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The use of exposure therapy for students with obsessive compulsive disorder

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Obsessive Compulsive Disorder
Advisor: Joanne Seelaus, Ed.D.
The Use of Exposure Therapy for Students with Obsessive Compulsive Disorder
Samantha Zelevansky
Master of Arts - Special Education
Submitted in partial fulfillment
of the requirements for the degree of
Master of Arts in the
Graduate Program
Caldwell College
2010
1
UMI Number: 1475135
All rights reserved
INFORMATION TO ALL USERS
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In the unlikely event that the author did not send a complete manuscript
and there are missing pages, these will be noted. Also, if material had to be removed,
a note will indicate the deletion.
UMI 1475135
Copyright 2010 by ProQuest LLC.
All rights reserved. This edition of the work is protected against
unauthorized copying under Title 17, United States Code.
ProQuest LLC
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Obsessive Compulsive Disorder
2
Abstract
People who suffer from obsessive compulsive disorder (OCD) can be characterized
as being caught in a pattern of repetitive behaviors that are frequently accompanied by
fearful and irrational thoughts. These behaviors are difficult to overcome and can have a
significant impact on day-to-day life. Students who suffer from OCD can have difficulty
functioning inside and outside of the classroom. This single-subject study attempted to
evaluate whether exposure therapy, a type of cognitive behavior therapy, can reduce the
occurrence of several in-class compulsive behaviors. Various methodologies were used to
triangulate data during this study. These methods consisted of observations, teacher
surveys and data collection through the use of differential reinforcement of other
behavior (DRO). This study provides some evidence that exposure-based therapy may aid
in reducing the incidence of obsessive compulsive behaviors.
Obsessive Compulsive Disorder
Table of Contents
CHAPTER 1- INTRODUCTION
Introduction
Statement of Problem
Research Question
Definition of Terms
4
4
4
5
6
CHAPTER 2- REVIEW OF LITERATURE
Definition of Anxiety Disorders
Types of Anxiety Disorders
Obsessive Compulsive Disorder
Obsessive Compulsive Disorder and Family
Obsessive Compulsive Disorder and Children
Obsessive Compulsive Disorder and School
Obsessive Compulsive Disorder and Autism
Treatments
Conclusion
8
8
9
10
11
12
12
13
14
15
CHAPTER 3- METHODOLOGY
Sample
Materials
Procedure
Data Collection
17
17
19
20
20
CHAPTER 4- ANALYSIS OF DATA
Results of Study
Data Analysis
Limitations
Implications for Teaching
Conclusion
22
22
25
26
27
28
REFERENCES
29
APPENDIX A
Administrative Consent Form
Parental Consent Form
32
32
33
APPENDIX B
DRO Tally Sheet
Behavior Report Card
34
34
35
3
Obsessive Compulsive Disorder
4
Chapter 1
Introduction
Statement of the Problem
People who suffer from obsessive compulsive disorder (OCD) can be characterized
as being caught in a pattern of repetitive behaviors that are frequently accompanied by
fearful and irrational thoughts, such as illness, death and making a mistake that would
have a disastrous result. These behaviors are difficult to overcome and can have a
significant impact on day-to-day life. Students who suffer from OCD can have difficulty
functioning inside and outside of the classroom. OCD can manifest itself in the
classroom in many ways. Students who suffer from OCD may have trouble getting to
school on time because of the rituals they have to perform before leaving the house, such
as washing their hands or ordering their belongings. The time consumed by obsessions
and compulsions can lead to dysfunction in social relationships, failure to complete
schoolwork and deeper anxiety.
As educators, it is important to recognize the symptoms of students with OCD so
teachers can provide strategies to reduce their obsessive compulsive behaviors. With
proper support, students will develop the skills needed to lead productive lives in the
classroom and in the larger world. Proper support will enable students to challenge
irrational thoughts and cope with the anxiety that defines OCD. When students learn to
confront their fearful thoughts and refrain from performing ritualistic behaviors, they will
be able to overcome the many academic, social and emotional challenges associated with
the disorder. The objective of this study was to provide exposure-based cognitive
behavior therapy to decrease the behaviors that prevent students with OCD from
succeeding in the classroom.
Obsessive Compulsive Disorder
5
Purpose of the Study
The purpose of this study was to lessen the obsessive compulsive behavior of
Annie, a 19-old student with OCD and autism who attends a private school for students
with special needs. It examined the effects of exposure therapy on the ritualistic behavior
and compulsions she displays in the classroom that can become disruptive to her teachers
and classmates. Such behaviors include repeatedly saying the names of her classmates,
looking at her watch and arranging the words on her school work in alphabetical order.
Now that she is 19 and unable to be placed in a work setting, it is imperative that steps
are taken to help Annie try and diminish these behaviors so she can lead a productive life
post-graduation and seek employment. This study provides educators with the
appropriate knowledge to identify and reduce the behaviors associated with OCD, while
helping Annie to lessen the obsessive compulsive behaviors that hinder her ability to
function in the classroom. As a result of this study, Annie may be more likely to succeed
in a school environment.
Hypothesis
It is hypothesized that exposure-based cognitive behavior therapy will lessen
Annie’s obsessive compulsive behavior.
Importance of the Study
It is important to find a successful treatment that can help Annie overcome the
considerable academic, social and behavioral difficulties related to OCD. Annie has a
year and a half left of school until she will graduate. She is currently unable to leave
school for job training as her peers do because of her compulsive behaviors. Additional
knowledge will help Annie’s teachers appropriately intervene when she is trapped
Obsessive Compulsive Disorder
6
performing an obsessive compulsive behavior. Exposure-based therapy may provide
Annie the confidence and control she needs to ease her fears.
Definition of Terms
For the purpose of this study, the following definitions will be used.
Obsessive Compulsive Disorder- An anxiety disorder characterized by the presence of
obsessions or compulsions (Adams & Burke, 1999).
Obsession- Thoughts, impulses, urges, or images that seem to force their way into a
person’s thinking (Adams & Burke).
Compulsion- A behavior that is performed intentionally to reduce the anxiety or
discomfort brought on by obsessions (Adams & Burke).
Cognitive Behavior Therapy- An approach to dealing with OCD where the patient
voluntarily and deliberately confronts a feared object or idea either directly or by
imagination (Purcell, 1999).
Differential Reinforcement of Other Behaviors (DRO) – Delivering reinforcement when
a target behavior is not emitted for a specified period of time (Alberto & Troutman,
2006).
Exposure Therapy – A procedure in which patients are forced into confronting a feared
object or situation, and then prevented from responding with their usual ritual (McGough
& Speier, 1993).
Assumptions and Limitations
One assumption is that Annie will be willing to cooperate with the exposures, as
her OCD behaviors have been a part of her life since she was a child, and it is difficult to
change behavior that has been rooted for so long. It is also assumed that there will be
Obsessive Compulsive Disorder
7
carry over between school and home, so Annie is able to practice the exposures outside of
school.
This study is limited to the amount of data that can be collected in a 16-week
period. It is also limited to the cooperation of Annie’s family in providing vital
background information on her history of OCD behaviors.
Plan of Study
The subject of this study was a high school student with OCD. The study examined
the effects of exposure therapy on the behaviors displayed by the student. Differential
reinforcement of other behavior (DRO) data was collected, as well as observations of the
student and teacher surveys, to better understand the timing and location of the OCD
behaviors. Baseline data on the frequency of the behaviors was collected for 1 week prior
to the introduction of the intervention. An analysis of the results from the DRO data,
observations, and teacher surveys provided insight into the student’s behavior.
Obsessive Compulsive Disorder
8
Chapter 2
Literature Review
Habits and routines are a normal part of living. There are habits that help keep
people safe and healthy, and rituals and routines that are calming and comforting.
However, for individuals with obsessive compulsive disorder, or OCD, obsessive
thoughts can cause repeated performance of ritualistic behaviors and routines or
compulsions. These behaviors can last for hours at a time and can interfere with work,
family and school. Most people with the disorder recognize that what they are doing is
senseless, but they are unable to stop it (Dickey, 1994).
Anxiety Disorders
Anxiety disorders are the most common mental illness in the United States,
affecting 40 million adults age 18 and older. Anxiety disorders may develop from a
complex set of risk factors, including genetics, brain chemistry, personality and life
events. Despite the fact that these disorders are treatable, only about one-third of those
suffering from an anxiety disorder receive treatment (Anxiety Disorders Association of
America [ADAA], 2009) Common characteristics of anxiety disorders include excessive
unease and worry occurring more days than not for at least 6 months. This worry can be
about any number of events or activities such as work or school performance, and is often
accompanied by physical symptoms such as fatigue, headache and nausea (American
Psychiatric Association Diagnostic and Statistical Manual of Mental Disorders, 1994).
Anxiety disorders can prevent people from coping and can disrupt daily life. Anxiety
disorders are not just a case of nerves, but illnesses, often related to biological makeup
and life experiences of the individual (Dickey, 1994).
Obsessive Compulsive Disorder
9
Types of Anxiety Disorders
There are many types of anxiety disorders, such as generalized anxiety disorder
(GAD), panic disorder, post-traumatic stress disorder (PTSD), specific phobias, social
phobias and obsessive compulsive disorder. GAD affects approximately 4 million adults
and is twice as common in women as in men. Individuals who suffer from GAD have
persistent worries about issues such as health, family and money and are not able to “snap
out of it.” Symptoms can include lack of concentration, fatigue and tension (Cancro,
2007).
Panic disorder is an intense fear that lasts for about 10 minutes or less. The
symptoms often mock those of a heart attack. It affects over 2 million adults and is once
again more common in women than men. Panic disorder can lead to avoidance of fearful
situations, such as elevators or crowds. Many people who suffer from panic disorder
become housebound because they are fearful of leaving the home in anticipation of
having another panic episode (Cancro, 2007).
Post-traumatic stress disorder occurs when an individual who has been exposed to
a traumatic event that threatened serious injury or death. Typically, the person’s response
to the experience involved fear and helplessness. Individuals who suffer from PTSD
frequently avoid situations in which they associate the event and can lead to intense
psychological stress (Cancro, 2007).
Approximately 6 million adults experience a specific phobia. Specific phobias are
intense fears associated with an object or situation that poses little or no real danger, such
as heights, animals or escalators. Specific phobias can start in childhood and persist
through adulthood. Individuals typically avoid the object or situation rather than try to
Obsessive Compulsive Disorder
10
face it. Similarly, social phobias are deep fears of social situations that can include
addressing a large group or becoming embarrassed or judged in front of other people.
Phobias affect over 3 million adults with men and women being equally likely to have the
condition. It too tends to start in childhood and continue on through adulthood (Cancro,
2007).
Obsessive Compulsive Disorder
Obsessive compulsive disorder can produce persistent thoughts, or obsessions,
that are difficult to ignore. Many people who suffer from OCD find that performing
certain rituals, or compulsions, can relieve the anxiety associated with the obsessive
thoughts. These compulsions can include repeatedly checking to make sure doors are
locked and the gas is turned off, repeating a name or a preoccupation with numbers.
Common in men and women, OCD affects over 3 million adults and can develop in early
childhood, becoming progressively worse into adulthood. The disorder can become
incapacitating when it is severe (Cancro, 2007). OCD is diagnosed when the compulsive
behaviors consume at least an hour a day and interfere with daily life (Dickey, 1994).
Historically, it has been thought that individuals with OCD perform compulsions as harm
avoidance, but researchers have discovered other underlying factors that may be
important, such as a feeling of incompleteness or imperfection (Pietrefesa & Coles,
2006).
According to Purcell (1999), OCD is generally a chronic disorder and sufferers
may have symptoms for decades. It is believed that neurobiological factors rather than
environmental influences are the primary cause of the disorder. Much of the research
points to a complication in the transmission of serotonin, one of the major chemicals
Obsessive Compulsive Disorder
11
found in the brain (Adams & Burke, 1999).
OCD and Family
OCD can run in families and may also have a genetic link (ADAA, 2009) A
growing body of literature points to family dynamics including distress, accommodation
and blame that may influence the nature and course of the disorder. Accommodation, the
process by which family members assist or participate in the individual’s rituals, is well
documented in OCD literature. According to a study conducted by Peris et al. (2008),
rates of accommodation among families with youths affected by OCD can be up to 75%.
Although not well studied, accommodation is likely to burden families, maintain OCD
symptoms and reinforce fear and avoidance behaviors, which can undermine progress
made through exposure-based treatments (Peris et al.).
Many parents struggle with the feeling that when they set limits by refusing to
accommodate the OCD, they are leaving their child to suffer with the disorder alone
(“Parenting a Child with OCD,” 1997).
Peris et al. (2008) state that “families of
individuals with OCD are put in a troubling double bind: altering routines to make way
for obsessive compulsive symptoms poses a significant burden, but refraining from the
accommodation is itself a difficult and stressful task” (p.1174). According to ChoateSummers (2008), some parents act preemptively to protect their child from situations that
may cause anxiety, therefore accommodating the OCD behaviors. This may be effective
in the short term, but leads to more difficulty in ultimately conquering an OCD symptom
or ritual.
Parents need to have tools such as differential attention and modeling, to help
their child deal with OCD. Behavioral reinforcements, such as stickers, praise or
Obsessive Compulsive Disorder
12
privileges can be effective in increasing a child’s motivation to cooperate with
treatments. Families are encouraged to develop a reward program specific to their child
(Choate-Summers et al., 2008).
OCD and Children
OCD affects 2-3% of children and adolescents, though these figures may
underestimate the fact that many children under the age of 9 tend to be secretive about
OCD symptoms and may have difficulty expressing their feelings to others. Current
treatment approaches have typically excluded children under the age of 7 because OCD
symptoms can be different in children and adults. Young children may have trouble
articulating the feared outcome behind their compulsions, which can make it difficult to
tell the difference between repetitive behaviors and developmental factors such as
bedtime routines, which are common in this age group (Choate-Summers et al., 2008).
Children with pervasive developmental disorders may exhibit stereotypical behaviors, but
these generally lack the cognitive anxieties that drive the rituals of OCD (McGough &
Speier, 1993).
Compulsive ordering and arranging are often seen in children with OCD. In a
study of the development of OCD, it was found that nearly half the sample of children
with OCD were engaged in ordering and arranging behavior (Radomsky & Rachman,
2003). Dickey (1994) states that if OCD becomes severe enough, it can keep a person or
child from holding down a job or carrying out normal responsibilities at home.
OCD and School
OCD can manifest itself in the school setting in many ways. Teachers may
observe a student with OCD arranging items on his or her desk until they are
Obsessive Compulsive Disorder
13
symmetrical, avoiding direct contact with door handles or knobs or making excessive
requests to use the bathroom (Adams & Burke, 1999). Tardiness is also a constant
problem for students who have trouble leaving the house before performing compulsive
rituals.
According to Purcell (1999), there are many issues that educators should consider
when dealing with students with OCD. Teachers should be educated on the disorder and
work with school psychologists as necessary to identify OCD symptoms and behaviors.
Other strategies for teachers include using a timer to help the student stay on task or
having the student work in a cooperative group where he or she can avoid getting trapped
by the urge to make constant revisions. Educators must also have a great deal of patience.
If a student with OCD is engaged in a lengthy ritual that is holding up the rest of the
class, the class should move forward without the student. Another strategy would be for
the OCD student to work with the teacher to set up a signal for when he or she is stuck in
a ritual and needs help. Relaxation techniques and cognitive behavior therapy are also
considerations to aid a student with OCD in the classroom, and cooperation and
partnership between school and home are important to the success of these students.
Obsessive Compulsive Disorder and Autism
There is research that links OCD and autism. Approximately 2% of children with
autism also have OCD (Lehmkuhl, Storch, Bodfish, & Geffken, 2007). Research suggests
that as many as 84% of children with autism also have an anxiety disorder. Behavior
symptoms of autism and anxiety can include repetitive movement, ritualistic or
compulsive behavior and atypical attention (Lytle & Todd, 2009). An issue that has
received some attention is whether secondary OCD should be diagnosed in individuals
Obsessive Compulsive Disorder
14
with autism. It can be hard to diagnose OCD in children with autism because of the
difficulty in telling the difference between repetitive behaviors, obsessions and
compulsions. The DSM IV (1994) suggests that repetitive behavior is a source of pleasure
in autism, but a source of anxiety in OCD. Children with autism are often described as
being obsessed with an item or area of knowledge, but the obsession is enjoyed and does
not cause anxiety as seen in OCD (Zandt, Prior, & Kyrios, 2006).
Treatments
Treatment options for OCD have improved over the years. The two most effective
are cognitive behavior therapy (CBT) and selective serotonin reuptake inhibitors (SSRI).
Studies have shown that more than 75% of OCD patients have been helped by medication
and shown a lessened intensity of symptoms. However, it is usually found that the
discontinuation of a SSRI leads to a relapse. Most individuals with OCD have to continue
with medication indefinitely (Purcell, 1999).
Behavior therapy by exposure and response prevention is highly effective for
OCD with about 75% of patients showing long-term improvement (Foa, Abramowitz,
Franklin, & Kozak, 1999). CBT is made up of three parts: exposure, response prevention
and cognitive therapy. Exposures place individuals in anxiety inducing situations that
invoke compulsions, and response prevention prohibits the compulsion or ritualistic
behavior from occurring (Sloman, Gallant, & Storch, 2007). For example, an individual
who fears germs and constantly washes his or her hands would be made to touch many
surfaces and then to refrain from washing his or her hands. This treatment is designed to
slowly guide a patient to tolerate the anxiety and to control his or her rituals so he or she
can eventually resist compulsions (Purcell, 1999).
Obsessive Compulsive Disorder
15
Fear hierarchies are the basis for exposure-based CBT. The development of the
fear hierarchy affords the opportunity for an individual to describe anxiety-provoking
events, and allows a therapist to better understand the state of the symptoms. The
hierarchy targets situations that provoke rituals. Naturally, the individual, with assistance,
begins exposures to the feared situation or object starting with the least distressing
(Sloman et al., 2007).
When working with children or young adults, setting up point reward systems
may facilitate exposure participation. For instance, if the child completes an exposure he
or she will receive one point, and each point earns the child 10 minutes of a computer or
puzzle (Sloman et al., 2007). Points can be carried over to home from school to help
prevent accommodation from occurring at home.
Behaviorally, OCD involves a cycle of continuous negative reinforcement. An
individual experiences distress from an obsession followed by performing a compulsion
to reduce his/her anxiety. This process prevents the behavior from naturally stopping and
increases the chance of future ritual performance (Sloman, et al., 2007). Although
behavior therapy and medications, alone or in combination, are effective for large
numbers of individuals with OCD, additional treatment components are essential in many
cases. Included among these are continued therapy, social skills training, support groups
and individual and family therapy (Adams & Burke, 1999).
Conclusion
OCD is a debilitating type of anxiety disorder for affected individuals and their
families. If left unmanaged, the severity of the symptoms can affect performance at work,
school or in social situations. CBT and medical interventions, along with the proper
Obsessive Compulsive Disorder
16
support from families, have greatly aided the treatment of OCD. Exposure-based
treatments have proven to be successful and can gradually be increased as the individual
becomes more comfortable.
Obsessive Compulsive Disorder
17
Chapter 3
Methodology
People with OCD can have difficulty maintaining relationships or keeping a job.
Students may have problems getting to school on time or completing schoolwork because
of their compulsive behaviors. If a student with OCD does not receive any intervention,
he or she is likely to fall behind at school. In the interest of preventing these possible
outcomes, this study attempted to verify whether exposure therapy lessens the obsessive
compulsive behaviors of a student with OCD.
Sample
This study included a 19-year-old female from an Orthodox Jewish community
who has been diagnosed with OCD and autism. She was chosen for this study due to the
severity of her compulsive behaviors. This study was conducted in a private school for
students with severe learning and/or language disabilities, autism or multiple disabilities.
There are 10 to 12 students in each class with one special education teacher and one
paraprofessional. The students are grouped by age, ranging from 5 to 21. The ratio of
males to females is fairly equal in each class. Annie, the student selected for this study, is
in a classroom with students aged 18 to 20. The students in her age group go out to work
for a few hours two to three times a week. There are six 45-minute periods in a school
day, three of which are spent outside of the homeroom; one in a math class, one in an
English class, and one in a gym, art or music class. In any given day, Annie may
transition between as many as four different classrooms and teachers.
Annie has several different obsessive compulsive behaviors that prevent her from
paying attention and completing her school work. These behaviors include repetition of
Obsessive Compulsive Disorder
18
student and teacher names and an insistence on arranging words in alphabetical order
before completing an assignment. Annie also has a preoccupation with numbers and will
recite multiplication tables out loud when she is anxious. These behaviors quickly
become disruptive to the other students in her class. Furthermore, when Annie starts a
behavior, it can be increasingly difficult to redirect her to her assignments and tasks.
The most challenging obsessive compulsive behavior Annie exhibits is her need
to look at her watch when the date matches the time. For example, on September 21
(9/21), Annie must look at her watch at 9:21, or she will become extremely anxious. She
has to be seated on a chair or step when she looks at her watch at this specific time or she
does not feel safe. Annie will start to get anxious as the time grows near, as she fears she
will not be able to match the date and time in a location where she can be seated. This has
a negative impact on her productivity because she is not able to focus on anything besides
her watch. Annie will have a panic attack if she is not able to match the date and time
each day.
This has been very problematic at school, even becoming a safety issue. Annie
will not leave the building during a fire drill if it happens to fall on the time she looks at
her watch. It has also caused her to lose a job because she refused to leave her job site to
board a bus back to school, and instead threw an angry tantrum.
Several strategies have been put in place to try and reduce Annie’s compulsive
behaviors. Attempted strategies to reduce her compulsions include social skills training,
a school-wide point system to earn participation in special school events and simply
taking her watch away for the day. These strategies do not address the root of the
behaviors, which is an increase in anxiety when she is not allowed to perform the
Obsessive Compulsive Disorder
19
compulsion. Annie’s anxiety can increase to the point of hyperventilation, pacing and
refusing to comply with adult directives. Point and reward systems have been
unsuccessful because Annie is only able to refrain from some of her compulsions for
short periods of time. While removing the watch seems like an obvious tactic, it needs to
be taken in gradually increased increments of time, or exposures, so that trust is
established between Annie and the adult taking the watch. If trust is not established,
Annie will not surrender her watch without a struggle.
In order to reinforce these kinds of behavior strategies, there must be carry-over
between school and home. The strategies will not be effective if the compulsive
behaviors are accommodated outside of the school setting. Therefore, teachers and family
members must be consistent with setting rules and boundaries for the types of behavior
that will be accepted in both home and school.
Other students with OCD may benefit from the use of the strategies in this study,
which may result in them being more focused at school and more comfortable overall.
With decreased anxiety levels and diminished compulsive behaviors, they will be able to
lead more productive lives.
Materials
Few materials were needed for this study. Annie is driven by puzzles, math
worksheets, computer games and calendars. These were used as reinforcers because they
were Annie’s favorite rewards for good behavior. DRO sheets were used to tally the
number of intervals of time Annie abstained from a behavior. Tallies were awarded for
the successful completion of each interval. Tally sheets were also be used to record the
frequency of Annie’s compulsive behaviors. A clear, plastic container was used to hold
Obsessive Compulsive Disorder
20
Annie’s watch when she was not wearing it.
Procedure
Baseline data was collected for 1 week to record the frequency of Annie’s
compulsive behavior during each period of the school day. These behaviors included
reciting multiplication tables aloud, repeating classmate names and looking at her watch.
During the baseline phases of this study, Annie was allowed to perform her compulsive
behaviors in her usual manner. She was verbally reprimanded and not allowed any
reinforcers, such as math worksheets, puzzles or calendars when she disrupted the class.
Following the baseline period, Annie began her exposures. DRO data was
collected, during which time Annie received a tally for every 4 minutes she did not
perform a compulsive behavior. Once she accumulated ten tallies, Annie received 10
minutes of a selected activity such as a math worksheet or computer game. The time was
gradually increased from 4 minutes to 10 minutes as she became more comfortable.
Additionally, Annie was asked to leave her watch in a small, clear container on
her teacher’s desk when she arrived at school every morning. The time spent without the
watch on her wrist began at 10-minute intervals and gradually increased to a full class
period as she became more comfortable. Trust was established between Annie and her
teacher as she realized that her watch was kept safe in a clear container and returned to
her at the end of each interval.
Data Collection
This study used three types of data collection methods to allow for triangulation of
data (Hendricks, 2006). Observational data, such as anecdotal notes, DRO tally sheets
and teacher surveys were collected. At the end of the study, the tallies were transferred
Obsessive Compulsive Disorder
21
to a line graph to help in analyzing the interventions. The researcher looked for
themes within the data and drew conclusions from it. The subject’s name was changed to
protect confidentiality.
Obsessive Compulsive Disorder
22
Chapter 4
Analysis of Data
Individuals with obsessive compulsive disorder can be characterized as having
intrusive thoughts or images (obsessions) and repetitive behaviors or rituals
(compulsions) to relieve anxiety, which interfere with daily functioning (Lehmkuhl et al.,
2007). This study investigated the effects of exposure-based therapy to reduce the
obsessive compulsive behavior of a student with OCD.
Results of Data
Through the use of differential reinforcement of other behavior (DRO) data, this
researcher observed and tallied each occurrence of a predetermined set of obsessive
compulsive behaviors during 45-minute intervals. The participant received a tally for
each period of 4 minutes that she was able to refrain from reciting multiplication tables
aloud, repeating classmate names, and looking at her watch. Annie could receive a 5minute break for earning five tallies or a 10-minute break for earning ten tallies. Once
Annie accumulated five tallies, she was allowed to select a reward of her choice, such as
a math worksheet or computer game. Annie was to carry her tally chart with her
throughout the day so DRO data could be collected in all of her academic classes.
Baseline data was collected during Week 1, as Annie demonstrated her compulsive
behaviors in her usual manner (see Graph 1). During Weeks 2-16, this researcher began
the intervention. Each morning, following a brief explanation, Annie would select the
reward she was to receive for earning enough tallies.
Obsessive Compulsive Disorder
23
Graph 1.
Annie showed a significant decrease in compulsive behaviors in the first week of
the intervention, from 71 to 39 occurrences. However, there was a significant increase in
her behaviors in Weeks 5 (69 occurrences) and 15 (56 occurrences). Week 5 marked
Annie’s return from Thanksgiving vacation and as a result, she had some difficulty
readjusting to the requirements needed to earn tallies. Week 15 also presented a
challenge, as Annie’s progress was disrupted by several school closings due to snow.
During Week 8 of the DRO data collection, this researcher began asking Annie to
leave her watch in a small plastic container on her teacher’s desk when she arrived at
school. Initially, the watch was to be left in the container for 10-minute intervals, which
Obsessive Compulsive Disorder
24
were to gradually increase to a full class period as Annie became more comfortable
without the watch. This component of the study proved to be quite challenging because
of how resistant Annie was to the idea of parting with her watch. At the start of Week 8,
Annie complied by putting her watch in the container, but only for the first period of the
day; she insisted on getting it back when she had to leave the classroom. During the
following week (Week 9), Annie had 33 occurrences of compulsive behaviors. Though
she looked at her watch less frequently (due to being without it for part of the day), she
increased her other behaviors to compensate.
At the end of Week 10, Annie’s watch broke during physical education class,
causing her to become very upset. Her homeroom teacher observed that she was “not able
to focus on her assignments and instead, anxiously paced around the classroom asking for
someone to fix her watch.” The teacher also stated that “Annie could not be reassured
that the time on the classroom clock was accurate.” This caused her to become more
upset, because she was unable to match the wall clock to her watch. Once Annie’s family
replaced the broken watch, this researcher was no longer able to successfully retrieve it
from Annie at the start of class, thus ending this component of the study.
Observations were also recorded in anecdotal report format. These data yielded
similar results to those noted in the DRO data collection. Annie was observed during 15minute intervals. During Week 1, prior to intervention, Annie appeared very anxious and
had much trouble attending to class instruction. She would recite multiplication tables
aloud, necessitating her teacher to constantly remind her to listen to directions. Following
the introduction of the intervention (Weeks 2-3), Annie showed an interest in earning
rewards for refraining from reciting multiplication tables, reciting names and looking at
Obsessive Compulsive Disorder
25
her watch. She showed a decrease in these compulsive behaviors and appeared less
anxious. On Weeks 4, 8, 10, 11 and 14, Annie was not recorded as having any
compulsive behaviors; she completed her assignments and participated in class activities.
During these weeks, she appeared happy and relaxed.
In addition, Annie’s teachers were given a survey upon completion of the DRO data
collection to determine whether Annie’s compulsive behaviors during their classes had
decreased over this period. The teachers were asked to describe Annie’s compulsive
behavior as occurring “never,” “seldom,” “sometimes,” “usually,” or “always.” When
asked if Annie was looking at her watch less frequently during the intervention, most
teachers answered “sometimes.” When asked if Annie recited classmates names and
multiplication tables less frequently during the intervention, most teachers answered
“usually.”
Analysis of Data
The results of the DRO sheets, observations and teacher survey were all in
agreement. Annie demonstrated improvement in the reduction of her compulsive
behaviors, though this improvement lacked consistency on a weekly basis. This is evident
(see Graph 1) in Weeks 2-5 when the number of occurrences spiked from 39 to 60, then
dipped to 0, then spiked back to 69 over the 4-week period where a teacher reported that
Annie was frequently repeating names and multiplication tables aloud. This also
happened in Weeks 14-16 when the number of occurrences went from 0 to 56 to 17.
There was a slight pattern, or cycle, to her compulsive behavior. This appeared to be
consistent with Annie’s difficulty straying from her normal routine of performing certain
behaviors. The return of these behaviors could be attributed to a change at home or
Obsessive Compulsive Disorder
26
structure in the classroom. The unexpected snow days altered Annie’s routine and made it
difficult for her to attend in class upon her return. Annie’s homeroom teacher reported
that she was “unfocused and repeating classmates’ names over and over” when she
entered the classroom after 2 days off from school. Another teacher reported that every
time Annie has a school absence, “she has to reset herself” to get back into her routine
because she was not used to being home during the week.
Limitations
There were a few limitations encountered during this study. Annie’s DRO charts
were passed between three teachers each day over the 15-week period of data collection.
Each teacher may have had a different level of tolerance for the three behaviors being
observed, therefore resulting in more or fewer tallies than another teacher. Perhaps if the
study had continued, the teachers could agree on a level of acceptable behavior.
Furthermore, the DRO data could not be collected reliably for the same amount of time
each day due to school assemblies, teacher absences and other unplanned events.
Another limitation was Annie’s school absences due to difficulty at home with
OCD behaviors and an atypical number of snow days during Weeks 9 and 15. These
changes in routine caused setbacks in Annie’s progress.
There were also limitations due to the setting as well. Because this study was only
conducted at school, it was difficult to determine whether the compulsive behaviors were
being tolerated at home. According to Annie’s parents, the behaviors performed at school
were not always present at home or were tolerated because other compulsions proved to
be more difficult to manage.
Obsessive Compulsive Disorder
27
Discussion
Overall, Annie demonstrated slight improvement in reducing her obsessive
compulsive behaviors. Sloman et al. (2007) suggest that reward systems may assist with
exposure-based therapy for young adults with OCD. Rewards were successful for Annie,
although not consistently over the 15 weeks. Given the results of this study, particularly
the dips and spikes in the DRO data, this researcher cannot conclude that exposure-based
therapy alone can reduce OCD behavior. In most cases, additional treatment such as
support groups or therapy is necessary to combat OCD behaviors (Adams & Burke,
1999).
Implications for Teaching
Although the data did not reveal a consistent change in Annie’s behavior, this
researcher would continue to use the DRO tally sheets throughout the remainder of the
school year. Due to the nature of Annie’s obsessive compulsive disorder, it is possible
that further research into the cycles of her obsessive behavior would be beneficial. While
time consuming and difficult to manage, the results may be more consistent if only one
behavior at a time is addressed. Furthermore, attempts to take Annie’s watch away
proved to be unsuccessful, possibly because too many compulsions were being addressed
at one time. Overall, the study helped Annie to stay on task and become more involved in
class lessons, however, the compulsive behaviors proved to be more powerful than a
reward on some days. It may also be helpful to involve Annie’s family more, as they
could provide more potent rewards or privileges at home to build upon the success at
school. If this study were to be conducted again with another student, this researcher
would collect more baseline data at the beginning of the school year to look for cycles or
Obsessive Compulsive Disorder
28
trends in the compulsive behaviors. Parent interviews would also certainly provide
insight into the nature of these behaviors. Working with the school behaviorist to
implement some calming or decompressing techniques to use with the student at the start
of each day would also ease the transition into exposure therapy.
Conclusion
This study demonstrated that exposure therapy through the use of differential
reinforcement of other behavior might have helped reduce the compulsions of a student
with obsessive compulsive behavior. Providing the student with rewards for refraining
from a compulsion had a positive impact on her behavior, but it was not consistent from
week to week. Because the nature of the student’s obsessions is to go in cycles, it would
be worthwhile to conduct this study with modifications over a longer period of time to
determine more precisely the effectiveness of the rewards on her compulsive behavior.
Obsessive Compulsive Disorder
29
References
Adams, G.B., Wilczynski, Burke, R.W. (1999). Children and adolescents with obsessive
compulsive disorder: a primer for teachers [Electronic version]. Childhood
Education, 76, 2-7.
Alberto, P.A. & Troutman A.C. (2006). Applied behavior analysis for teachers. Upper
Saddle River, NJ: Pearson Education, Inc.
American Psychiatric Association. (1994). Diagnostic and statistical manual of mental
disorders (4th ed.). Washington, DC: Author.
Anxiety Disorders Association of America (2009). Obsessive compulsive disorder.
Retrieved November 7, 2009, from: http://www.adaa.org.
Cancro, R. (2007). Anxiety disorders: Recognizing the symptoms of six of the common
anxiety disorders [Electronic version]. The Exceptional Parent, 37, 27-31.
Choate-Summers, M.L., Freeman, J.B., Garcia, A.M., Coyne, L., Przeworski, A.
Leonard, H.L. (2008). Clinical considerations when tailoring cognitive behavioral
treatment for young children with obsessive compulsive disorder. Education and
Treatment of Children, 31, 395-416.
Foa, E.B., Abramowitz, J.S., Franklin, M.E., Kozak, M.J. (1999). Feared consequences,
fixity of belief, and treatment outcome in patients with obsessive compulsive
disorder. Behavior Therapy (30), 717-724.
Hendricks, C. (2009). Improving schools through action research: A comprehensive
guide for educators. Upper Saddle Ridge, NJ: Pearson Education, Inc.
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Lehmkuhl H.D., Storch, E.A., Bodfish, J.W., Geffken, G.R. (2008). Brief report:
Exposure and response prevention for obsessive compulsive disorder in a 12-yearold with autism. Journal of Developmental Disorders (38), 977-981.
Mataix-Cols, D., Nakatani, E., Micali, N., Heyman, I. (2008). Structure of obsessive
compulsive symptoms in pediatric OCD. American Academy of Child and
Adolescent Psychiatry (47), 773-778.
National Institute of Mental Health. (1994). Anxiety Disorders
(DHHS Publication No. NIH-94-3879). Washington, DC: U.S. Government
Printing Office.
McGough, J., Speier, P. (1993). Obsessive compulsive disorder in childhood and
adolescence [Electronic version]. School Psychology Review (2), 243-253.
Parenting a child with OCD: Sorting strategies for parents [Electronic version]. (1997).
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child and family characteristics. American Academy of Child and Adolescent
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Pietrefesa, A.S., Coles, M.E. (2008). Moving beyond an exclusive focus on harm
avoidance in obsessive compulsive disorder: Considering the role of
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Obsessive Compulsive Disorder
Radomsky, A.S., Rachman, S. (2003). Symmetry, ordering and arranging compulsive
behaviour. Behaviour Research and Therapy (42), 893-913.
Sloman, G.M., Gallant, J., Storch, E. A. (2007). A school-based treatment model for
pediatric obsessive compulsive disorder. Child Psychiatry and Human
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31
Obsessive Compulsive Disorder
32
Appendix A
Administrative Consent Form
MEMO
To: Principal
From: Samantha Zelevansky
Date: September 29, 2009
Re: Action Research Project
As you are aware, I am currently completing my Masters in Special Education at
Caldwell College. It is required that I complete an Action Research project in order to
graduate. As discussed, my research will focus on school-based interventions for a
student with obsessive compulsive disorder.
I need your signature acknowledging that you have been informed of the general nature of
the project and of any foreseeable potential risks. I will be collecting data on the use of
exposure therapy and its effect on a student with OCD. My data collection will take
place during the months of January, February and March of 2010.
My study will be conducted with the utmost confidentiality and professionalism. It is
my intention that this study will prove to be beneficial to your staff and colleagues.
Samantha Zelevansky
Special Education Teacher
Signature_____________________________________
Obsessive Compulsive Disorder
33
Appendix A
Parental Consent Form
October 1, 2009
Dear Parents,
I am currently pursuing a master’s degree in the field of Special Education at Caldwell
College in Caldwell, New Jersey. A requirement of the program is to complete an indepth study in the form of an action research project. I have decided to do my research on
obsessive compulsive disorder. My focus is on strategies to reduce obsessive compulsive
behavior in a classroom setting. I would like your permission to include your child in
this study.
My research will include observations and data collection on the frequency of the
compulsive behaviors demonstrated in the classroom, as well as strategies to help reduce
them. Be assured that this information is completely confidential; neither your child’s
name nor yours will be used in this paper. Your cooperation would help me greatly in my
research. If you are willing to grant me permission, please sign the slip below and return
it to me.
Sincerely,
Samantha Zelevansky
Special Education Teacher
My child, __________________________ , has my permission to participate in Mrs.
Zelevansky’s research project.
______________________________
Parent Signature
Obsessive Compulsive Disorder
Appendix B
Date:_______________________
DRO Interval: 4 minutes
Criteria: 5 tallies = 5 min break, 10 tallies = 10 min break
Period
Tallies Earned
Disruptive
Behavior?
Comments
34
Obsessive Compulsive Disorder
Appendix B
35
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