3/10/2015. Help! My Brain s Stuck! Repetitive Behaviours (RBs) in Children and Adolescents. Conflicts of Interest. Test YOUR Repetitive Behaviour IQ

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1 Help! My Brain s Stuck! Repetitive Behaviours (RBs) in Children and Adolescents None to disclose Conflicts of Interest Drs. Kim Edwards, Holly McGinn, & Sandra Mendlowitz Ontario Psychological Association Conference Friday February 20 th, 2015 Test YOUR Repetitive Behaviour IQ Test YOUR Repetitive Behaviour IQ 1. Which is not an RB? (multiple choice: pick 1) A. Trichotillomania B. Onychophagia C. Autism D. Dermatillomania 2. RB's are maintained by (multiple choice: pick 1) A. A cycle of reinforcement B. Elevated dopamine levels C. School failure D. Allergies 3. What are the two most common comorbid disorders with Tourette Syndrome? 4. In early childhood (e.g., 2-6 yrs old), many children demonstrate some obsessive-compulsive behaviors that are part of normal development. (true/false) 5. Hair pulling usually develops as a result of a traumatic experience. (true/false) Learning Objectives (1) Presentation & assessment of TS, OCD, & TTM (2) Similarities & differences among RBs (3) Behavioural model of RBs & treatment (4) Developmental issues impacting treatment What are RBs? Why study RBs? Outline What causes & maintains RBs? (Behavioural Model) Tourette Syndrome (TS) Trichotillomania (TTM) Obsessive Compulsive Disorder (OCD) Similarities & Differences among RBs Developmental Issues Leaky Brake Analogy 1

2 Labels Body Focussed RBs What are RB s? Obsessive-Compulsive (OC) Spectrum Conditions Impulse Control Disorders Why Study RBs? Behaviours Dermatillomania/Excoriation (Skin Picking) Onychophagia (Nail Biting) Trichotillomania (Hair Pulling) Tics Compulsions Stereotypies (Autism) Nervous Habits or Actual Problems? RBs: Myths and Facts Etiology Not as severe as other psychiatric conditions Uncommon Socially acceptable Purposeful Only impact the individual with the RB Genetics Brain Circuits Cortico-striatal-thalamo-cortical (CSTC) circuits Neurotransmitters Dopamine, Serotonin, Noreepinephrine Environment Behavioural Model of RBs Behavioural Model of RBs Internal Environment Tics TTM External Environment Negative Reinforcement o absolved of expectations or demands Positive Reinforcement o attention, comfort, support, reward OCD 2

3 Meet Brad Tics & Tourette Syndrome (TS) Tics: Assessment & Diagnostic Issues Tics: Assessment & Diagnostic Issues Sudden, rapid, recurrent, non-rhythmic motor movements or vocalizations Motor Vocal Simple Blinking Throat clearing Complex Facial grimace + Head twist Echolalia Premonitory Urge Relatively common (20%) More common in boys (4:1) Tic Disorders (DSM 5): Tourette Syndrome Persistent (Chronic) Motor or Vocal Tic Disorder Provisional Tic Disorder Comorbid Conditions (The + in TS+) ADHD = 50%, OCD = % (Himle & Woods, 2005; Scahill et al., 2005; Scahill et al., 2009; Woods & Himle, 2004; Woods 2008) Course Comprehensive Behavioural Intervention for Tics Peak Severity Ages Onset Ages 4-7 Decline in severity for most Internal Environment: Habit Reversal Training Awareness Training Competing Response External Environment: Positive and Negative Reinforcement Psychoeducation (e.g., Leckman et al., 1998; Woods & Specht, 2013) (Woods et al., 2008) 3

4 CBIT Efficacy Tics: Tips & Tricks European clinical guidelines for TS & other tic disorders, 2011 Canadian guidelines for the evidence-based treatment of tic disorders, 2012 Practice Parameters for the Assessment & Treatment of Children & Adolescents with Tic Disorders, 2013 Education is often the only treatment needed Don t forget about the comorbid conditions Shift in the way we think about tics Ignore vs. Increase awareness? (Bennett et al., 2013) TTM (Hair-Pulling Disorder) Trichotillomania (TTM) DIAGNOSTIC CRITERIA DSM 4TR Impulse Control Disorders Not Elsewhere Classif. DSM-5: Obsessive Compulsive Disorders & Related Disorders DSM 4-TR Recurrent pulling out of one s hair resulting in hair loss Increasing sense of tension immediately before pulling out the hair / when attempting to resist behavior Pleasure, gratification, or relief when pulling out the hair Repeated attempts to decrease or stop hair pulling. The disturbance (hair pulling- DSM 5) is not better accounted for by another mental disorder and is not due to a general medical condition (e.g., a dermatological condition) The disturbance (hair pulling- DSM 5) causes clinically significant distress or impairment in social, occupational, or other important areas of functioning The hair pulling is not better explained by the symptoms of another mental disorder (e.g., attempts to improve a perceived defect or flaw in appears in body dysmorphic disorder) DSM 5 Developmental Perspectives Pulling/Picking Sites Site % Adults % Children Scalp Eyebrows Eyelashes Legs Arms Pubic 17 9 other 25 - More than one site - 58 The Trichotillomania Impact Project: Exploring Phenomenology, Functional Impairment, & Treatment Utilization J Clin Psychiatry 67:12, December 2006 Developmental Perspectives Pulling/Picking Characteristics Pulling/Picking Characteristic Adults % of time Children Unpleasant urges prior 71-89% 29% never/almost never experienced pre-tension To achieve a certain bodily sensation 30-70% 13% never/almost never pleasure or relief Preceded by bodily 71-89% - sensation Preceded by anxiety 0-10% - Urge increases when resisting 71-89% - Post pulling anxiety % - Awareness of pulling 71-89% 4% never/almost never The Trichotillomania Impact Project: Exploring Phenomenology, Functional Impairment, & Treatment Utilization J Clin Psychiatry 67:12, December

5 TTM -Rituals Tactile stimulation of lips or face. A need to pull in a particular manner. Ritualistically placing, saving, or discarding hairs. Twirling, rolling, or examining the hair. Hairs that don t feel right (i.e. coarse). Hairs that don t look right (i.e. color). Compelled to achieve an absolutely even hairline. Need to extract an intact hair bulb. Need to bite or mince the hair or bulb Swallowing hair (trichophagy) Comorbid Disorders DSM % Depression 57 Generalized Anxiety Disorder 27 Simple Phobia 19 Alcohol Abuse 19 Substance Abuse 16 OCD 13 Social Phobia 11 Eating Disorders 11 TREATMENT Treatment Cognitive Behavioral Therapy Identify dyfunctional thinking and challenge thoughts Relaxation training Behavioral Habit Reversal Training Awareness training Identify preceding urge, self-monitoring place (tv, bedroom, bathroom, etc), emotions, sensory; aware of triggers Stimulus control Reduce urge; techniques to prevent pulling Wearing gloves; holding pencils REMOVE environmental cues! Competing response Incompatible behaviors at onset of urge Engaging in physically incompatible behavior making a fist until the urge diminishes Habit Reversal Training TTM Keys to Successful Outcomes Thorough and knowledgeable assessment Emphasize treatment is a progress Motivational for change Use of first line treatments: Cognitive Behavioral (CBT) and Habit Reversal Training Obsessive-Compulsive Disorder (OCD) 5

6 Meet Claire OCD: Assessment & Diagnostic Issues Obsessions and/or compulsions that take up more than an hour a day and cause significant distress or impairment Obsessions Recurrent and persistent thoughts, urges, or images that are intrusive and unwanted Compulsions Repetitive behaviors or mental acts that one feels driven to perform in response to an obsession or according to rules OCD: Assessment & Diagnostic Issues Common themes: Contamination and cleaning Checking or symmetry Ordering or counting Fear of harm to self or others Lifetime prevalence = approx. 2%, chronic, fluctuates Mean age of onset is bimodal peaks at 11 and 23 years 1 st Peak Early-onset OCD Age 11 More common in boys than girls More likely comorbid with tics Generally more severe 2 nd Peak Age 23 Treatment Guidelines for OCD (CBT and SSRIs) Efficacy CBT alone or CBT with SSRI Practice Parameters for the Assessment & Treatment of Children & Adolescents with OCD, 2012 Cognitive Behavioural Therapy (CBT) CBT for OCD: Critical Components Controlled studies support the efficacy of Cognitive Behavioural Therapy (CBT) that emphasizes Exposure and Response Prevention (ERP) Parental involvement is crucial for success Child not responsible for controlling symptoms Parents do not accept symptoms Parents accept/tolerate symptoms Child responsible for controlling symptoms Treatment Component Psychoeducation Symptom Monitoring Relaxation Training Cognitive Strategies Exposure & Response Prevention (ERP) Homework Operational Definition Both the child and the family need to have an accurate understanding of OCD Identify/track sx frequency and duration; Set targets to work towards Deep Breathing, Muscle Tension Relaxation, Imagery Generate and reinforce accurate thoughts to challenge obsessions and compulsions Confronting an OCD-eliciting situation (action, object, place, etc.) while preventing the associated compulsions and/or avoidance Change cannot occur exclusively through CBT sessions; strategies must be practiced at home 6

7 Childhood OCD: Tips & Tricks Childhood and adult OCD are more similar than not. However, some differences exist : Obsessions develop later that compulsions Poor insight is more common in children Comparing & Contrasting RBs Children tend to under-estimate the impact of their OCD Children are more likely to present with comorbid OCD and tics Similarities vs. Differences Similarities vs. Differences 8 statements on the next 2 slides Decide whether statement is a similarity (applicable across the RBs discussed OCD, TTM, TS) or whether it is a difference (applicable to 0,1 or 2 but NOT all RBs discussed) (1) Behaviour done in response to a sensation (2) Comorbidities are common & frequent (3) Competing responses are part of treatment (4) Onset usually before age 10 Similarities vs. Differences (5) Symptoms wax and wane (6) Personal distress required for treatment How did you do? (7) More common in males (8) Medications could be useful 7

8 Similarities vs. Differences Comprehensive Comparison Similarities (2) Comorbidities = common + frequent (5) Symptoms wax & wane (8) Medications could be useful Differences (1) Behaviour done in response to a sensation (3) Competing responses are part of treatment (4) Onset usually before age 10 (6) Personal distress required for treatment (7) More common in males Developmental Issues An Analogy for Understanding RBs I m not sure if I m ready to change Unconcerned by RB Lack of insight into RB Parent involvement Brake Shop Model Welcome to the Leaky Brake Club Leaky brakes over attention +/or impulsivity (ADHD) Leaky brakes over thoughts (OCD) Leaky brakes over movements and/or sounds (TICS) Leaky brakes over behaviour (ODD, CD, rage) Leaky brakes over senses (Sensory integration disorder) Take Home Messages Patient & Family Resources Leaky Brakes = Help child understand RB Society: Just Stop vs. Patient: I would if I could Awareness of behaviour & reinforcement patterns RBs = a spectrum Function of behaviour important differential More research needed! 8

9 Clinician Manuals/Resources Woods & Miltenberger (2001). Tic disorders, trichotillomania, and other RB disorders: Behavioural Approaches to Analysis and Treatment. USA: Kluewer Academic Publishers OCD OCD in Children and Adolescents: A Cognitive-Behavioral Treatment Manual by John March and Karen Mulle Tics Woods et al., (2008). Managing TS: A behavioural intervention for children & Adults. Therapist Guide. USA: Oxford University Press. Thank You Questions, Comments, Thoughts Contact Information: kim.edwards@sickkids.ca holly.mcginn@sickkids.ca sandra.mendlowitz@sickkids.ca TTM Golomb & Vavrichek ( 2000) The hair pulling habit and you: How to solve the TTM puzzle. Maryland: Writers Cooperative of Greater Washington. 9

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