OBSESSIVE THOUG HTS When your child tries to fight the thoughts, can he/she beat them? How much control does your child have over the thoughts? (In contrast to the preceding item on resistance, the ability of the patient to control his/her obsessions is more closely relat ed to the severity of the intrusive thoughts.) 0 COMPLETE CONTROL l MUCH CONTROL usually able to stop or divert obsessions with some effort and concentration 2 MODERATE CONTROL sometimes able to stop or divert obsessions 3 LITTLE CONTROL rarely successful in stopping obsessions, can only divert attention with difficulty
71 4 NO CONTROL experienced as completely involuntary, rarely able to even momentarily divert thinking QUESTIONS ON COMPULSIONS (ITEMS 6 10) Please answer the following questions regarding your childs habits they cant stop. Circle the one best answer that best describes your childs symptoms. 6. TIME SPENT PERFORMING COMPULSIVE BEHAVIORS How much time does your child spend doing these things? How much longer than most people do es it take to your child to complete usual daily activities because of the habits? (When compulsions occur as brief, intermittent behaviors, it may be impossible to assess time spent performing them in terms of total hours. In such cases, estimate time by determining how frequently they are performed. Consider both the number of times compulsions are performed and how many hours of the day are affected.) How often does your child do these habits? [In most cases compulsions are observable behaviors (e.g., handwashing), but there are instances in which compulsions are not observable (e.g., silent checking).] 0 NONE 1 MILD spends less than 1 hr/day performing compulsions or occasional performance of compulsive behaviors 2 MODERATE spends from 1 to 3 hrs/day performing compulsions or frequent performance of compulsive behaviors 3 SEVERE spends more than 3 and up to 8 hrs/day performing compulsions or very frequent performance of compulsive behaviors 4 EXTREME spends more than 8 hrs/day performing compulsions or near constant performance of compulsive behaviors 7. INTERFERENCE DUE TO COMPULSIVE BEHAVIORS How much do your childs habits get in the way of school or doing things with friends? Is there anything your child doesn't do because of them? (I f currently not in school, determine how much performance would be affected if child were in school.) 0 NONE 1 MILD slight interference with social or school activities, but overall performance not impaired 2 MODERATE definite interference with social or school performance, but still manageable
72 3 SEVERE causes substantial impairment in social or school performance 4 EXTREME incapacitating 8. DISTRESS ASSOCIATED WITH COMPULSIVE BEHAVIOR How would your child feel if prevented from carrying out their habits? How upset would your child become? (Rate degree of distress/frustration child would experience if performance of the compulsion were suddenly interrupted without reassurance offered. In most, but not all cases, performing compulsions reduces anxiety/frustration.) How upset does your child get while carrying out their habits until they are satisfied? 0 NONE l MILD only slightly anxious/frustrated if compulsions prevented; only slight anxiety/frustration during performance of compulsions 2 MODERATE reports that anxiety/frustration would mount but remain manageable if compulsions prevented; anxiety/frustration increases but remains manageable during performance of compulsions. 3 SEVERE prominent and very disturbing increase in anxiety/frustration if compulsions interrupted; prominent and very disturbing increase in anxiety/frustration during performance of compulsions. 4 EXTREME incapacitating anxiety/frustration from any intervention aimed at modifying activity; incapacitating anxiety/frustration develops during performance of compulsions. 9. RESISTANCE AGAINST COMPULSIONS How much does your child try to fight the habits? Only rate effort made to resist, not success or failure in actually controlling the compulsions. 0 NONE makes an effort to always resist or symptoms so minimal doesn't need to actively resist l MILD tries to resist most of the time. 2 MODERATE makes some effort to resist 3 SEVERE yields to almost all compulsions without attempting to control them, but does so with some reluctance 4 EXTREME completely and willingly yields to all compulsions
73 10. DEGREE OF CONTROL OVER COMPULSIVE BEHAVIOR How strong is the feeling that your child has to carry out their habit(s)? When your child tries to fight them w hat happens? How much control do they have over their habits? 0 COMPLETE CONTROL l MUCH CONTROL experiences pressure to perform the behavior, but usually able to exercise voluntary control over it. 2 MODERATE CONTROL moderate control, strong pressure to perform behavior, can control it only with difficulty 3 LITTLE CONTROL little control, very strong drive to perform behavior, must be carried to completion, can only delay with difficulty 4 NO CONTROL no control, drive to perform behavior ex perienced as completely involuntary and overpowering, rarely able to even momentarily delay activity
74 The Child Sheehan Disability Scale ( C SDS P ) Please circle the number indicating how much your childs anxiety symptoms are currently interfering with various areas of life: The symptoms have disrupted your childs schooling: 0 1 2 3 4 5 6 7 8 9 10 Not at all Mildly Moderately Markedly Extremely The symptoms have disrupted your childs social life : 0 1 2 3 4 5 6 7 8 9 10 N ot at all Mildly Moderately Markedly Extremely The symptoms have disrupted your work : 0 1 2 3 4 5 6 7 8 9 10 Not at all Mildly Moderately Markedly Extremely The symptoms have disrupted your social life : 0 1 2 3 4 5 6 7 8 9 10 Not at all Mildly Moderately Markedly Extremely The symptoms have disrupted your familys home life : 0 1 2 3 4 5 6 7 8 9 10 Not at all Mildly Moderately Markedly Extr emely
75 F amily Accommodation Scale (FAS) During the past month 1) How often did you reassure the patient ? a. Never b. 13 times/month c. 1 or 2 times/week d. 36 times/week e. Daily 2) How often did you provide items for the patient's compulsio ns? a. Never b. 13 times/month c. 1 or 2 times/week d. 36 times/week e. Daily 3) How often did you participate in behaviors related to the patient's compulsions? a. Never b. 13 times/month c. 1 or 2 times/week d. 36 times/week e. Dai ly 4) How often did you assist the patient in avoiding things that might make him/her more anxious? a. Never b. 13 times/month c. 1 or 2 times/week d. 36 times/week e. Daily 5) Have you avoided doing things, going places, or being with people because of the patient's obsessive compulsive disorder? a. Never b. 13 times/month c. 1 or 2 times/week d. 36 times/week e. Daily 6) Have you modified your family routine because of the patient's symptoms? a. No b. Mild c. Mo derate d. Severe e. Extreme 7) Have you had to do some things for the family that are usually the patient's responsibility? a. No b. Mild c. Moderate d. Severe e. Extreme 8) Have you modified your work schedule because of the patient's needs? a. No b. Mild c. Moderate d. Severe e. Extreme 9) Have you modified your leisure activities because of the patient's needs? a. No b. Mild c. Moderate d. Severe e. Extreme 10) Does helping the patients in these ways cause you distress? a. Never b. Mild c. Moderate d. Severe e. Extreme 11) Has the patient become distressed anxious when you have not provided assistance? T o what degree? a. Never b. Mild c. Moderate d. Severe e. Extreme 12) Has the patient become angry/abusive when you have not provided assistance? To what degree? a. Never b. Mild c. Modera te d. Severe e. E xtreme 13) Has the patient spent more time completing rituals when you have not provided assistance? How much more? a. Never b. Mild c. Moderate d. Severe e. Extreme
76 Measure of Parental Anxiety Becks Anxiety Inventory (BAI ) Below is a list of common symptoms of anxiety. Please carefully read each item in the list. Indicate how much you have been bothered by that symptom during the past month, including today, by circling the number in the corresponding space in the colu mn next to each symptom. Not At All Mildly but it didnt bother me much. Moderately it wasnt pleasant at times Severely it bothered me a lot Numbness or tingling 0 1 2 3 Feeling hot 0 1 2 3 Wobbliness in legs 0 1 2 3 Unable to relax 0 1 2 3 Fe ar of worst happening 0 1 2 3 Dizzy or lightheaded 0 1 2 3 Heart pounding/racing 0 1 2 3 Unsteady 0 1 2 3 Terrified or afraid 0 1 2 3 Nervous 0 1 2 3 Feeling of choking 0 1 2 3 Hands trembling 0 1 2 3 Shaky / unsteady 0 1 2 3 Fear of losing contro l 0 1 2 3 Difficulty in breathing 0 1 2 3 Fear of dying 0 1 2 3 Scared 0 1 2 3 Indigestion 0 1 2 3 Faint / lightheaded 0 1 2 3 Face flushed 0 1 2 3 Hot/cold sweats 0 1 2 3
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87 BIOGRAP HICAL SKETCH Cary Jordan was born in 1975 in Port Clinton, Ohio to parents Edward Jordan and Judy Moon of Oak Harbor, Ohio. Cary was raised in Oak Harbor, Ohio and graduated from Oak Harbor High School in 1993. He went on to attend Terra Community Colleg e from 1994 1996 and graduated with an Associate in Science degree with a major in m arketing. Cary moved to Florida shortly after graduation in order to help his mother and brother who lived in Tampa. He began a career at Automatic Data Processing (ADP) as a software, database, and network support technician. Cary worked for ADP from 1997 2002. Following a year long position teaching computer certification courses from 2002 2003 at Hillsborough Community College, Cary decided to go back to school in order to pursue a doctorate in psychology. He returned to school at Saint Petersburg College and obtained an Associate of Arts degree in 2004 with a major in l iberal a rts. In 2004 he enrolled at the University of South Florida Saint Petersburg majoring in p sychology. He graduated Magna Cum Laude in the summer of 2005. From 20052006 he worked on a National Institute of Health (NIH) grant examining optimism training for parents who have children with Autism, under Dr. Mark Durand Ph.D. During this time he applied to graduate school and was successfully accepted at the University of Floridas American Psychological Association ( APA) accredited School Psychology Program. During this time Cary met his wife Laura, whom he married in November of 2007. While at t he University of Florida, Cary trained and worked closely with Dr. Eric Stroch and Dr. Gary Geffken treating and researching child and adult anxiety disorders. After successfully completing all graduate coursework, Cary was matched with the Childrens Hos pital of Michigan APA accredited internship program in pediatric psychology. Cary continues to treat anx iety disorders with an emphasis on Obsessive
88 Compulsive Disorder (OCD) in both adults and children after receiving his Ph.D. from the University of Florida in the summer of 2011.