I have not spent a great deal of time discussing mental illness in children on PBB; however, today I came across an interesting article on the treatment of pediatric obsessive-compulsive disorder (OCD) and thought it might be useful to describe its summary of treatment outcomes. In this article, published in Cognitive and Behavioral Practice by Wendi Marien of the Monroe Clinic and Eric Storch, Gary Geffken, and Tanya Murphy of the University of South Florida and the University of Florida (2009), the authors discussed the relative virtues of cognitive behavioral therapy (CBT) and antidepressant treatment for pediatric OCD and presented some preliminary data on an intensive family-based version of CBT for children who have had poor responses to pharmacological treatments in the past.
What is OCD?
As we have discussed in prior articles on this topic, OCD is an anxiety disorder marked by two distinct characteristics: obsessions and compulsions. Obsessions are defined as intrusive thoughts and/or images that are experienced as unwanted by the individual and which cause significant anxiety or distress. Compulsions are repetitive behaviors (e.g., hand-washing) or mental actions (e.g., counting to particular numbers) utilized in an effort to reduce distress or prevent unwanted outcomes. In some cases, such as excessive hand washing in order to reduce the obsessive fear of contamination by germs, the compulsive behavior represents a logical but exaggerated response to the obsession. In other cases, such as counting to a particular number in order to prevent a loved one from being injured, the compulsive behavior exhibits no logical connection to the obsession.
In order for a diagnosis of OCD to be warranted, the obsessions and compulsions need to cause significant distress and/or impairment and must take up a substantial amount of time (e.g., several hours per day). In other words, normative childhood anxiety or ritualistic behaviors are not necessarily indicative of any form of pathology. Additionally, avoidance behaviors (e.g., avoiding using public restrooms or touching objects in the restroom due to obsessive fear of contamination) should be considered as contributing to distress and/or impairment.
In this article, Marien and colleagues (2009) cite prior work indicating that the 6 to 12 month prevalence rates of OCD in children and adolescents is 1.3%-4.0%. Those numbers might seem small, but they are essentially on par with the prevalence rates of most mental illnesses in adults.
Pharmacological treatments for pediatric OCD
Marien and colleagues (2009) provided a summary of research findings on the utility of prescribing pharmacological treatments - particularly serotonin reuptake inhibitors (SRI's) - for pediatric OCD as well as a summary of the findings comparing pharmacological treatments to CBT. The authors noted that a substantial portion of clients who present at their clinic were first treated for pediatric OCD through the prescription of an SRI and/or the use of non-empirically supported forms of psychotherapy despite clear evidence that the best approach is to begin treatment with CBT, either alone or in combination with a selective serotonin reuptake inhibitor (SSRI; Pediatric OCD Treatment Study Team [POTS], 2004). There are a number of reasons why this scenario might unfold and the authors mentioned several of them (e.g., inadequate training in the use of empirically supported treatments), but these reasons are not the focus of our article.
Although the use of SRI's is not the most effective form of treatment, there is substantial evidence that they are quite helpful in the treatment of pediatric OCD. In several trials, SRI's have been shown to be superior to placebo in the treatment of pediatric OCD (e.g., Abramowitz, Whiteside, & Deacon, 2005). This is obviously a promising finding; however, when SRI's are compared to CBT, the results are not nearly as favorable (e.g., POTS, 2004). In several studies, although children on SRI's exhibited significant improvement in their symptoms of OCD, their symptoms remained in the moderate range of severity (e.g., Abramowitz et al., 2005; March et al., 1998). In fact, of those who do respond positively to SRI's, only a small minority actually remit. In the POTS (2004) study, only 21.4% of children treated with sertraline remitted. Additionally, once medication is discontinued, relapse rates are extremely high, meaning that pharmacological treatments for pediatric OCD, in many cases, require chronic treatment (Leonard et al., 1991; Pato, Zohar-Kadouch, Zohar, & Murphy, 1988).
CBT for pediatric OCD
CBT for pediatric OCD is not much different than CBT for adults with OCD. Treatment includes an initial psychoeducation component, in which the children are taught about the nature of OCD and CBT and told what to expect from treatment. Additionally, cognitive components, including the challenging of distorted thoughts, the generation of helpful thoughts, and the use of supportive self-talk are used. Clinicians differ in the degree to which they utilize cognitive skills with children, although there is no reason to believe that dropping this component is in any way essential. Finally, treatment also involves exposure exercises. For this component, the child generates a list of feared situations, ranked in order by the degree to which they are fear provoking, and is systematically exposed to those situations over time, beginning with the least frightening situations. The child is asked to remain in the exposure situation until his or her anxiety either disappears or decreases to a manageable level and is told not to engage in compulsive behaviors while this is happening. Exposure exercises can be conducted as imaginal exercises (e.g., imagine the situation) or in vivo, with the latter being preferable when possible. In addition to engaging in these exercises in session, the child is encouraged to practice at home daily in order to ensure that treatment gains generalize to the child's home environment. This entire process is often referred to as exposure and response prevention (EXRP).
Studies have shown that CBT results in greater symptom reduction than do SRI's or placebo (Abramowitz et al., 2005). Additionally, children treated with OCD, on average, exhibit only mild OCD symptoms post-treatment as opposed to the moderate symptoms experienced by children treated with SRI's. In the POTS (2004) trial, which compared CBT alone to sertraline alone and the combination of the two, combination treatment was found to be superior to the other two conditions with respect to reducing symptoms, although combo and CBT alone did not differ post-treatment on the proportion of participants who remitted. Ashbahr et al., (2005) found that, while group CBT and sertraline both significant reduced OCD symptoms in children, children treated with group CBT has significantly lower relapse rates than did children treated with sertraline 9 months after treatment ended.
So are you saying that pharmacological treatments for OCD do not work?
Marien and colleagues (2009) were definitely not saying that SRI's or SSRI's are ineffective. Rather, they were simply pointing out that, while such treatments are better than nothing, they do not produce effects that are as impressive as those produced by CBT, either in individual or group format. As such, CBT is considered the front-line, empirically supported treatment for pediatric OCD. There are plenty of disorders for which the opposite conclusion is true (e.g., schizophrenia or bipolar spectrum disorders in adults), so this statement is not a biased commentary by a clinical psychologist attempting to further his or her own cause, but rather a frank and open discussion of empirical evidence which, in this case, is more supportive of psychosocial than psychopharmacological approaches to treatment.
What about the families of children and adolescents with OCD?
The second half of Marien et al.'s (2009) article discussed prior research on the use of families in the treatment of pediatric OCD and a proposed intensive form of family based CBT for this population. Summarizing all of this information is beyond the scope of today's post, but let me give you a quick sense of what they found and what they have proposed.
First of all, there is compelling evidence that incorporating families into CBT for pediatric OCD can be helpful (e.g., POTS, 2004). Given that the child or adolescent with OCD is not the only one impacted by the symptoms, this seems like a promising line of research potentially capable of helping many people at once.
In addition to this basic finding - including families can be good - there is also a debate as to whether intensive treatment might be a better approach. Typically, CBT involves weekly sessions spread out over the course of several months. Intensive treatments on the other hand, often involve daily sessions spread out only across a few weeks. Storch and colleagues (2007) compared intensive CBT to weekly CBT for pediatric OCD and found that, at post-treatment, the intensive treatment resulted in a higher rate of remittance (75%) than did the weekly treatment (50%), but that the two groups were essentially equal at 3-month follow-up (72% and 77% respectively). This seems to indicate that intensive treatments result in quicker gains, but that, in the long run, the two approaches result in equal improvements. As such, the relative value of intensive versus weekly treatment depends upon the degree to which fast improvement is needed and whether one approach is more convenient and/or financially plausible than the other.
In response to the positive findings for group and family-based CBT for pediatric OCD, the authors detailed their own proposal for an intensive form of family-based CBT. The treatment includes daily 90-minute treatment sessions for 3 weeks. At least one parent is required to be present at all sessions and a substantial amount of attention is spent on teaching parents to be informed consumers aware of the nature of OCD, the treatments that are available, cutting edge research, and ways to help their child implement the treatment protocol without reinforcing OCD behaviors. Marien and colleagues (2009) actually provide a detailed description of the session-by session content and I encourage you to read the original article if you are interested in learning precisely how their approach to therapy is conducted.
As of now, the research into this particular approach is still ongoing. That being said, the authors were able to provide some preliminary data on the efficacy of the approach. Importantly, the sample used by the authors in their work is comprised of children and adolescents who have failed to fully respond to pharmacological treatments. As such, their findings not only demonstrate that their treatment approach is useful, but that it works with children and adolescents who have not responded to prior attempts at treatment. In an open trial of 5 youths ranging in age from 4 to 14, they found that all five responded to treatment, with symptoms reduced, on average, by nearly 70% after 3 weeks (Storch et al., 2007). Obviously, this is too small a sample for any sort of conclusion, but it was simply the initial trial the authors used to ensure that the treatment was promising enough to pursue further. In a subsequent trial using 30 youths ranging in age from 7 to 19 years of age, in which every participant had a history of two or more failed trials of pharmacological treatments (SRIs and/or SRI augmented with atypical antipsychotics), symptoms were reduced, on average, by 54% in 3 weeks and treatment gains were maintained at 3-month follow-up. Again, the sample is too small to draw any conclusions, but a massive clinical trial of this treatment approach is now ongoing and results will be forthcoming.
Conclusion
In conclusion, the authors presented a compelling case that, while SRI's can be useful in treating pediatric OCD, CBT is substantially better. This statement is based upon the fact that it reduces symptoms more significantly, leads to greater rates of remittance, and exhibits lower rates of relapse. Additionally, the authors provided preliminary evidence that an intensive form of family-based CBT for pediatric CBT could be highly useful, but more data are needed before we can draw any firm conclusions on that point.
If you would like to learn more about obsessive compulsive disorder, we recommend the following products, all of which are available through our online store:
- Stop Obsessing!: How to Overcome Your Obsessions and Compulsions
by Edna Foa and Reid Wilson
- Mastery of Obsessive-Compulsive Disorder: A Cognitive-Behavioral Approach Client Workbook
by Edna Foa and Michael Kozak
- Mastery of Obsessive-Compulsive Disorder: A Cognitive-Behavioral Approach Therapist Guide
by Edna Foa and Michael Kozak
- Family Based Treatment for Young Children With OCD: Therapist Guide
by Jennifer Freeman and Abbe Marrs Garcia
- Family-Based Treatment for Young Children with OCD Workbook
by Jennifer Freeman and Abbe Marrs Garcia
Mike Anestis is a doctoral candidate in the clinical psychology department at Florida State University
