Treatment of pediatric obsessive-compulsive disorder: A case example of intensive cognitive-behavioral therapy involving exposure and ritual prevention

Knowledge and competency standards for specialized cognitive behavior therapy for adult obsessive-compulsive disorder

Obsessive-Compulsive Disorder (OCD) is a leading cause of disability world-wide (World Health Organization, 2008). Treatment of OCD is a specialized field whose aim is recovery from illness for as many patients as possible. The evidence-based psychotherapeutic treatment for OCD is specialized cognitive behavior therapy (CBT, NICE, 2005, Koran and Simpson, 2013). However, these treatments are not accessible to many sufferers around the world. Currently available guidelines for care are deemed to be essential but insufficient because of highly variable clinician knowledge and competencies specific to OCD. The phase two mandate of the 14 nation International OCD Accreditation Task Force (ATF) created by the Canadian Institute for Obsessive Compulsive Disorders is development of knowledge and competency standards for specialized treatments for OCD through the lifespan deemed by experts to be foundational to transformative change in this field. This paper presents knowledge and competency standards for specialized CBT for adult OCD developed to inform, advance, and offer a model for clinical practice and training for OCD. During upcoming ATF phases three and four criteria and processes for training in specialized treatments for OCD through the lifespan for certification (individuals) and accreditation (sites) will be developed based on the ATF standards.

Quality of life and burden in caregivers of youth with obsessive-compulsive disorder presenting for intensive treatment

BACKGROUND

Pediatric obsessive-compulsive disorder (OCD) is associated with deleterious familial effects; caregivers are often enmeshed in the disorder and can experience considerable burden and decreased quality of life (QoL). Consequently, this study examined burden and QoL in caregivers of youth with OCD enrolled in an intensive outpatient or partial hospitalization program.

METHOD

The relationships between caregiver QoL and burden and the following variables were investigated: OCD symptom severity, functioning (youth functional impairment, general family functioning), family (family accommodation, parental relationship satisfaction, positive aspects of caregiving), and comorbid psychopathology (caregiver anxiety and depressive symptoms, youth internalizing and externalizing behaviors). Seventy-two child and caregiver dyads completed clinician- and self-rated questionnaires.

RESULTS

Components of caregiver QoL correlated with caregiver-rated functional impairment, family accommodation, youth externalizing behaviors, and caregiver psychopathology. Aspects of caregiver burden correlated with child OCD symptom severity, functional impairment related to OCD, as well as caregiver and child comorbid psychopathology. Caregiver depressive symptoms predicted caregiver QoL, and caregiver depressive symptoms and child externalizing symptoms both predicted caregiver burden. Caregiver burden did not mediate the relationship between obsessive-compulsive symptom severity and caregiver QoL.

CONCLUSION

Ultimately, elucidating factors associated with increased caregiver burden and poorer QoL is pertinent for identifying at-risk families and developing targeted interventions.

The Principles of Extinction and Differential Reinforcement of Other Behaviors in the Intensive Cognitive-Behavioral Treatment of Primarily Obsessional Pediatric OCD

This case study describes the application of intensive cognitive-behavioral treatment (CBT), focusing on extinction and differential reinforcement of other behaviors (DRO), in an adolescent girl with primarily obsessional obsessive-compulsive disorder (OCD). “Abby,” a 13-year-old, Caucasian female, showed meaningful changes in OCD symptomatology during five consecutive sessions of intensive treatment. Abby’s mother also reported dramatic improvements in Abby’s functioning and in the mother-child relationship. Improvements continued to be reported by Abby and her mother and observed by therapists during follow-up sessions. The results of this case study provide preliminary support that intensive CBT incorporating extinction, cognitive restructuring skills, and DRO may be an effective treatment for pediatric OCD.

Cognitive-behavioral therapy for pediatric obsessive-compulsive disorder: Empirical review and clinical recommendations

The efficacy of cognitive-behavioral therapy (CBT) for pediatric obsessive-compulsive disorder (OCD) has been the subject of much study over the past fifteen years. Building on a foundation of case studies and open clinical trials, the literature now contains many methodologically sound studies that have compared full CBT protocols to waitlist controls, pill placebo, psychosocial comparison conditions, active medication, combined treatments, and brief CBT. This review is part of a series commissioned by The Canadian Institute for Obsessive Compulsive Disorders (CIOCD) in an effort to publish in one place what is known about the efficacy of treatments for OCD. A total of fourteen studies were identified; collectively their findings support the efficacy of CBT for youth with OCD. CBT protocols that emphasized either strictly behavioral or cognitive conceptualizations have each been found efficacious relative to waitlist controls. Efforts to enhance CBT׳s efficacy and reach have been undertaken. These trials provide guidance regarding next steps to be taken to maximize efficacy and treatment availability. Findings from studies in community clinics suggest that significant treatment benefits can be realized and are not reported only from within academic contexts. These findings bode well for broader dissemination efforts. Recommendations for future research directions are provided.

A baseline controlled examination of a 5-day intensive treatment for pediatric obsessive-compulsive disorder

This study extends support for a 5-day intensive exposure and response prevention (ERP) treatment protocol for pediatric obsessive compulsive disorder (OCD). Twenty-two children with OCD received ERP treatment twice daily for 5 days. The treatment also emphasized teaching children and parents how to conduct ERP independently after they returned home. Symptoms were assessed at four time-points: Baseline, 4 weeks later at pre-treatment, one week after the intensive treatment 5-day treatment, and at 3 month follow-up. Changes on the primary outcome measure, clinician severity ratings on the Anxiety Disorders Interview Schedule for Children, and secondary measures, indicated that OCD symptoms remained stable from the evaluation to baseline and improved significantly from baseline to follow-up. Moreover, parental accommodation of OCD decreased significantly from baseline to post-treatment and from post-treatment to follow-up. These data suggest that the 5-day intervention demonstrates efficacy in reducing OCD symptoms and may initiate change in parent accommodation that continues to improve after the family returns home.

An uncontrolled examination of a 5-day intensive treatment for pediatric OCD

This study examined the feasibility of a 5-day intensive treatment for pediatric obsessive-compulsive disorder (OCD). Fifteen children with OCD received a week-long treatment based on exposure and response prevention (ERP). The intervention also emphasized teaching children and parents how to conduct ERP independently at home. All families completed the week-long treatment and symptoms improved significantly as measured by self- and parent-report forms, as well as the Children's Yale-Brown Obsessive-Compulsive Scale, F(2, 22)=45.67, p<.05. Total CY-BOCS scores decreased significantly from pretreatment (M=28.00, SD=4.24) to posttreatment [M=16.00, SD=6.0, F(1, 11)=34.38, p<.05] and from posttreatment to 5-month follow-up [M=11.5, SD=7.3; F(1, 11)=12.94, p<.05]. This level of improvement was consistent with other intensive treatments for pediatric OCD. The study suggests that the 5-day program is a promising treatment for children with OCD who do not have access to local providers.

Sequential cognitive-behavioral therapy for children with obsessive-compulsive disorder with an inadequate medication response: a case series of five patients

Few data have been reported on the efficacy of cognitive-behavioral therapy (CBT) for youth with obsessive-compulsive disorder (OCD) who have not responded to prior treatment with medication. Given this, we report an open trial of CBT for children who have remained symptomatic following medication trials. Five children with OCD who had an inadequate response to psychotropic medications (e.g., limited response and/or unable to be titrated to a complete dose due to side effects) received treatment in a 3-week intensive CBT program. Assessments were conducted at baseline and after treatment. All participants were classified as treatment responders (much improved or very much improved) and the severity of clinician-rated OCD symptoms and impairment significantly decreased after the intervention. Although a number of limitations of this preliminary report exist, this study provides preliminary support for the utility of an intensive intervention for youth with OCD who have had an inadequate response and/or adverse side effects.

Family-based cognitive-behavioral therapy for pediatric obsessive-compulsive disorder: comparison of intensive and weekly approaches

OBJECTIVE

To examine the relative efficacy of intensive versus weekly cognitive-behavioral therapy (CBT) for children and adolescents with obsessive-compulsive disorder (OCD).

METHOD

Forty children and adolescents with OCD (range 7-17 years) were randomized to receive 14 sessions of weekly or intensive (daily psychotherapy sessions) family-based CBT. Assessments were conducted at three time points: pretreatment, posttreatment, and 3-month follow-up. Raters were initially blind to randomization. Primary outcomes included scores on the Children's Yale-Brown Obsessive-Compulsive Scale, remission status, and ratings on the Clinical Global Impression-Severity and Clinical Global Improvement scales. Secondary outcomes included the Child Obsessive Compulsive Impact Scale-Parent Rated, Children's Depression Inventory, Multidimensional Anxiety Scale for Children, and Family Accommodation Scale. Adjunctive pharmacotherapy was not an exclusion criterion.

RESULTS

Intensive CBT was as effective as weekly treatment with some advantages present immediately after treatment. No group differences were found at follow-up, with gains being largely maintained over time. Although no group x time interaction was found for the Children's Yale-Brown Obsessive-Compulsive Scale (F(1,38) = 2.2, p = .15), the intensive group was rated on the Clinical Global Impression-Severity as less ill relative to the weekly group (F(1,38) = 9.4, p < .005). At posttreatment, 75% (15/20) of youths in the intensive group and 50% (10/20) in the weekly group met remission status criteria. Ninety percent (18/20) of youths in the intensive group and 65% (13/20) in the weekly group were considered treatment responders on the Clinical Global Improvement (chi1(2) = 3.6, p = .06).

CONCLUSIONS

Both intensive and weekly CBT are efficacious treatments for pediatric OCD. Intensive treatment may have slight immediate advantages over weekly CBT, although both modalities have similar outcomes at 3-month follow-up.