Presented by Jacquelyn Gola, Psy.D.
Although OCD is diagnosed using one set of criteria, it manifests differently across the lifespan. This presentation will explore OCD across different age groups. Webinar attendees will learn how OCD presents in children, adolescents, and adults and how Exposure and Response Prevention therapy (ERP) could be adapted for each age group.
Dr. Gola provides psychological treatment of children, adolescents, and adults with a wide range of psychological disorders using evidence-based cognitive behavioral therapy (CBT), including Exposure and Response Prevention (ERP/ExRP), Comprehensive Model for Behavioral Treatment (ComB), Prolonged Exposure (PE), Acceptance and Commitment Therapy (ACT), and Parent Management Training (PMT). She also conducts psychological evaluations for pre-operative bariatric surgery candidates, as well as psychological and psychoeducational testing for children and adolescents to assess attention issues, executive functioning difficulties, learning disabilities, and other psychological disorders. Dr. Gola has extensive expertise in evidenced-based treatments for OCD, anxiety disorders, specific phobias, PTSD, and trichotillomania. She obtained her formative experiences and training at the Center for the Treatment and Study of Anxiety (CTSA) and the Child and Adolescent OCD, Tic, Trich, and Anxiety Group (COTTAGe) at the University of Pennsylvania.
3:48 Now to the introduce introduction of tonight’s presenter, doctor Jacqueline Gola, doctor Gola received her undergrad degree from the University of Delaware and her doctor of Psychology from LaSalle University in Philadelphia. 4:04 In addition to treatment of children, adolescents, and adults with a wide range of psychological disorders, she also conducts psychological evaluations for free operative bariatric surgery candidates, as well as psychological and psycho educational testing for children and adolescents to assess attention issues, executive functioning, different difficulties, learning, disabilities, and other psychological disorders. 4:36 She has extensive experience in evidenced based treatments for OCD, anxiety disorders, specific phobias PTSD, and Trichotillomania. She trained at the Center for the Treatment and Study of Anxiety and the Child and Adolescent OCD, Tick, Trick, and Anxiety Group at the University of Pennsylvania. Doctor Gola welcome, we are delighted to have you this evening, and I’m pleased to turn this presentation over to you. 5:14 Thank you, Marti, for the introduction. 5:20 OK, soon as I can get rid of this, I can get started. 5:25 Thank you, everybody, for joining me today. 5:41 The orange arrow will remove the screen for you. 5:45 OK, my talk is going to be about the developmental considerations for OCD in kids, teens, and adults. So I’m going to jump right in. 6:00 I just started with there was a comic about OCD. 6:03 Um, I think this comic shows the reality of living with OCD on this girl, who she illustrates how she must have to do everything a times in a row and if she loses counter messes up, … start over. If she doesn’t do this for parents will die. 6:20 These intrusive thoughts repeat over and over and over. 6:25 I think this comic shows not only the reality of living with OCD, but also the irrationality of OCD and how stuck a person can get getting caught up in compulsions. 6:37 So we’re going to start with OCD facts. 6:41 I’m just to go through the DSM five criteria for OCD, OCD diagnosis as a diagnosis of OCD and requires the presence of obsessions Convulsions or bolts. 6:54 Obsessions are defined as recurrent and persistent thoughts, urges, or images that are experienced as intrusive and unwanted and that most individuals called marked anxiety and distress. 7:06 And the individual attempts to ignore or suppress such thoughts, urges or images, or to neutralize them with some other thoughts or action. 7:17 Compulsions are defined as repetitive behaviors, or mental acts that the individual feels driven to perform in response to An obsession, or according to rules that must be applied rigidly. 7:28 They’re aimed at preventing or reducing anxiety or distress or preventing some dreaded event or situation. 7:33 However, these behaviors or mental acts are not connected in a realistic way with what they’re designed to neutralize or prevent, or clearly access. 7:41 They’re time consuming that clause or cause clinically significant distress or impairment and social occupation or other important areas of functioning. 7:50 They’re not attributable to a substance or another medical condition, and finally not better explained by the symptoms of another mental disorder. 7:59 So here are listed some common obsessions and Compulsions that we see in OCD. 8:04 This list is not exhaustive. But as you can see, there’s a lot of different subtypes of OCD or flavors of OCD. Some people call it. 8:14 Um, some people who have OCD might have one type of obsession but a lot of people have many or they overlap. 8:24 OCD typically latches onto what’s important to the person or maybe what’s important to them in that moment or that current time. 8:34 Sometimes refer to the whack a mole of OCD. So, you know, maybe OCD latches onto harm at one point in a person’s life but then at another point it can switch over and to you know for instance a taboo or sexual type of theme. 8:51 So it’s not uncommon that we see people with many different types of obsession, subtypes of obsession. 9:00 So, some basic facts about early onset of CDA. 9:04 So, um, it affects about one to 2% of the population, so 1 or 2 of 100. 9:13 Early onset, which is defined as before puberty, is more common in boys and there was a family history of OCD or tics. 9:21 It’s often associated with other anxiety disorders, ADHD, and tick disorders. 9:26 So, often, we see people with comorbid disorders. 9:28 The onset is typically gradual, but it can be sudden, and I’ll talk about that in later slides, and the course’s, typically, waxing and waning over over the course of the Disorder. 9:47 So there’s a high high comorbidity of OCD and tic disorders especially in children. There’s definitely a genetic link. Up to 60% of Tourette Syndrome sufferers have reported to have OCD symptoms and 50% of children with OCD are reported to have chicks. 10:07 15% meet met criteria for criteria for Tourette syndrome. 10:12 That is a good topic to be on, on this, on today’s webinars. And then … is characterized by earlier age of onset overrepresentation in males. Symptomatology that tends to include touching, tapping, rubbing, and concerns about symmetry and Exactness. 10:33 So too, erratic OCD. 10:36 This name is given to a presentation that, that shows blended features of both OCD and Tourette’s syndrome. So I think it’s more of a newer label. 10:50 But you know, oftentimes we see children who have behaviors that can look like compulsions but they also could look like complex motor checks and it’s difficult to distinguish between the two. So these compulsions usually involve look at just right requirement. So these children might have to do certain behaviors until they feel right to them. 11:16 The emphasis is on symmetry arrangement. And touching, ordering, opening up, and all these. 11:23 So, um, usually, you know, with, With, With checks, as some of you may know, they may be like purposeless. So they may, they may just involve a physical feeling that they have to engage in this checks in these ticks on. one question that I may have to try to distinguish between the two is A, there’s a fear concept plans or some sort of like cognitive component to it. 11:51 So a lot of these, children with a … might report that they couldn’t carry out the compulsion. It would feel like the discomfort wouldn’t end. 12:01 Or it would feel like intolerable if they won’t be able to sort of take it. Or a vague notion that, like something bad’s gonna happen, but nothing specific. 12:11 As far as treatment goes, treatment would involve a modified approach. So it would involve both ERP. 12:22 But also incorporate some of the complimentary techniques that has been proven to work for the effective. for. for tourettes So like progressive muscle relaxation, diaphragmatic, breathing imagery, and competing responses. So teaching the child to be able to tolerate that feeling of not giving in to that compulsion. 12:43 So they may just to, for example, they may do, they may be instructed to do their compulsion until it’s Instead of just re doing it wrong or less number of times than what feels right. 12:56 Or they might be taught a competing response or behavior that they can do instead of the compulsion when they have that urge that’s physically incompatible with the conclusion. 13:09 I’m going to talk a little bit about pandas and pans on the slide. So, I’m going to touch on that. 13:16 So, people might be familiar with these. 13:21 Is diagnoses. 13:25 Pans distinction between the two? Panniers is more recent diagnosis that’s more sort of encompasses pandas. 13:33 Um, so while Panda’s is a neuropsychiatric disorder, that’s associated with strep infections, hands Can actually be, might not have a known trigger, or it could be due to another infectious agent, or non infectious agents, such as Lyme Disease. So the hallmark of these disorders that OCD symptoms are a result. 14:03 So, Panda’s, it’s caused by autoimmune reaction within the brain, so the immune system attacks, the basal ganglia instead of the infection. 14:11 And one of the biggest so, does what we see is like a sudden and severe onset of OCD symptoms though that’s a clue and that it could be the B, the result of a … diagnosis. 14:30 So, like I said, a sudden and rapid onset rather than a gradual onset of symptoms here’s a list of other panelists or pan specific symptoms that come along with the OCD symptoms. 14:43 Um. 14:45 I’m not going to go in to treatment at this at this point so much. 14:51 But, just know that the OCD symptoms are treated with ERP in the same way. 15:09 OK, so, as you can see here, this is our diagram of the obsessive compulsive cycle here. 15:17 So, as you can see here, the obsessions are these repetitive images or thoughts or impulses. It causes distress in the person or anxiety. Even fear or shame are discussed. 15:31 Wow. 15:32 So, the person then engages in compulsions so, the OCD makes up, like, rules about what the person has to do. 15:41 It may not make sense, but what they have to do if they’re in their mind or, or, you know, or actions that they take, that will give them relief. 15:53 So the distress subsides temporary temporarily, Um, so the compulsions are negatively reinforced because of the immediate relief. 16:02 They were either the obsessions are nullified, or the anxiety goes down immediately. 16:11 So what happens is? 16:15 So you can see, though, although the relief disk the distress and relief subsides temporarily every time that the obsession, it comes back up. 16:26 The cycle continues, so it strengthens the connection between the obsessions and compulsions. 16:33 The patient may learn that compulsions or avoidance works well together. Get rid of the obsessions right away. 16:39 However, every time that they do this, cycle’s strengthened. 16:45 So I’m going to talk about that a little bit more in the next, upcoming slides. 16:54 The exposure and response prevention. 16:59 So, exposure and response prevention is the gold standard treatment for OCD. 17:03 Um, we know through extensive research that is the most effective treatment for OCD. 17:09 in addition to the SSRI medications, exposure refers to exposure to the thoughts, images or objects or situations, the bringing on these on these things that create anxiety or discomfort and that start the obsessions. 17:25 So these can be in vivo, meaning in doing something in percentages like touching utility, or imagine all, such as like, writing a story of the persons’ worst-case scenario of this is something that, no, we can actually do in real life. 17:46 Response prevention refers to resisting compulsion compulsive behavior. That decrease anxiety, or neutralize the obsessions once things ID or obsessions have been triggered. 17:57 Um, and there’s some mistreatment of rights, the OECD cycle and creates new learning. We’ll talk about that as well. 18:13 Oh, the vicious cycle of avoidance. 18:16 Um, like I mentioned previously, scrappers, another interpretation of the previous one of the cycle. 18:26 This graph represents how avoidance works, or compulsions, to temporarily get rid of obsessions and relieve the person’s anxiety each time. 18:40 As you can see you and the grinding peaks. 18:42 When a person either avoids the situation or engages a compulsion, like I said before, the … 18:47 relieves anxiety temporarily but the anxiety stays high, long term and each time the person has confronts the situation or this thought or trigger, the cycle then continues on and on and on. 19:04 Um, they don’t learn any other way of coping with obsessions and also times also what happens. 19:12 A lot of the times with people with OCD is that the Compulsions expand as well. So the, but we know very few days. Like, so OCD is never satisfied. So maybe for a while, the person is doing a certain set of compulsion. 19:26 So maybe they have to no say some sort of farm good thought, or like some sort of ritualistic prayer or something in their head. 19:36 And that works for OCD to get rid of the thought or get their anxiety down. But other times, what happens is that the rules might change, OCTs, rules may change, it’s pretty tricky. 19:49 And the person has to do more more compulsions or maybe have to repeat the compulsion over and over um, or or generalize to like new situations where the person may not. 20:01 may not feel the need to do convulsions before. 20:06 So, as you can imagine, that will get in the way, In definitely easily get in the way of the person just conducting their normal life. 20:17 This, this graph shows the adaptive cycle approach. 20:23 So, I didn’t know it actually did that, though. 20:30 This graph shows what happens when or what could happen, rather, when, when the person sits with the discomfort and does not engage in their rituals. 20:42 So, this is the, the basic tenets of ERP is to teach the person that, um, they can, if they can break the cycle, if they can, learn to either, stop the compulsions, eliminate the convulsions, or reduce them. 20:59 They often learn that there are fears do not materialize, or that they can tolerate discomfort longer than they expected. 21:06 So oftentimes, you can see in this graph, the anxiety might reach a peak. But over repeated exposures. 21:14 So doing these exposures over and over and over again across multiple days, anxiety, unnaturally might go down. 21:23 Because, um, anxiety can’t stay high forever. 21:28 Though habituation might set in faster. So one analogy that I use to describe this is, you know, if we jump in a cold pool, we might want to jump out quickly. 21:39 Because it might be really cold in we don’t like it. 21:42 But if we stay in the pool, the temperature of the … doesn’t change, your body just gets used to the temperature or the water. So that’s how habituation might work. 21:53 four are exposures. 21:59 Um, I’m going to contradict myself a little bit here. 22:02 So I want to do put a slide in about inhibitory Learning Model. So, what this is. 22:13 There’s a lot of research in the last few years that about this model, which brings in a lot of recent research about how the brain learns and remembers information related to fear. 22:23 So, um, this model, actually, instead of focusing on habituation for anxiety for OCD treatment, the focus is on building the tolerance of anxiety or discomfort. 22:36 Um. 22:38 So, we know that … 22:40 is a little complicated on, some people don’t experience habituation on the ring or between exposures, but still improve functioning. Some people have a good response to therapy, but might relapse later on. 22:53 And some like habituate are able to habituate but still don’t improve so we know that it’s complicated. 23:01 We also know that when the focus is on habituating two anxiety, that’s still suggests that anxiety may be bad or dangerous, that we need to get rid of it as fast as possible, to be able to live our life, which is definitely not the goal of ERP. 23:19 So we know that this isn’t true. 23:21 So we want the person to live with their anxiety, even as you know it’s habituation is natural and it’s nice when that happens, but they want to teach a person that they can live their life with anxiety, so we focus more on Responding to obsessions. 23:41 So, if the person is not engaging in there, um, compulsions, and instead they’re able to, you know, learn other strategies, then they then they have a then we’ll have better management of their OCD and be able to do the things that they want to do. Rather than letting OCD control them. 24:04 Um, so with the human inhibitory learning model, the exercises of the exposure exercises are designed to disconfirmed expectations. 24:14 So this aim is getting, providing a person with a new knowledge. 24:20 So with exposures, with AARP, the person will learn that their fears are less likely than the NRO CDs telling them. 24:28 Or less severe than they predicted that their anxiety and their obsessional thoughts themselves are safe, safe and … 24:37 and that the compulsive rituals are not necessary for safety or to tolerate anxiety. 24:49 So. 24:52 For effective ERP. 24:56 The, the goal is to help the person learn that the feared stimulus to save. So what happens is, is when they’re successful exposures. 25:05 Over time and over repetitions, it actually blocks out or inhibits the existing fear. 25:12 So, this is where the new learning occurs, There’s this new learning, and their brain. Well, kind of went out. 25:19 If it’s repeated, and there’s enough of this, I’m just confirming these expectations. 25:30 OK, so, now I’m going to just focus on OCD in children. 25:35 So, although the criteria is the same and the DSM OCD looks quite different in children and young children, especially in teens and adults, that’s why I’m focusing that on that in this presentation. So, there are these nuances and treatment, depending on the age of the patient. 26:00 So, so, good education is like, a huge component. 26:04 Before we jump into any, Any of the, the real work of the OECD. 26:12 So, OECD’s Conceptualized as a neural behavioral problem. 26:17 It’s not, it’s not anyone’s fault. 26:20 So, we talk about it as analogy like diabetes or asthma. 26:24 So, so, we’re gonna reduce any stigma or blame for the OCD. You know. This is something that we are, that we learn how to better cope with and better treat. 26:37 Um, sometimes I talk about OCD is like a brain glitch to kids. So, your brain is just overreacting. 26:45 And, you know, maybe the brain thinks it’s something, these things are dangerous, but it’s sending out a lot of these false alarms. 26:54 So there’s a lot of education about OCD and anxiety and how that works with her brain and body. 27:05 Um, and there’s a lot of, there’s a lot of teamwork with this treatment. 27:10 So, I try to talk in terms of, now, we’re, we, the team being maybe parents, the kid, and, and, you know, myself as a psychologist are working together to beat their own CD bullying, and this works pretty well with kids that are are competitive as well. 27:32 Um, one step is to increase their awareness of OCD symptoms. 27:37 So, this is both for the kids and parents for May start with, after really getting into some of the education, we’ll start with tracking OCD of the kids and the parents. They want to really We want to really know their OCD, like know what really well. So that way we can fight against it. We want I want the kids and parents to really understand the connection between obsessive of chefs, obsessions and compulsions. Once we really know, like all their, you know, their obsessions and compulsions, we want them to fully understand how they link together. 28:17 So, um, with kids, it’s important to use age appropriate metaphors and language. So it’s going to be more concrete, more specific, and child friendly. 28:29 So some of these exercises I like to have the child maybe name the OCD. 28:36 And this helps to externalize it. 28:38 So I like doing this for kids because it helps them really be able to identify whether … is and and see it as like this bully that they’re going to back the House back or, or sometimes with other kids be, and then draw their their worry monster or bullying. 28:56 No, sometimes I like to have them draw other islands of OCD. So they might draw out there what kind of different islands of OCD that they have. So what are their different obsessions, and how that gets in the way of their life. 29:15 Sometimes I like to have kids read books and videos about other kids or the CD. The unstuck movies are really great line. 29:29 And sometimes creating books about Childs OCA, especially if they really like being creative. 29:36 Here are some, I’m gonna go through some of these kid friendly analogies here that I like to use within the, you know, in sessions. So, one analogy I’d like to use a lot is talking about OCD like the dog at the dinner table. 29:53 So the way this works is, I talk about how the city is like the dog begging for food at the dinner table. So here’s a picture of my dog and he’s really good at that. 30:06 So if the dog’s used to being fed, the dog’s going to always be begging for food whenever there’s food present. 30:15 I use this to talk about how, you know, if we suddenly stop deciding to feed the dog, the dog is not going to just go away because he’s used to being fed. So he might actually up the ante a little bit. 30:25 And Paul, and maybe bark and wine, and just be extra annoying because he knows that he’s used to being fed. 30:34 But, and if we really didn’t want that behavior anymore, we wanted to stop the dog from begging. We’re going to be really firm and consistent and really withstand that as much as possible. Until finally, the dog will eventually learn that he’s not getting any food. 30:50 Haven’t done that yet with my dog. That’s really difficult. But I think this analogy works really well, especially when kids have dogs, and you can talk about their dog. 30:59 To teach them that, even if it’s really tough and the beginnings of the first time that they’re fighting back, it will get easier. And this is the same thing for the bully the playground analogy. So, it’s the same concept. 31:13 Um, weeds in the garden, and I use that analogy to talk about how. When we work on a CD, we have to make sure we get all of the week. So, if you leave any, it’s going to grow back, or it might grow back. So we wanna make sure we don’t, we don’t leave anything, OCD can be really tricky. 31:29 So I tell them that we, center of the city, he tries to get the kid the side with them. But we want to watch out for that. 31:36 And we want to be like a detective in that. 31:39 I already talked about the jumping in, the pool analogy, learning an instrument, or practicing a sport, can be a good analogy just to talk about how important it is to really practice. So even though even if we’re meeting once a week, it’s, this treatment involves doing their homework. So they’re going to have exposure homework every day. 31:57 So just like you know, practicing soccer, learning, the trumpet they have to keep practicing so they’re ready for, like, they recite or the game day, which is like, they’re their life, when this pops up. 32:10 They want to have the skills. 32:20 OK. 32:22 So, I’m talking more about exposure for kids. 32:30 Parents are a large part of treatment. So, especially for younger children. 32:36 Because it’s going to be just as much as teaching parents about the treatment of the children. 32:41 Oh, I’ll talk a little bit more about, um, parents as well and a little bit later in the slides. 32:51 So, but, you know, depending on the child’s age, it may determine how much the parents are in the session. So, for younger kids, they might be in, for, majority of the session, there might be more parent only sessions. 33:03 And the treatment sessions may be more more time with just the children, if they’re a little bit older. 33:11 But, there’s always that, always going to be parents involved. So, with kids, there’s going to be a greater use of goal setting and reinforcement. So, a lot of the times of with children. 33:22 I like to use a sticker chart for exposure work. So, maybe, you know, we might have some exposure homework, and we know, create a fun, know, calendar, a chart for what they have to do over the weekend. 33:41 I have them come up with, like, a re pries menu that they want to earn. 33:47 So it’s really important to give them incentives because this is really tough work. 33:50 Um, and they may not be internally motivated to do the work at that point. 33:56 It might just be, the parents really wanting them to get some help with this. So it’s really important to reward them for their efforts. 34:06 Sometimes, they also do that in sessions. 34:08 When, when they do some really good exposure work, we set some time aside of the needed game. 34:15 I know that they, they know that they’re being rewarded. 34:19 Hmm. 34:22 OK, so, exposure should be finding creative, the more that this can be, like, fun for them, and sort of, That they’re engaged in it, I think the better that is. So just some examples here, there’s, um, you can use, Go fishing CDA. 34:44 Maybe mad Lib’s with like taboo words. 34:48 OCD, harm, bingo, for one kid, I remember I worked with. 34:52 We, he had a fear of that, that, like, bad luck would come to his family. 34:59 So we are, are we playing? We made like a bingo card and we all play together. And we had to say some pretty scary things about what might happen to them, but it was like a really good exposure and connecting exposures to really fun and natural contingencies. 35:12 So for example, like playing on a contaminated playground, maybe not in this right now, that might not be a good exposure right now, but otherwise, something that could be part of their everyday life, but that they can easily generalize to their language. 35:33 Can also use things like apps, like, I’ve always change your app to say some, some of their obsession, that lauder, some of the thoughts that they think are scary. 35:48 OK, and a Fiercer monitor that I like to use, sometimes, again, not necessarily to focus on anxiety, but to help children maybe come up with their hierarchy, but use the scarce thermometer retreat. one, maybe in the session, and they can have fun with making it. And it helps them gage, like, how anxious so they feel in that situation. How anxious would they feel if we did one of these? exposures might be hard for them to gage, But I think this is a helpful tool. 36:26 OK, and just a, um, a couple, a few points about how OCD might look different As far as the symptoms, the content and Web sessions. 36:37 There might be a higher rate of fear of cuttack, catastrophic events or death or illness of itself using for themselves or parent recording behaviors. 36:50 And it’s important to note that younger children might lack insight about the irrationality of their actions. 36:57 So they might not perceive their symptoms as unreasonable or excessive. 37:03 So they might not just be there yet developmentally, and that’s OK. 37:07 We can still moving forward with, with the treatment. 37:13 Even if that might not be present yet. 37:22 OK, there’s a lot of information on this slide, but going back to parent responses. So it’s really important for parents, with kids of any age, to really be important, to be aware of how they might feed their child’s OCD. 37:42 We know that like children are all rely on their parents for getting help with relieving anxiety or avoiding or anxiety, so the parents have a pretty big role here. 37:54 We know that one of the, probably the most, the most common conversation is talking to parents about, um, accommodations or participation in their childrens’ rituals. 38:08 So, oftentimes, the parent might have this belief that maybe they’re there, it’s their job, to protect their children. Of course. An Ag she can’t, he or she can’t handle this situation, and they want to convert their child. 38:24 So, it’s important to talk about how accommodations or, or participation or rituals could what that will look like, and how that actually feeds into their their child’s OCD. 38:37 So, we all have a conversation with parents about what is, how they can validate their child anxiety, but look out for, and start to eliminate what would be actually, you know, feeding right into the cycle? So, examples here, like, parents will re-assure their child, that nothing bad will happen every time they ask. 38:59 And a lot of times, it becomes repetitive washing or showering when the child requests this from their parent to avoid spreading contaminant. 39:09 The list can go on and on. 39:11 But this is definitely an important aspect. 39:16 Um, sometimes parents might be over demanding, they might have thoughts like this is a frightening, you know, they’re just acting like this for attention and this is definitely validating their experience of fear and that might push them to approach something too difficult for them. 39:33 Sometimes parents might actually, um, you know, it’s very common for there to be two poles. 39:39 So, you know, maybe the parent might feel like there are oftentimes protective and maybe they’re not doing enough to promote the child’s like self-sufficiency. 39:48 So they might have inconsistently responding between over Protective Andover demanding. 39:56 So, um, I took these, sort of, um, these labels from our really great parent program, for Anxious Children. 40:09 And Supportive Talk, describes how parents, you know, sort of, the ideal response. 40:15 So, it’s important to teach parents how to be. How do we validating of the child’s fears, But encouraging them to withstand anxiety. So, you know, this is scary for you, but I think you can get through It. may be something that they know, that they might think it’s my job to prepare him for dealing with their challenges in life. So, it combines like an acceptance and look like legitimizing their children’s fears. But also this belief that the child has the ability to withstand more anxiety than they have now, or at least a little bit more anxiety. 40:49 And that kind of response really drives the child into, you know, they will pick up on that, and they will they will learn that, or at least believe, that they can. 41:04 OK, so. 41:10 Now, I’m going to just move on to OCD and adolescence. So, I’m going to talk a little bit more about that, and how that might differ from children. 41:22 So the content of obsessions, there might be higher rates of sexual religious obsessions and children. And, you know, I think that makes sense, because, you know, teens may be in a period of time where this is more important to them, or this is definitely coming up as far as something that they’re thinking about more really considering more. 41:42 Their insight is typically greater. 41:45 They’re just getting older and learning more about the world. Of my patients, who’s 18 now, had to see this at least 13. 41:54 Said that he is comparative behaviors, or it was peers, and it became more clear to him like, what was normal. 42:02 There’s a funny meme from John Hirshfield about, uh, Sexual Unaggressive themes and OCD. 42:10 Here’s a lot of good ones on his page. 42:17 Alright, and pair it with teens. So, just like with children, like, parents can also be a large part of the rituals, or the targets of their obsession. 42:26 Obsession. 42:28 Um, some there might be some kids on their mighty battles against their parents. Instead of their OCD. 42:37 Um, I see that a lot more with with with teens are adolescents who or even children that they don’t want to fight against OCD. 42:46 So they are maybe protecting if they, you know, they don’t have any reasons themselves to fight it and maybe their parents are the ones to really drive the, you know, pushing the treatment and erbium you know, doing what they should be doing in these cases. 43:07 You know, they might hide rituals, they might fit with their parents and their therapist. Maybe they might say you know. 43:14 This is an OCD or they might minimize it on some of these some of these um, children or adolescents they might act like aggressively or hostile if they’re asked to like refrain from the rituals. 43:27 Um, I’m mentioning here, I can go more into this, but, you know, one thing I’ll talk about with parents is, you know, and those cases, what to, how to, how to deal with those like inappropriate or unacceptable behaviors. Like maybe there was aggressive behaviors or hostile behaviors. 43:45 And talking about how they may like punish those behaviors. 43:51 And sometimes parents can get a little bit, you know, they might be unsure, you know, I don’t want to punish the child’s OCD. 43:59 But a distinguish this from, you know, the child has, they have anxiety and we’re not punishing the child’s anxiety, or their feelings of anxiety or discomfort, but the punishment will be about how they’re responding to it. 44:14 So, I hope you try to work with these, These teens about, are these children, how to better deal with their anxiety, um, how to better manage their anxiety, so they’re not acting out like this as much. 44:30 Um, so, you know, like I said before, if, especially with older teens, you know, it’s important for parents to have the sake of education, to have the resources and the guidelines of what to do and what not to do. But the emphasis is on the teen owning their own treatment. So the parents can be, you know, what’s important for them to be supportive and encouraging other teens, efforts, but the AARP also focusing on eliminating the accommodations. 44:59 Any participation and rituals. Teens can also get rewards for attending therapy and doing their homework, so that might look more like glass tours or gift cards, cruder gains, money, then. Again, this is really tough work. 45:13 So, So, it’s, you know, I think it’s really helpful for them to know that they can, you know, that they can get something else for you. 45:26 OK, Little bit more, It’s about working with teens. 45:32 So, it’s, It’s, this is more collaborative like, so, I’m working with teens on, you know, I talk about how I’m, I’m the Coach. So, I acted as. maybe a cultural. 45:43 I might be an expert on OCD but they’re the expert in themselves. I can’t impose the treatment on them. So they definitely don’t want another adult to tell them what to do. 45:54 So, you know, I tell them that they can, you know, they can make a choice. 45:57 This is how I expect that the OECD will go if they don’t, you know, get on board with with Trish trying to treat it now. 46:06 You know, they can make a choice of, you know, if they’re if they’re ready or not. 46:11 Sometimes I know that this is tough for parents if they’re not ready, but I try to get a buy in from them. So I try to I try to engage and actively. So I might have conversations about like how OCD my interview interfere with their life. How it might affect things that matter to them now. 46:29 So they’re probably not gonna care about, you know, if I talk about no way in the future, what their life would look like, but what does it look like now? 46:36 Is it getting in the way of school, or their friends or sports, know, how cell, what would their life look like if they didn’t have it, or if it was better managed? 46:48 So they start to consider what a life will be, like, without it. 46:54 Like I said, it’s important to tailor to their interests, and their developmental stage, So I always hope to get that buying with them. 47:06 Um, there’s also some analogies that I think can be appropriated to teenagers more. 47:11 So, I talked about some of these, but an analogy can be like, you know, retraining. just like you’re training your muscles. 47:19 You’re training your brain for kids that like football or sports. 47:24 We can, you know, I can talk about like We want to know what she’s going to do next to counter it, just like you play football play or with a strategy game. You know, we want to attack, you know, we don’t want to be passive and wheat for CD. We want to know what to come next like to eat it. 47:44 And, you know, I hope to have them learn that they have a degree of influence over it, so I want to try to help them increase their influence. 47:55 I want to talk more about fear consequences. 47:58 So, maybe with teens, you know they’re at that, they’re a little bit older and they can, they can talk a little bit more with me about like what they are afraid it’s going to happen if they don’t engage in or rituals. I’ll talk more about realistic and unrealistic risks and benefits, and a greater use of just confirmatory evidence. 48:18 So, we’ll talk about, you know, how did the how did that they are doing exposures. Like, how did that go as compared to what their OCD is telling them or what they expected? 48:28 Um, I like this. I really liked this, um, this comic, it’s, you know, if you can’t get rid of your fear, can’t get rid of your fears, but you can learn to live with them. 48:43 She’s having a Tea Party with her, but her weren’t a monster. 48:49 Alright, Um, Lastly, I’m just going to move into just some considerations with adults. 48:58 So, um, the prognosis is best, like many, you know, many things were treated early so left left untreated as a child, it might complicate complicate life into adolescence and adulthood. 49:16 So it’s it’s best when it is caught early. 49:21 And you know, we teach them a set of skills so the skill no matter what the no matter what the their their obsessions may lie or the age or no. 49:34 It’s it’s always going to be the same strategy, the same treatment. 49:40 So, these, if the skills are practiced more, of course, they might be better prepared to keep on dealing with it. 49:48 There’s more time or they’re strengthening skills by reinforcing it over time. 49:53 Um, so, there’s some studies that suggest some factors that are linked to a greater persistence of OCD, So, how severe the illnesses a need for hospitalization and early onset and psychiatric comorbidity? 50:08 And, as I said before, it’s OCD typically has a product course spanning over several decades with Watson, waxing and waning Symptom Severity. 50:26 Um, the one adult onset OCD or, you know, what we know that OCD can occur at any age but it generally tends to first appear between 8 and 12 and between teenagers in adulthood. 50:37 So the adult side is defined as when the onset is after puberty. 50:43 This is actually equally common in males and females associated with more depression and other anxiety disorders, and the onset of symptoms could title specific trigger, such as a loved one, death of a loved one, and loss of a job. 50:55 Birth of a child. 51:01 We know that like I said before, OCD symptoms just lacked on what’s important to the person so could latch onto the person’s, you know, children certificate, others, religion, or sexuality. Here are some examples of content. 51:16 For example, like post-partum OCD, that might have links to proof part of depression. 51:21 The symptoms could suddenly appear or maybe get worse. 51:26 after. 51:28 You know, a woman has it as children and it could latch onto that. 51:36 OK I’ll just treatment considerations for adults with OCD. 51:43 Support system is important for anyone with adults, they don’t have the same kind of built-in support system that lots of that most children do. So, patients just tend to do better when they have like a healthy support system. 51:55 So, people on their life, friends, family, and others that they feel supported by, that they can talk to you and, know that they feel that they can, and they don’t have to hide their OCD. 52:08 Treatment might involve eliminating accommodations in behaviors that family members might be doing that reinforce the OCD Cycle. So this, you know, your parents who might be working with significant other or they might be brought into some sessions. 52:23 So they can learn more about OCD and how to help their partner. 52:27 And the motivation for for adults are typically higher. So usually, they are self referred or, you know, they, they want to get the treatment, or the distress is high, or their appearances is getting in the way of functioning. 52:45 Um, I think, because at the time, I’m, I’ll answer some questions on this slide, these slides if needed, but I think I’m going to go ahead and skip these couple of slides. 53:01 Here’s another meme about uncertainty. 53:07 Just going to go ahead and skip these for time for questioning. Here’s a couple of books for kids. I really like about OCD. These are my favorites. 53:16 Books for parents. 53:20 Some online resources. 53:24 OK, pod, as I didn’t get to the last slides, but um, here are some contact information for me. I am at the Center for Emotional Health of Greater Philadelphia. 53:35 We have offices in Cherry Hill and Princeton. 53:38 I work out of both of those specialize in working with all ages, Kids, teens, adults with OCD and anxiety disorders. 53:47 Also, body focus repetitive behaviors, Tourette’s is obsessive compulsive spectrum disorders. 53:56 Just to let everyone know, we do have free OCD support groups and the FRB support groups in monthly and sharing them with Princeton so they’re free and I think the next one is actually maybe the next two are canceling because Corona, but are usually well attended. Thank you, everybody, for listening. 54:18 All right. Then I have some questions and I’m going to launch into them onto them right away. 54:25 So, I have a question from someone who is, has a question about, uh, how young might an OSI, how young night someone be with an to get an OCD diagnosis diagnosis? That’s not T S related. So this individuals’ asking the question teaches a preschool. And sometimes, they sinks of the child is what what she says, in quotes is, is, is Iraq Brain. So, they might think of this child is having. 55:01 oh, having an issue when they get stuck and can’t change they change their way out of doing something and and she’s asking the question here is that, you know, could this be OCD And, um, is that too young? 55:17 So, we’re talking about 3 to 4 year olds here, OK. 55:22 That’s a very good question, I don’t know. 55:27 If I see if I see a child with those kinds of behaviors may be like very rigid. 55:33 Um, first of all, I’m going to I’m going to ask a lot more questions. 55:37 Of course, the child may be too young to, you know, to talk about, you know, why they’re doing this or the function of their behaviors. 55:46 It’s probably unlikely that it would make like a clinical diagnosis of OCD for a child that young. 55:54 Because you know it it might be really tough to distinguish what, you know, what exactly that is. 56:03 Some kids might, who might later developed, she might have very like range and behaviors or these kinds of kids that have difficulty with maybe transitioning. Maybe it may look like sort of perfectionism behaviors but at that early age, I think it’s tough to make the diagnosis. I think the child’s a little bit older. 56:29 Maybe even around. Like maybe like we might not like I said before OCD is usually not, doesn’t really come out as a CD until maybe a little bit later with a child’s life maybe like 7 or 8. 56:41 So I think you know I might we have. 56:45 Yeah, go ahead. You finished. I’m sorry? 56:49 No, So, we don’t, we don’t actually often see kids at our practice that young They might first be, you know, the parent might first spring the child to like there their pediatrician and it might be like TQM and keeping an eye on these behaviors for a little bit of time. Before any, like you know, any psychologist or at least a Psychologist like myself would be brought in to the picture. 57:14 Do you think In one of the slides I mean that there was some mention of of early onset of OCD and I understand it’s, it’s not this young. However, There’s a, there’s a family connection. 57:30 So, I mean, we’ve had kid, we’ve had families with kids with Tourette that, you know, had three children with Tourette and by the time it got to the third child say they would diagnosing this kid it’s at nine months old. So, you know, so if there was a hint family history of that, you, you might see something at at a much younger age than you would expect to just says. Is that as a correct thinking a little bit. 57:59 Yes, Yes, And, again, you know, probably, I would imagine that it is really difficult to tell, at that young age, you know, if it is, if there are the arctic’s, are the conditions, right? We can’t really difficult to figure that out. 58:19 But for a teacher, with this child, in the, in the classroom, you know, it’s, it’s something that certainly needs, would need to be kind of observed and noticed then if, if they had a child behaving in this fashion that it may not just be there being obstinate. There’s the potential that something else might be going on. Definitely. definitely. 58:46 OK. 58:49 Would, So this question, I’m not quite sure. I have it correctly, but would a reward system be appropriate to use in school? And then, further, the question is, As, in an IEP, your co-ordinate with teachers? And, if you think so, could you give us some examples of that? 59:10 Sure. 59:12 Um, typically, at least one, I think, yes, the answer can definitely be worked into an IEP and used at school. I don’t typically work with schools when I work with families. 59:26 I don’t typically work with, with teachers, unless it’s really being shown, mostly at school. 59:36 A lot of the times, actually, it’s. 59:40 You know, we might see it, like, predominantly at school, or predominantly at home, but some examples. 59:47 No. I think it’s going to be consistent. So I might work with both, like the parents and the teacher. So we have a clear understanding of, like what is actually being, you know, what is actually being rewarded. 1:00:00 So so maybe for, um, know, if the child’s like working on something specific exposures has to do with school. So if the exposures are school related and then the teachers know about it, you know, maybe they can do like a check in with a kid. At the end of the, you know, the end of the day, are there specific teacher, that will check in with the kid and ask them, you know, how they did with their exposure work. 1:00:29 Um, especially if, like I said, if the exposures involve school, so maybe like, there’s no the child maybe feel contaminated when they’re in school. So they’re, you know, maybe a certain child. I’ve heard this a few times before a certain shroud is sort of like, contaminated. 1:00:48 So maybe they’re, you know, maybe in when they’re in that classroom, for instance, and they’re doing exposure, like touching maybe the desk or meal book bag or something like that. 1:01:01 The teacher could, you know, maybe they can reward them with something that they will the typical reward that they will give the kids like, you know, maybe it’s like a sticker chart they have in school. 1:01:12 I think that’s a good way of, you know, of being able to incorporate that into the classroom. 1:01:19 OK, All right, good, thank you. 1:01:23 Have a question about supporting support for a child. 1:01:29 And so the question has to do with how to begin. And we ask the question is from someone who is just kind of Starting out with this whole situation. And they’re trying to figure out, what’s the first, the best first step? And, and they reference, you know, a psychologist or is it a counselor? And again, those distinctions there to the public eye, maybe? 1:01:56 maybe very similar, but in reality, the difference between a psychologist and a counselor is, is very distinct, and I wondered if you could just address that a little bit. So the parent would get a better understanding of who does what? 1:02:13 Clarify the distinction between like a counselor and a psychologist. Is that the question? 1:02:17 Yes, yes, yes, and do you know, if they’re referring to like, like a school counselor? 1:02:25 Know, it’s, it’s not clear and not, it’s not clear on that, but I don’t think so, I don’t think so, and then the parent posted something else that this child is is 10 has had a T S diagnosis since five and there’s waxing and waning and in worries and OCD and so forth. So, they’re trying to figure out, now, since this diagnosis. So, this was five years ago now that they’ve been trying to work this out on their own, but they feel that they need to step outside of that now, and get some more professional help. 1:03:05 OK, OK, Well, if it looks like it could be OCD, I would say, find, definitely, find a Psychologist, or, or, or, or, a therapist or professional who specializes in OCD. 1:03:25 That’s really important because some people so, therapists or psychologists like could say that they that may be they they do CVT or OCD can be listed in like a long list of other, you know, disorder like childhood disorders. But it is important to find someone that will specialize in OCD. So, maybe they can do a better do a better job and being able. They are going to be able to make that, maybe, make the diagnosis and, and, you know, make the appropriate referrals. 1:03:58 Um, so I know the IO CDF that’s one of the links there. The International STD Foundation website has a link where you can find a therapist find someone that does specialize in OCD. 1:04:12 So, I mean, I would say that that would be the first step, just so, maybe that psychologists will either make a diagnosis or rule out that diagnosis. 1:04:23 OK, All right, good. Thank you. 1:04:26 Does treatment for traumatic OCD look different than treatment for quote unquote regular OCD? 1:04:37 Mentions in the previous slide, it looks, you know, at least in my experiences with, with kids with like this try to go CD, it’s it’s very similar. 1:04:49 It’s, it’s, you know, we’re still reviewing exposure and response revenge and I’m still teaching, you know, all about what OCD is and and how and how exposure and response range and works. I help them understand like that rationale and then I teach them how to do, how to sit with that, that feeling, there might just be different ways of doing it. So, like I kinda was mentioning a little bit before. 1:05:16 So, you know, we’re still going to do exposure, but the exposure might be, you know, we’re in my office and they have to, have to bring on that feeling of not just right. So with one, with one teen who had this … 1:05:28 CD presentation, he would, he would like, every time you open like a drawer, like sat down on the couch or open the water bottle, you know, these kinds of, like just every day movements. He would have to do it until it feels right, so we just, for exposure, we go around. And, you know, he would do it wrong. where he would like, leave doors open or sit in like a weird way. They didn’t feel right. 1:05:54 And, and that was the exposure piece in some with some of the hallmark would involve that same thing. But, like I said, we incorporated different complementary technique. So, there are some competing responses, Bill, in for when? you know, sometimes sometimes kids, they need something else to do and, you know, they’re so used to doing these behaviors, and they’re so quick. 1:06:23 So, we will use competing responses and then, like I said, you know, I might not use, like relaxation or, you know, relaxation training with OCD, but I will use it if it’s more of like this theoretical CD. 1:06:38 I say those are the main differences. 1:06:41 Differences, OK. How does ERP work when both C obsession and the compulsion are purely mental? 1:06:52 Oh, good question. 1:06:54 Um. 1:06:57 So with mental compulsions, first of all, some people might not realize that there’s medical motions. We definitely want assess for that. 1:07:07 But when it’s just mental, there’s, it might be trickier because we’re not, you know, we’re not working with like a physical compulsion, but there’s others. There’s a lot that we can still do. 1:07:20 So it depends on, I guess it depends on what the medical abortion is. 1:07:23 So for some people, their convulsions might be like, rehearsing, maybe like rehearsing something and do you know, rehearsing? What happened in the past and like making sure, you know, something didn’t happen. That was inappropriate. They didn’t harm the person, so I have someone who that’s like a big medical portion for them so they will do there. 1:07:44 No. It’s like, it’s, it’s, they have to think about what happened and make sure, sort of like, make sure that it wasn’t something bad. 1:07:53 Um, and, you know, some other medical motions could be re-assuring to, like, telling themselves, like, oh, you know that, that didn’t happen, everything was OK. Like, I didn’t hurt, you know, I didn’t hurt that person. A meal, sort of like that, mental checking. 1:08:10 Go with those kind of proportions. There’s a lot of different strategies that can be used, and some work better for some than others. So I like to use a lot of mindfulness techniques. 1:08:21 So John Hirshfield talks a lot about, there’s a really great workbook I didn’t recommend in here, but that works a lot with using mindfulness incorporation for OCD treatment. So, learning how to just acknowledge maybe, OK, this is my OCD talking, but learning how to get back to the present because your OCD is going to pull you into the past. So this might be like a healthy distraction so the person might recognize, you know, they’re poor to engage in the rental rituals and, you know, we might identify what could be healthy distractions to bring them back to the present moment. 1:08:57 They also can do things I teach my patients, how to like maybe spoil those. So maybe they use like, exposure statements and say things like, you know, maybe, you know, going with the uncertainty, like, oh, maybe you know, maybe that didn’t happen, or maybe I did, you know, maybe I did hurt my child or, maybe, you know, maybe I did. 1:09:16 Maybe I was too aggressive too, so just going with what might be the beyond the fear. So, there’s a lot of different things that can be done. 1:09:27 Hmm. Hmm, hmm hmm, OK so here’s a question regarding a 14 year old that has TS and OCD and he does get stuck on some things and the Mom is saying that she tries constantly to re-assure him that these things won’t happen. 1:09:46 Keith has to keep repeating herself about that, and it’s, it’s kind of an endless cycle. And she’s not quite sure how to how to handle that beyond the reassurance. 1:09:59 Any suggestions there? Sure. 1:10:03 So that’s a That’s a really common combos. 1:10:06 Um, so I would suggest that, Well, first of all, How old is this child? 1:10:15 I’m sorry, 14, 14? 1:10:18 OK, so, you know, I’m not sure if, how much she knows the 14 year old knows or is engaged in, you know, any treatment, but I would, I would want him both the parent and him to, to understand the rationale behind why the mom can’t provide reassurance. 1:10:43 So, know, I think that’s important because, you know, free she just all of a sudden stops giving her and said, You know, giving the reassurance to the 14 year old son. You know, it might, know, might not be She might not be able to continue doing it in that way. Like I said, I think it’s important for them to understand why that that reassurance can’t be continued. 1:11:08 But, instead of doing that, like, I would, I would tell a parent to give different responses to reassurance seeking. So, for instance, I might tell parents Know that I can only answer this once. You know, we want to be able to work together to be … So, I’m only answering the ones that I can’t answer of again. I’m sorry. 1:11:34 Just does that work? That’s why I really strongly encourage. You know, it might not be met with resistance. Right? So, I think parents, how could have a lot of trouble with this. 1:11:52 So I think that’s a, that’s something that, um, you know, we have conversations about. 1:11:56 So there are different responses, but I think the main main idea is to to, to have them understand, you know, that they can’t be part of the ritual. 1:12:08 And you know, it might be like, you know, maybe ignoring or saying, I’m sorry, I know you want, I know you’re feeling really anxious right now but I can’t, you know, I can’t be a part of this, um, a hum. 1:12:22 I work with, you know, especially if the parent is part of the ritual, then it’s tough. 1:12:30 It’s not easy, but it’s, you know, it it has to be consistent for them to be able to be able to fight, fight it themselves. 1:12:41 Yeah, and it puts the parent really in the middle then too. I mean, it gets complicated. Yeah. We’ve gone over here. We’re going to we’re going to do one more question here. OK. 1:12:54 So, we have a TS OCD Team. 1:13:00 Does the therapist have to have both TS and OCD experiment experience or expect expertise? 1:13:08 And again you know from from our position as the Tourette organization, we would be feeling that, Yes, you would, that’s a, the answer to that would be yes but from your perspectives and would you kinda talk about that a little bit? 1:13:28 So you said they present with both … an OCD and OECD. Yeah. So what kind of a therapist are you looking for in that situation? 1:13:38 Yeah, so I agree. I would say it’s it would be best to look for a therapist that specializes in both. 1:13:45 And I think, you know, because they, they’re so common in the comorbidity is so common. 1:13:52 And it’s you know, it’s sort of part of this whole general like conceptualization. 1:13:59 I would say that most cases, the therapist would have experience with both. 1:14:08 But, yes, I think it’s important, and especially if both are presenting at the same time, maybe not less of, you know, maybe less importance. 1:14:15 If, for instance, like, maybe the OCD symptoms are are like primary concern. And maybe that she has symptoms or maybe, you know, not popping up in that in that time. 1:14:28 Like, maybe it was, um, now maybe they’re not currently experiencing problems with checks and I would say maybe a little bit less important. 1:14:40 But like I said, I think I would imagine that that OCD specialists would have experienced some sort of experience with text reading. Which was to Yes. Yeah. Yeah. I know, I said last question, but there’s an interesting one here is that I think is relevant. So this last question. So, the question is regarding ERP and it’s in the question is via telehealth network for a teenager, 14 years old? And the question is, do you have any experience in that, and would that work? 1:15:24 You’re saying doing exposures through tau. Yeah. Yeah. See the ERP. Yes. via, you know, via telehealth program. I mean, you know, in New Jersey, we’re very fortunate because there’s there’s a lot of services around this, but I can imagine it’s not the case. It is not the case all over. 1:15:45 So have you had any experience with doing that? 1:15:49 So, that’s a great question, and very timely. 1:15:54 Know, right now, the way things are right now in our environment, we are doing in our practice at least, we’re doing a lot of telehealth. 1:16:03 For the time being and, you know, we’re getting a glimpse of what it might be like in rural areas where people might not be able to go to the office for? 1:16:12 No, for ERP, sexual therapy. 1:16:16 Um, personally, I’ve had a little just only a little bit of experience doing ERP over tele therapy. 1:16:26 No, Of course, there’s a lot of barriers, know. It’s challenging, and that obviously, you know, we’re not going to be face-to-face working together. We’re going to be in different environments. But I think it’s definitely doable. You know, we still kid you know, especially if they’re on a laptop or you know their phones they can still take, you know, take me with that wherever they’re doing their exposures. To be really great for people who are OCD lives at home And maybe like I sometimes go out to, you know, if we need to do exposures in the home, I’ll go out to their their homes. But you know, maybe you know, maybe there’s limitations there So tele therapy can be great to be able to do exposures that way. 1:17:14 So it’s almost like I’m there. We can still, I can still get them to I can still do all the same therapy. And we can still go through exposures. I can be there with them. 1:17:22 Um, and, I would think, too, it’s, it depends on how motivated the kid is to judge, you. 1:17:31 know, so, that, that certainly fact is in, but at 14, you know, I would think that that motivation would would be there For Sure. Definitely! We are finding that was Telehealth. Some of the patients with ADHD, you might have a little bit of a harder time, but, you know, we’re not, I might not be as engaging. But, we’re lucky to have that option. 1:17:57 Yes, we are. Well, thank you. I am going to wrap it up here, and that’s the end of the Q and A, and I will, I’ll turn that back over to Kelly. 1:18:08 Thank you. 1:18:18 Thank you all for joining us on our webinar for Developmental Considerations for OCD and kids, teens, and adults. There is an exit survey which we need everyone to turn into throughout. The webinar blog is now open and available for the next seven days on the Endrew CTAS website for any additional questions that were not covered in tonight’s presentation. That website is WWW dot J C T S dot org. Also, an archived recording of today’s webinar will be posted to our website. 1:18:55 Our next presentation, Parenting the Anxious Child, will be presented by doctor Marla Dobler, and is scheduled for April 29th, 2020, this webinar. Thank you, doctor goals, for your presentation. And thank you, everyone, for attending. Goodnight. Thank you so much.