Outcomes of Cognitive Behaviour Therapy for Obsessive Compulsive Disorder in a Clinical Setting: A 10-Year Experience from a Specialist OCD Service for Children and Adolescents

Controlled studies show that cognitive behavior therapy (CBT) is an efficacious treatment for young people with obsessive compulsive disorder (OCD). More evidence is needed for effectiveness in clinical settings. We conducted a case note review of 318 patients attending an OCD clinic. Outcomes for 75 patients who received treatment in the clinic were analysed. Following acute treatment, total CYBOCS (Children Yale-Brown Obsessive Compulsive Scale) score was significantly reduced (22.6 to 10.9, p  = .0001). Gains were maintained at long-term follow-up. Our results suggest that CBT is an effective treatment for child and adolescent OCD delivered in a clinical setting.     

A randomised controlled trial of cognitive behavioural treatment for obsessive compulsive disorder in children and adolescents

Cognitive behaviour therapy (CBT) for young people with obsessive compulsive disorder (OCD) has become the treatment of first choice. However, the literature is largely based on studies emphasising exposure and response prevention. In this study, we report on a randomised controlled trial of CBT for young people carried out in typical outpatient clinic conditions which focused on cognitions. A randomised controlled trial compares 10 sessions of manualised cognitive behavioural treatment with a 12-week waiting list for adolescents and children with OCD. Assessors were blind to treatment allocation. 21 consecutive patients with OCD aged between 9 and 18 years were recruited. The group who received treatment improved more than a comparison group who waited for 3 months. The second group was treated subsequently using the same protocol and made similar gains. In conclusion, CBT can be delivered effectively to young people with OCD in typical outpatient settings.     

Cognitive behavioral therapy for obsessive-compulsive disorder: An update

Cognitive-behavioral therapy (CBT) for obsessivecompulsive disorder (OCD) has been shown to be a highly effective treatment for children and adults. In the current review, we briefly describe the historical developments of the treatment, and recent findings related to five areas of inquiry: 1) Does intensity of CBT impact outcome? 2) Does CBT work better on some subtypes of OCD than others? 3) How do cognitive and behavioral strategies relate to outcome? 4) How well does CBT work for children and adolescents with OCD? and 5) Does the combination of CBT and medication work better than CBT alone? After a discussion of these questions, we mention some areas currently being examined.     

Obsessive-compulsive disorder in children.

Childhood OCD is a chronic and commonly disabling disorder with a lifetime prevalence of 2% to 3%. Traditionally OCD was a neglected diagnosis, but renewed research interest over the past decade has led to significant advances in the understanding of the disorder in young people. OCD is relatively consistent across the age span in terms of prevalence, phenomenology, etiology, and response to treatment. Comorbidity, especially depression and other anxiety disorders, is common in children with OCD and may exert a negative influence on treatment response and long-term outcome. Nevertheless, CBT and SSRI therapy have been shown to be effective and well-tolerated therapies for children with OCD.     

The therapeutic alliance in the cognitive behavioral treatment of pediatric obsessive-compulsive disorder

Although cognitive-behavioral therapy (CBT) for pediatric obsessive–compulsive disorder (OCD) is considered a first-line treatment, not all youth have a positive treatment response, suggesting need for investigating factors that may enhance or reduce treatment effects. Few studies have investigated predictors of treatment response in pediatric OCD, and there is an absence of studies examining the influence of treatment process variables (e.g., therapeutic alliance [TA]) on treatment outcome. Using a multiple-informant and multiple-time point design, the current study examined the role of the TA in family-based CBT for pediatric OCD. Analyses examined (1) the predictive value of the TA on OCD symptom reduction and (2) whether changes in the TA over time predict treatment response. Findings indicated that (1) stronger child-rated, parent-rated, and therapist-rated TAs were predictive of better treatment outcome and (2) larger and more positive early alliance shifts (as rated by changes in child-rated TA between sessions 1 and 5) were predictive of better treatment outcome. Implications for the treatment of youth with OCD within family-based CBT are discussed.     

An Evaluation of a New Autism-Adapted Cognitive Behaviour Therapy Manual for Adolescents with Obsessive–Compulsive Disorder

Obsessive–compulsive disorder (OCD) and autism spectrum disorder (ASD) frequently co-occur. Standard cognitive behaviour therapy (CBT) for OCD outcomes are poorer in young people with ASD, compared to those without. The aim of this naturalistic study was to evaluate the effectiveness of a novel adolescent autism-adapted CBT manual for OCD in a specialist clinical setting. Additionally, we examined whether treatment gains were maintained at 3-month follow-up. Thirty-four adolescents underwent CBT; at the end of treatment, 51.51% were treatment responders and 21.21% were in remission. At 3-month follow-up, 52.94% were responders and 35.29% remitters. Significant improvements were also observed on a range of secondary measures, including family accommodation and global functioning. This study indicates this adapted package of CBT is associated with significant improvements in OCD outcomes, with superior outcomes to those reported in previous studies. Further investigation of the generalizability of these results, as well as dissemination to different settings, is warranted.

     

Cognitive behavioral treatment for young children with obsessive-compulsive disorder.

Obsessive-compulsive disorder (OCD) is a distressing and functionally impairing disorder that can emerge as early as age 4. Cognitive behavior therapy (CBT) for OCD in youth shows great promise for amelioration of symptoms and associated functional impairment. However, the empirical evidence base for the efficacy of CBT in youth has some significant limitations, particularly as related to treating the very young child with OCD. This report includes a quantitative review of existing child CBT studies to evaluate evidence for the efficacy of CBT for OCD. It identifies gaps in the literature that, when addressed, would enhance the understanding of effective treatment in pediatric OCD. Finally, it presents a proposed research agenda for addressing the unique concerns of the young child with OCD.     

The effect of aerobic exercise alone and in combination with cognitive behavioural therapy on obsessive compulsive disorder: A randomized control study

PurposeCognitive behavioural therapy (CBT) has been found to be an effective treatment for OCD, but there remains a significant proportion of individuals who fail to show a treatment response. Aerobic exercise has previously been associated with decreases in anxiety and depression, as well as improvements in OCD symptoms in small-scale studies. The purpose of the present research was to use a randomized control trial design to examine the effects of exercise alone and in combination with CBT, on OCD symptoms and secondary symptoms.Method125 participants were randomly assigned to one of four treatment groups: waitlist control, exercise, CBT, and CBT with exercise. OCD symptom severity was measured at four points over the course of treatment, secondary outcome measures were gathered at three points over treatment.ResultsCBT alone and combined with exercise was associated with significantly greater OCD symptom reduction than exercise alone or the control groups. Total exercise frequency predicted OCD symptom reduction in the groups in which exercise was measured. Group membership did not significantly predict reductions in secondary outcome measures.ConclusionExercise frequency, rather than the presence or absence of exercise, appears to predict OCD symptom reduction, as did participation in CBT.     

Cognitive behaviour therapy and medication in the treatment of obsessive-compulsive disorder

Objective: To compare cognitive behaviour therapy (CBT) with CBT plus medication; medication alone; and placebo in the treatment of adult obsessive–compulsive disorder (OCD). Method: Forty‐eight participants (43 completers) were recruited into two protocols. In the first protocol, 21 people with OCD were randomly allocated to either a standard medication (fluvoxamine) or standard placebo condition for a 5‐month period. Both these groups subsequently received CBT for a further 5 months. In the second protocol, 22 people with OCD received CBT, one group was already stabilized on an antidepressant of choice; the second group was drug naïve. Results: All active treatments, but not the placebo, showed clinical improvement. There was no difference in treatment response to CBT regardless of whether participants had previously received medication or placebo. Conclusion: CBT has a more specific antiobsessional effect than medication but CBT plus medication shows greatest overall clinical improvement in mood.     

Can memory and executive functions in patients with obsessive–compulsive disorder predict outcome of cognitive behavioural therapy?

Background: Most studies find that patients with obsessive–compulsive disorder (OCD) have impaired memory and executive functions. Cognitive behavioural therapy (CBT) is the recommended psychotherapeutic treatment of patients with OCD. We hypothesized that impairments in memory and executive functions would predict poor outcome of CBT. Aim: To investigate whether memory and executive functions in patients with OCD could predict outcome of CBT. Methods: We assessed 39 patients with OCD before CBT with neuropsychological tests of memory and executive functions, the Hamilton Depression Rating Scale, and the Global Assessment of Functioning Scale. Furthermore, we assessed severity of OCD symptoms before and after CBT using the Yale–Brown Obsessive Compulsive Scale. Results: There were no statistically significant differences between recovered (41%) and non-recovered patients (59%) on any neuropsychological test variables or on any baseline demographic variables. Furthermore, change in OCD symptoms was not predicted by neuropsychological test performances or baseline severity of OCD symptoms. The only statistically significant finding was that non-recovered patients had lower social functioning before CBT than recovered patients (p = 0.018, d = 0.797). Conclusions: Memory and executive functions in patients with OCD could not predict outcome of CBT, but level of social functioning may be a predictor of CBT outcome. Some of the main clinical implications are that we cannot use memory and executive functions, or baseline severity of OCD symptoms to determine which patients should be offered CBT.     

Family-based treatment of early-onset obsessive-compulsive disorder

Despite a meaningful common core of symptoms observed across the life span, there are particularly unique features of early-onset (prepubertal) obsessive-compulsive disorder (OCD) that make consideration of early presentation different from adolescent or adult onset and that may have important implications for treatment. This article will first review the unique features of early-onset OCD, focusing particular attention to the developmental and familial context of these children's symptoms. The literature on behavioral family interventions for other childhood disorders, specifically anxiety, as well as that on family processes (e.g., parent-child interactions) in families of children with OCD will be reviewed. The pediatric OCD cognitive-behavioral therapy (CBT) literature (CBT alone and CBT plus medication) will also be reviewed, focusing on current evidence-based treatment guidelines. Finally, a model of family-based treatment for young children with OCD and some preliminary pilot data will be presented.     

Thematic similarity and clinical outcome in obsessive-compulsive disorder group treatment

Despite the existence of efficacious cognitive-behavioral group treatments for obsessive-compulsive disorder (OCD), no data has been presented regarding the potential impact of symptom or thematic similarity among group members. The purpose of this study was to evaluate the effect of thematic similarity among group members on outcome after cognitive-behavioral (CBT) or exposure/response prevention (ERP) treatment for OCD. Results consistently demonstrated across a range of measures no impact of thematic similarity, nor any interaction of similarity by treatment type (ERP versus CBT), on treatment outcome. These data suggest that OCD treatment groups can be formed based on consecutive client intake without negatively impacting efficacy.     

Cognitive-behavioral therapy for obsessive-compulsive disorder: a non-randomized comparison of intensive and weekly approaches

This study examined the relative efficacy of intensive versus weekly cognitive-behavioral therapy (CBT) for adults with obsessive-compulsive disorder (OCD). Sixty-two adults with OCD received either 14 sessions of weekly (n=30) or intensive CBT (n=32; daily psychotherapy sessions) in a non-randomized format. Assessments were conducted at Pre-treatment, Post-treatment, and 3-month Follow-up by raters who were blind to treatment group at the Pre-treatment assessment. Intensive and weekly CBT were similar in efficacy at Post-treatment and Follow-up and associated with large treatment effect sizes. Since many people with OCD do not have access to trained CBT providers, intensive treatment may be a viable option in such cases.     

Early childhood OCD: preliminary findings from a family-based cognitive-behavioral approach

ObjectiveTo examine the relative efficacy of family-based cognitive-behavioral therapy (CBT) versus family-based relaxation treatment (RT) for young children ages 5 to 8 years with obsessive-compulsive disorder (OCD).MethodForty-two young children with primary OCD were randomized to receive 12 sessions of family-based CBT or family-based RT. Assessments were conducted before and after treatment by independent raters blind to treatment assignment. Primary outcomes included scores on the Children's Yale-Brown Obsessive Compulsive Scale and Clinical Global Impressions-Improvement.ResultsFor the intent-to-treat sample, CBT was associated with a moderate treatment effect (d = 0.53), although there was not a significant difference between the groups at conventional levels. For the completer sample, CBT had a large effect (d = 0.85), and there was a significant group difference favoring CBT. In the intent-to-treat sample, 50% of children in the CBT group achieved remission as compared to 20% in the RT group. In the completer sample, 69% of children in the CBT group achieved a clinical remission compared to 20% in the RT group.ConclusionsResults indicate that children with early-onset OCD benefit from a treatment approach tailored to their developmental needs and family context. CBT was effective in reducing OCD symptoms and in helping a large number of children achieve a clinical remission.     

Treatment outcome for adolescent obsessive-compulsive disorder in a specialized hospital setting

Although few data are available concerning adolescents with obsessive-compulsive disorder (OCD), the existing literature suggests that cognitive-behavioral therapy (CBT) is the first-line treatment of choice for adolescents with mild to moderate OCD. A combination of CBT and serotonin reuptake inhibitors (SRIs) is recommended for more severe forms of OCD, based on the Expert Consensus Guidelines for the Treatment of Obsessive-Compulsive Disorder and the Pediatric OCD Treatment Study (POTS). Despite the effectiveness of CBT, a recent meta-analysis found that 27% of adolescent outpatients fail to show clinically significant improvement following CBT and many also fail to show improvement with pharmacotherapy. One alternative for those who do not improve with outpatient treatment is an intensive inpatient program. Within the last 10 years, two specialty hospitals have created programs that provide intensive CBT milieu treatment with multidisciplinary support (e.g., nursing, psychopharmacology) to treat adolescents with OCD. This naturalistic study describes treatment outcomes in 23 patients who received treatment in one of these programs between 2005 and 2006. Results suggest significant improvements on the majority of outcome measures, with 70% of the patients judged to meet criteria for clinically significant change. Thus, inpatient treatment appears potentially efficacious, although future controlled trials with larger samples are needed.     

Evidence Based Research in CBT with Adolescent Eating Disorders

Cognitive behaviour therapy (CBT) is increasingly becoming the treatment of choice for a number of adolescent mental health problems, including depression ( Harrington et al., 1998 ) and obsessive compulsive disorder (OCD), ( March, 1995 ). In considering the role of CBT in the treatment of adolescent eating disorders, it is helpful to review the phenomenology of anorexia and bulimia nervosa in this age group and to assess the theoretical relevance of a cognitive behavioural approach to their management. The evidence base has been reviewed in the recently published National Institute of Clinical Excellence (NICE) Guidelines on the treatment of eating disorders ( NICE, 2004 ). To date, CBT approaches have not been widely tested in controlled trials in this age group. However, a randomised controlled treatment trial is under way in the North West of England (The TOuCAN Trial), in which CBT is an important component of one of the interventions being studied and this will be described.     

Tics moderate treatment outcome with sertraline but not cognitive-behavior therapy in pediatric obsessive-compulsive disorder.

BACKGROUND: The presence of a comorbid tic disorder may predict a poorer outcome in the acute treatment of pediatric obsessive-compulsive disorder (OCD). METHODS: Using data from the National Institute of Mental Health (NIMH)-funded Pediatric OCD Treatment Study (POTS) that compared cognitive-behavior therapy (CBT), medical management with sertraline (SER), and the combination of CBT and SER (COMB), to pill placebo (PBO) in children and adolescents with OCD, we asked whether the presence of a comorbid tic disorder influenced symptom reduction on the Children's Yale-Brown Obsessive Compulsive Scale (CY-BOCS) after 12 weeks of treatment. RESULTS: Fifteen percent (17 of 112) of patients exhibited a comorbid tic disorder. In patients without tics, results replicated previously published intent-to-treat outcomes: COMB > CBT > SER > PBO. In patients with a comorbid tic disorder, SER did not differ from PBO, while COMB remained superior to CBT and CBT remained superior to PBO. CONCLUSIONS: In contrast to CBT outcomes, which are not differentially impacted, tic disorders appear to adversely impact the outcome of medication management of pediatric OCD. Children and adolescents with obsessive-compulsive disorder and a comorbid tic disorder should begin treatment with cognitive-behavior therapy alone or the combination of cognitive-behavior therapy plus a serotonin reuptake inhibitor.     

Case study: bibliotherapy and extinction treatment of obsessive-compulsive disorder in a 5-year-old boy

Cognitive-behavioral therapy (CBT) is an effective treatment for childhood obsessive-compulsive disorder (OCD). However, no case studies of children younger than 7 years old have been published. This case report describes a 5-year-old boy with severe OCD. Treatment consisted of parent- and teacher-directed extinction of compulsive reassurance-seeking, and bibliotherapy with an age-appropriate book on OCD. Compulsive behavior decreased rapidly and remained at a low level through the remainder of treatment. At posttreatment and at 1- and 3-month follow-up assessments, the patient's OCD symptoms were markedly improved. This report suggests that very young children may respond well to brief CBT.     

Longitudinal trajectory and predictors of change in family accommodation during exposure therapy for pediatric OCD

Family accommodation (FA) is key in the maintenance of OCD. However, most studies are cross-sectional, and have not identified long-term trajectories and correlates of FA changes over treatment. This study investigated changes in clinician-rated FA over 10 sessions of cognitive behavioral therapy (CBT) for 142 children with OCD, as well as several key predictors/correlates: (a) clinician-rated OCD symptom severity, (b) child- and parent-rated functional impairment, (c) parent-rated treatment expectancies, and (d) child- and parent-rated therapeutic alliance. Multi-level models indicated that FA changed significantly during treatment, with gains maintained over 6-months. Baseline clinician-rated OCD severity did not predict changes in FA. Significant interactions indicated that children with higher child- and parent-rated impairment exhibited greater FA improvements over treatment (versus children with lower impairment). Child- and parent-rated therapeutic alliance and parent-rated expectancies did not predict FA changes. Finally, FA mediated the relationship between OCD severity and parent- (but not child-) rated impairment. Reverse mediation models were also significant. Findings indicate that CBT can successfully reduce FA (a) even if children experience high OCD severity and interference in school, relationships, and family life, and (b) regardless of non-specific factors like treatment expectancies and alliance. FA reductions are an important mechanism mediating treatment response.     

Cognitive behavioral therapy for pediatric obsessive-compulsive disorder: Development of expert-level competence and implications for dissemination

Pediatric obsessive-compulsive disorder (OCD) is associated with substantial morbidity, comorbidity, family difficulties, and functional impairment. Fortunately, OCD in youth has also been found responsive to cognitive behavioral therapy (CBT) both alone and in combination with medication. This paper highlights key areas a treatment provider must be highly knowledgeable in to be considered an expert in cognitive behavioral therapy (CBT) for pediatric obsessive-compulsive disorder (OCD). We describe the areas of knowledge that must be mastered to gain expertise, as well as the more difficult to quantify personal qualities that may allow a clinician to convey this knowledge in an expert manner. We provide detailed discussions of CBT theory, assessment strategies, implications of the treatment outcome literature for clinical decision-making, and how best to navigate CBT. We also discuss what the expert needs to accomplish by engaging youth and families throughout the evaluation and treatment process.