the society for clinical child and adolescent psychology ......evidence-based treatment of obsessive...

The Society for Clinical Child and Adolescent Psychology (SCCAP):

Initiative for Dissemination of Evidence-based Treatments for Childhood and Adolescent Mental

Health Problems

With additional support from Florida International University and The Children’s Trust.

Keynote Evidence-based Treatment of Obsessive Compulsive Disorder in Children and Adolescents

John Piacentini, Ph.D., ABPP Child OCD, Anxiety, and Tic Disorders Program

UCLA Semel Institute for Neuroscience and Human Behavior

Disclosure

Royalties for Treatment Manual and Child Workbook from Oxford University Press

OCD Diagnostic Criteria

OBSESSIONS

• Unwanted, repetitive, intrusive thoughts, impulses, images

• Cause marked distress

• Not simply excess worries about everyday topics

• Individual attempts to ignore, neutralize or suppress

• Usually recognized as product of one’s own mind

I just know

I left the

oven on.

Obsessions – Adult

I just know

I left the

computer on.

Obsessions – Child


COMPULSIONS

• Repetitive behaviors or mental acts conducted in

response to obsession

• Typically performed in stereotypic or rule-bound fashion

• Behavior logically unrelated to obsessive fear or else

completed in manner out of proportion to fear

• Aimed at reducing stress or preventing dreaded event

OCD Diagnostic Criteria Features in Childhood

Obsessions

• May be less well-formed in children than adults

• “Bizarre” easily misdiagnosed

Accompanying Feelings

• Fear/Anxiety, Doubt, Disgust, Unacceptable urges,

Sensory Incompleteness

Checking Compulsions

Strike a match, Ernie.

I need to check and

see if I remembered

to turn off the lights.

Children and adolescents do not need to recognize

that symptoms are excessive or unrealistic

Symptoms must be:

• Distressing,

• Interfering, or

• Time consuming

Not due to another Axis I disorder or general medical

condition


OBSESSION COMPULSION

Contamination Washing / Cleaning

Concern about Harm Checking / Others

Need for Symmetry Arranging / Tapping

Fear of losing things Hoarding

Fear of embarrassment Avoidance

“Just Right” Phenomenon Repeating

Moral obsessions Confessing / Telling

Obsessions and Compulsions

Clustering of Symptoms

Hasler et al. (2007)

• Aggressive / harm obsessions & checking compulsions

• Contamination obsessions & cleaning compulsions

• Symmetry / order obsessions & arranging / precision

compulsions

• Saving / collecting obsessions & hoarding / saving

compulsions

• Sexual/religious obsessions & mental compulsions

Major Symptom Factors of OCD

(Leckman et al, 1997; Summerfeldt et al, 1999; Calamari et al, 1999)

Childhood OCD

• 1-3% prevalence

• More common in boys prepubertally

• Onset may be abrupt or gradual

• Onset or exacerbation may be related to psychosocial trauma

or stress in some cases

• Symptoms may wax and wane or be chronic and progressive

• Child may be able to ignore/resist symptoms at times

(e.g., with friends, at school)

• Symptoms worse when child sick, stressed, or tired

• Variable course: 41% full-OCD after 1-15yr FU; 60% at least

some symptoms (Stewart et al., 2004)

OCD-Related Functional Impairment

• One of 10 most disabling medical conditions worldwide (Murray and Lopez,

1996)

• 151 OCD youngsters and their parents completed parallel self-report rating

scale (COIS) assessing OCD-related dysfunction in three areas:

home/family, school, and social

• 88% of parents and 85% of children reported at least one area of significant

OCD-related dysfunction.

• Half of sample reported significant OCD-related dysfunction at home, in

school, and socially.

• Parents more likely to report home/family problems, children more likely to

report problems related to mental rituals.

Piacentini et al., 2003

Most Common Problems Parent Report

Concentrating on school work 72 %

Doing homework 68

Doing assigned chores at home 67

Getting ready for bed at night 66

Getting along with parents 66

Bathing / grooming in the morning 62

Getting dressed in the morning 60

Getting to school on time 59

Taking tests 59

Completing in-class work 57

Sleeping at night 56

Getting along with sibs 55


Most Common Problems Child Report

Concentrating on school work 64 %

Letting others touch / use things 62

Doing homework 60

Being with a group of strangers 56

Completing in-class work 55

Getting ready for bed at night 54

Bathing/grooming in morning 52

Doing assigned chores at home 52

Sleeping at night 49

Getting along with parents 49

Getting to school on time 48

Writing in class 48

Taking tests 46


Child-Report Parent-Report ______________________________ ______________________________

No Slight Significant No Slight Significant Parent- Problem Problem Problem Problem Problem Problem Child Diff

% % % % % % t (P>C)

GLOBAL PROBLEM RATINGS

Problems at School 20 36 44 20 33 47 1.52

Problems socially with friends 46 35 19 24 42 33 4.33 ***

Prevented from going places 48 32 20 43 32 25 1.50

Problems at home/with family 23 29 48 8 27 66 4.28 ***

*** p < .001


OCD-Related Impairment Parent-Child Differences

Comorbidity in Childhood OCD

N %

Other Anxiety Disorders 47 42.0

ADHD 22 19.6

ODD/CD 10 8.9

Tic Disorders 12 10.7

MDE/Dysthymia 12 10.7

One Comorbid Disorder 82 73.2

Multiple Comorbid 35 31.3

(N=112) UCLA Child OCD Program

OCD Neurobiology

Serotonin Hypothesis: SSRI efficacy, but 5-HT and metabolites

not found to consistently differ between OCD and normals in CSF

or peripherally

5-HT binding studies suggest impaired 5-HT binding may play a

role in OCD pathogenesis

Mixed evidence for dopaminergic involvement. Increased

dopamine transmission in basal ganglia may relate to

hyperactivity of cortico-striato-thalamo-cortico circuit.

Cortico-Striatal-Thalamic Model

Circuit possibly involved in

regulation of repetitive thoughts

and behaviors: underactive

caudate nuclei so that thoughts,

actions generated by

orbitofrontal cortex are not

suppressed

Baseline Glucose Metabolism in OCD

NORMAL OCD Schwartz, 1996

OCD Neuroanatomy

Increased glucose metabolism or other indices of activation in

the orbitofrontal cortex and caudate nuclei

Normalizes with behavioral and pharmacological treatment

(Schwartz et al., 1996)

Part of a circuit possibly involved in regulation of repetitive

thoughts and behaviors: underactive caudate nuclei so that

thoughts, actions generated by orbitofrontal cortex are not

suppressed

Change in Glucose Metabolism Pre/Post CBT

Schwartz, 1996

OCD Neuropsychology

Deficits in systems subserved by dorsal and ventral

corticostriatal circuitry

Executive function: set-shifting, spatial working memory

(DLPFC); alternation tasks, decision-making (OFC)

Cognitive flexibility, reversal learning ?

Methodologic problems (small N, heterogeneous samples)

limit conclusions that can be drawn

OCD Genetics

Family studies show rates of OCD significantly greater in relatives of

probands vs. controls (12% vs 2%) (Pauls et al., 1995)

Familiality increases with increased homogeneity of proband symptom type

(e.g., cleaning, hoarding, etc.)

GAD and agoraphobia show strong association to OCD phenotype (family

rates remain elevated when dx controlled for in probands)

Major depression elevated in relatives but likely secondary to OCD

Perhaps predisposition for anxiety, not specific dx, is inherited

Tics and earlier onset age associated with higher rates (esp in combination)

Nicolini et al (2009)

OCD Genetics

Segregation analyses suggest evidence for both single and

polygenic inheritence

Ordering and symmetry, OCD with eating disorder, early onset age –

Autosomal Dominant

Candidate gene studies:

COMT, MAO-A, Dopamine transporters and receptors – studies typically

small with mixed results.

More evidence for SERT (serotonin transporter) and 5-HT receptor

genes

Glutamate transporter SLC1A1 has been associated with OCD in

multiple studies

Nicolini et al (2009)

Pediatric

Autoimmune

Neuropsychiatric

Disorders

Associated with

Strep

http://www.google.com/imgres?imgurl=http://www.christmasgifts.im/wp-content/uploads/2009/10/dragon_scroll.jpg&imgrefurl=http://www.christmasgifts.im/page/3/&usg=__Q1YTdoZ7lcj1YkbW8FUPMQJ8UN4=&h=308&w=438&sz=53&hl=en&start=18&itbs=1&tbnid=2RByyqTnAPoOxM:&tbnh=89&tbnw=127&prev=/images%3Fq%3Dkung%2Bfu%2Bpanda%26hl%3Den%26gbv%3D2%26tbs%3Disch:1



• Presence of obsessive-compulsive disorder and/or a tic disorder

• Pediatric onset of symptoms (age 3 years to puberty)

• Episodic course of symptom severity

• Association with group A Beta-hemolytic streptococcal infection (a

positive throat culture for strep or history of Scarlet Fever)

• Association with neurological abnormalities (motoric hyperactivity,

or adventitious movements, such as choreiform movements)

PANDAS Diagnostic criteria

http://www.nimh.nih.gov

• NO

• Almost all school aged children get strep throat at some point in their

lives.

• The average child has 2-3 strep throat infections each year.

• PANDAS is considered only when there is a very close relationship

between the abrupt onset or worsening or OCD and/or tics, and a

preceding strep infection.

• If strep is found in conjunction with two or three episodes of OCD/tics,

then it may be that the child has PANDAS.

• PANDAS IS NOT A VALIDATED DISORDER

Strep + OCD = PANDAS ?


OCD

• Treat the OCD symptoms according to

best practice standards

Strep infection

• Treat the strep infection according to

best practice standards

What to do for PANDAS


• Steroids

• Plasmapheresis

• Intravenous immunoglobulin

• Antibiotic prophylaxis

What not to do for PANDAS


Cognitive Aspects

of OCD

Intrusive Mental Processes

80-90% community experience occasional intrusive

thoughts

Similar in content to obsessions from patient

samples (e.g., Rachman & de Silva, 1978)

Exacerbated by stress but subside

Thought-Action Fusion

Individuals with TAF:

Experience thoughts and actions about harm as equivalent

(thinking it is same as doing it)

Believe that having an intrusive negative thought is as wrong as

acting it out (thinking it is as bad as doing it)

Exaggerated Responsibility

Failing to prevent or trying to prevent harm to others is the same

as having caused harm

Responsibility is not attenuated by low probability of occurrence

Cognitive Biases in Adult OCD

(Rachman, 1993)

Cognitive Processses in Child OCD

OCD children report higher levels of responsibility, probability of harm and severity, thought action fusion, and less cognitive control compared to nonclinic comparison children.

OCD children only reported less cognitive control than anxious comparison children.

Specificity of cognitive biases to OCD is questionable in children. May be developmental phenomenon

Barrett & Healy, 2002

Cognitive Processses in Child OCD

Experimental manipulation of responsibility during BAT.

Manipulation inflated perceived responsibility for harm in OCD children

However, this did not lead to increases in estimated probability or severity of harm or distress.

CBT led to significant decreases in perceived responsibility for harm, probability and severity of harm, and distress.

Although CBT effective in addressing responsibility, this bias may not be as important in child OCD versus adult disorder.

Barrett & Healy, 2004

Obsessive

Compulsive

Cycle

Obsessive Compulsive Cycle

Obsessions Intrusive, repetitive

negative images

or impulses

Distress Anxiety, fear, disgust or

shame

Compulsions Repetitive thoughts

images or actions

Relief Distress subsides

temporarily

Negative Reinforcement

Trigger

Assessment of

Childhood OCD

Accurate Diagnosis of OCD in Youth

• Young children tend to think in the moment and hence

misrepresent symptoms or severity

• Adolescents may under-report symptoms (especially boys)

• The nature of certain symptoms (otherwise normative

behaviors) leads to misdiagnosis or being missed

completely

• Accurate diagnosis in youth is dependent upon both

child/adolescent AND parent report (DiBartolo, Albano, Barlow

& Heimberg, 1998)

Assessment of Childhood OCD

GOALS • Determine baseline severity

• Identify comorbidities and

other complicating factors

• Monitor response to treatment

CONSIDERATIONS • Secretive nature of symptoms

• Multiple informants

• Developmental issues

• Family assessment

Assessment of OCD

Diagnostic Interview Schedules

• Provides reliable differential diagnoses

Behavioral Assessment Techniques

• Fear and Avoidance Hierarchies

• Behavioral Avoidance Tasks

Questionnaires

• Self-Report; Parent-Report; Teacher Ratings

Differential Diagnosis

Other Anxiety Disorders

GAD, SAD, Panic

Pervasive Developmental Disorders

Asperger’s Syndrome

Tic Disorders

Compulsion vs. Complex Motor Tic

Other Disorders

Children’s Yale-Brown Obsessive Compulsive Scale (CYBOCS)

10 Items

5 items on Obsessions Subscale

5 items on Compulsions Subscale

Each item scored 0 - 4

20 Point Maximum for Obsessions

20 Point Maximum for Compulsions

Total Score ranges from 0-40

CYBOCS ge 15 clinically significant OCD

CY-BOCS: Checklist Categories

• Washing/Cleaning

• Checking

• Repeating

• Counting

• Ordering/Arranging

• Hoarding/Saving

• Excessive Games/Superstitious Behaviors

• Rituals Involving other persons

• Sexual Obsessions

• Somatic obsessions

• Aggressive Obsessions

• Miscellaneous

Child OC Impairment Scale (COIS-R)

• Measure of OCD-specific impairment

• Parallel Child/Adult Versions

• Covers School, Social, Home

• Good psychometrics

• Useful in helping break down child resistance to treatment


Summary of Child Assessment

Multi-informant:

• child, parent, teacher

Multi-method:

• Self-report, clinician driven, behavioral, observational

Developmentally sensitive

Ongoing through treatment

Assessment

1. OCD Symptoms, Severity, Impairment

2. Comorbid Disorders

Treatment Planning

1. Effective vs. ineffective treatments

2. Assess insight and motivation

3. Determine most appropriate treatment setting

4. Assess need for combined medication and CBT

5. Prioritze treatment of comorbid disorders

6. Address family and environmental factors

Education: patient, family, etc.

OCD Treatment Planning

Cognitive Behavioral Treatment of

Childhood OCD

• Psychoeducation - to reduce blame, stigma, anxiety

• Assessment - “Fear Thermometer” to create sx hierarchy

• Graded Exposure

• Response Prevention

• Use of Graphics - visual record of progress

• Reward Program - motivation and address comorbidity

• Cognitive Restructuring - to manage anxiety and obsessions

• Homework - to foster generalization

• Family Work - to foster maintenance of tx gains

CBT Program for Childhood OCD

to address “core” OCD symptoms

Psychoeducation

GOALS: Reduce stigma, blame, and anxiety

Prevalence

• Common Disorder (0.5 - 2%)

Neurobiological Framework

• “Asthma” analogy

Ethological Perspective

• Anxiety as “False Alarm”

Anxiety has been conserved as an

evolutionary trait across species because

it serves a protective function

Ethological Perspective

OCD as a False Alarm

Fire Drill Analogy

The fire alarm is scary sounding to get your attention and

make you leave the school building in case there’s a fire.

But sometimes the alarm goes off when there’s no fire (a

false alarm). It still sounds scary, even though there’s no real

danger.

OCD is like a false fire alarm. It makes you scared even

when there’s no real danger. In treatment you will learn how

to ignore your OCD false alarm so it doesn’t bother you

anymore

0

1

2

3

4

5

6

7

8

9

1 0

Time

S U D S

OCD Habituation - 1

OCD Symptom Hierarchy

OCD Symptom Hierarchy

Fear Thermometer (SUDS)

Situation SUDS

Walking through kitchen door 10

Checking locks at night 9

Turning TV on and off (3 times) 6

Flipping lightswitch (3 times) 6

Erasing/Rewriting Homework 4

Brushing teeth 3

Throwing away old homework 2

Easiest to resist (Least Scary or Upsetting)

Hardest to Resist (Most Scary or Upsetting)

10

9

8

7

6

5

4

3

2

1

0

Negative Reinforcement Cycle

Obsessions Repetitive negative,

images or impulses

Distress Anxiety, fear, disgust or

shame

Compulsions Repetitive thoughts

images or actions

Relief Distress subsides

temporarily

Negative Reinforcement

X

Exposure Plus Response Prevention (ERP)

EXPOSURE

• Begin with item low on Symptom Hierarchy

• Therapist models behavior first

RESPONSE PREVENTION

• Individual encouraged to resist ritualizing

• Assess SUDS (anxiety) level at frequent intervals

• Continue exposure until anxiety decreases > 50% from peak

• Repeat exercise as often as possible in session

Exposure Graph

Writing Crooked

Optimizing Exposure Efficacy Craske et al., 2008; BRAT

Within and between session habituation does not predict anxiety

reduction over time in adults

Length of fear expression predicts extinction learning

Treatment Implications

• Exposure goal - sustained fear tolerance not fear reduction

• Patient expectations about exposure

• Unpredictability of exposure (e.g., symptom grab bag)

• Sustained exposure

• Developmental considerations

Unclear if this applies to younger children

Cognitive Restructuring

Externalize: Recognize and Relabel Fears as OCD

• “I won’t get sick if I touch this, its just my OCD talking”

Reality Testing

• Challenge irrational beliefs

Mindfulness-based Approaches

• Neutral, non-affective reaction to symptoms and fear

Learn to Tolerate Uncertainty

• Bad things do happen, just not very often

Exposing Obsessive Thoughts

Homework

How Often

• Daily for 30-45 minutes or

until anxiety disappears

What is Practiced

• Situations covered in session

• Situations unable to be covered

in session

Reviewed in Session

Covered by Reward Program

NAME: DATE: SYMPTOM: EXPOSURE INSTRUCTIONS: HOW OFTEN: HOW LONG: WAYS TO FIGHT OCD THOUGHTS: REWARD:

0

1

2

3

4

5

6

7

8

9

10

1 2 3 4 5 6 7 8

Time or Trial

Feeli

ng

Th

erm

om

ete

r

Reward Program

How Often

• Younger children or more

difficult tasks require more

frequent rewards

What Gets Rewarded

• Effort not results

• Clearly defined behaviors

Selecting a Reward

• Desired, strong, realistic

Family Factors in Childhood OCD

Treatments for child OCD typically do not lead to

symptom remission

0

10

20

30

40

50

60

70

80

%

Combined CBT Meds

TREATMENT GROUP

POTS I: Symptomatic at Post-Tx (CYBOCS > 10)

Combo 46%

CBT 61%

SSRI 79%

POTS Team, 2004

Predictors of Worse CBT Response

Adult Studies

• Comorbidity

• Motivation

• Fixity of Beliefs

• Family Factors

– Expressed Emotion

– Patient expectation of criticism

Abramowitz et al. (2000); Chambless et al. (1999); Foa et al. (1997)

Predictors of Worse CBT Response

Child/Adolescent Studies

• More severe OCD

• Poorer psychosocial functioning

• Family history of OCD

• Family factors

– Overall family dysfunction

– Parental blame/criticism

– Poorer family cohesion

– Higher family conflict

Barrett et al. (2005); Piacentini et al. (2002); Peris et al. (submitted); Mars Garcia et al. (2010)

Family environment may

be an important

intervention target

• Family Distress/Dysfunction (66 – 90%)

• Elevated rates of parental OCD (20 – 50%)

• Elevated rates of Parental Blame

• Elevated rates of Expressed Emotion

• Family Accommodation (62 – 100%)

• Actual participation in OCD rituals (50 – 75%)

Family Factors in Child OCD

Allsopp & Verduyn, 1990; Apter et al., 1984; Bolton et al., 1983; Cooper et al. 1996; Peris et al., 2008; Piacentini et al. 2003; Storch et al., 2007; Van Noppen et al., 1991

Family accommodation is thought to

be a barrier to treatment inasmuch

as it reinforces avoidance behaviors

and undermines exposure-based

exercises

Family Accommodation

Calvocoressi et al. (1995; 1999)

• High rates of family accommodation

• Associated with increased family distress

Amir et al. (2000)

• Modification of family routine linked with depression

• Refusal to accommodate linked to anxiety

• Accommodation not linked to severity of child’s OCD

Storch et al. (2007)

• Family accommodation may mediate the relationship between

• OCD symptom severity and associated functional impairment



Participation in OCD

reassure patient 14% 30% 56%

participate in rituals 41 14 45

Consequences of not participating

pt becomes distressed/anxious 19 47 34

pt becomes angry/abusive 48 29 22

Modification of family routine

modified family routine 33 55 13

Distress

when OCD not accomodated 27 60 13

Less than

1x/month Weekly Daily

Mild

None Moderate Severe

Peris et al., 2008

Family Context of Childhood OCD

• FAMILY ACCOMMODATION very common

• 60-90% report participating in child’s OCD via reassurance or worse

• 50-80% report child reacts negatively when accommodation is

resisted • positively correlated with OCD severity and presence of comorbid

externalizing symptoms

• 75% of parents report distress when giving in to their child’s OCD • given parental resistance is key part of CBT, this needs to be addressed

in treatment

Peris et al., 2008

Parental OCD and Family Context

Parent YBOCS > 15

YES NO

FES Organization 3.2 5.4 **

FA Distress 2.1 1.1 **

FA Consequences 5.8 3.6 *

Parental OCD

- Associated with less family organization

- More negative consequences of OCD limit setting

- Greater distress when limit setting

* p < .05, ** p < .01, *** p < .001

Peris et al., 2008

• Higher child CYBOCS scores associated with greater family

participation in child rituals, greater modification of family routine,

and more negative child response to OCD-related limit setting

• Higher family conflict associated with more negative child

response to limit setting and greater parental distress when

accommodating child symptoms

• Higher family cohesion associated with opposite pattern


Family Context of Childhood OCD

Asking families of OCD children – especially distressed

families - to resist accommodating child symptoms likely to

lead to:

- Emotional distress on part of family

- Negative reaction on part of child

FCBT: Individual child+family interventions which specify structured

weekly intervention sessions focused on changing family dynamics

ICBT: Primarily individual child treatments which include family

members in a less-structured or less-frequent manner, often as a

brief check-in at the end of individual sessions

Individual vs. Family CBT ??

Barrett, Farrell, Pina, Peris, & Piacentini, 2008

Family Intervention

Goals of Family Intervention

• Reduce level of conflict and feelings of anger, blame, guilt

• Enhance family problem solving

• Facilitate disengagement from child’s OCD symptoms

• Rebuild normal (OCD-free) family interaction patterns

• Foster environment conducive to maintaining treatment gains

Evidence-base

For Treatment

Of Childhood OCD

Controlled Medication Trials

• Clomipramine - DeVeaugh-Geiss et al., 1992

• Fluoxetine - Riddle et al., 1992; Geller, 2001;

Liebowitz, 2003

• Fluvoxamine - Riddle et al., 2001

• Sertraline - March et al., 1998

• Paroxetine – Geller et al., 2004

Meta-Analysis of SRIs for OCD Geller et al. (2003)

Methods • All published placebo-controlled medication trials

• Twelve studies with 1,044 total participants

• Four outcome measures: CYBOCS, LOI, NIMH, CGI

• CMI, PAR, FLUV, FLX, SER

Findings • Mean ES = 0.46 (95% CI = 0.37 - 0.55) (p<.001)

• Overall ES is modest

• CMI > PAR=FLUV=FLX=SER

• No relationship between ES and publication date

Psychosocial Treatment

Of Childhood OCD

# of Studies Design Description

2 Type 1 Rigorously designed RCTs

4 Type 2 One or more design limitations

10 Type 3 Open trials

Psychosocial Tx of Child OCD


JCCAP Special issue on EBTs for Childhood Disorders

N Outcome

De Haan (1998) 22 CBT > CMI

Barrett et al. (2004) 77 Ind-CBT = Group-CBT > WL

POTS I (POTS Team, 2004) 112 COMBO >? CBT >= SER > PBO

Controlled Efficacy Trials for Child OCD


JCCAP Special issue on EBTs for Childhood Disorders

N Outcome

De Haan (1998) 22 CBT > CMI

Barrett et al. (2004) 77 Ind-CBT = Group-CBT > WL

POTS (March et al, 2004) 112 COMBO >? CBT >= SER > PBO

POTS II (March et al, under review) 124 MM+Full CBT > MM+CBT-lite > MM

UCLA (Piacentini et al, under review) 71 CBT > PsychoEd/Relax Training

Controlled Efficacy Trials for Child OCD

Comparison across trials complicated by methodological differences

Comparison of CBT and CMI DeHaan et al. (1998)

0

5

10

15

20

25

Pre Post

CY

BO

CS

To

tal

Sco

re

CBT

CMI

Effect Size

CBT = 1.56

CMI = .86

Comparison of Individual & Group CBT Barrett et al. (2004)

0

5

10

15

20

25

0 14

Week

CY

BO

CS

To

tal

Sco

re

I-CBT

G-CBT

WL

I-CBT = G-CBT > WL

Effect Size

ICBT = 2.84

GCBT = 2.63

Pediatric OCD Treatment Study (POTS) Duke (J. March), Penn (E. Foa, M. Franklin), Brown (H. Leonard)

128 OCD youngsters randomized to:

- CBT - SER - COMBO - Pill PBO

SAMPLE CHARACTERISTICS

Gender (female): 50%

Mean age: 11.7 (2.7)

Age range: 7-17

Ethnicity (Caucasian): 93%

Any Comorbid Disorder 80%

• Internalizing Disorder 63%

• Externalizing Disorder 27%

- ADD/ADHD and on Psychostimulant 10%

POTS (2004)

Change in CYBOCS Total Score POTS STUDY

0

5

10

15

20

25

30

0 4 8 14

Week

CY

BO

CS

To

tal

Sco

re

COMB

CBT

SER

PBO

COMB > CBT = SER > PBO

Effect Size

CBT = .98

Comb = 1.46

0

50

100

150

200

250

PBO SER COMB

Sert

rali

ne (

mg

)

Median

Mean

Lower Med Doses in Combo Group POTS STUDY

0

0.2

0.4

0.6

0.8

1

1.2

1.4

1.6

1.8

2

SER CBT COMB

Eff

ect

Siz

e (B

tw S

s)

Penn

Duke

Treatment x Site Interaction DUKE-PENN (POTS) STUDY

UCLA CBT for Child OCD Study

Randomized Controlled Trial comparing:

• F/CBT – CBT (ERP+Cog Restructuring) plus a structured family

component

• P/RT – Psychoeducation plus Relaxation Training

F/CBT included weekly manualized family CBT component

Twelve sessions therapy delivered over 14 weeks

Piacentini et al. (under review)

Supported by NIMH R01 MH58549

0

10

20

30

40

50

60%

Resp

on

ded

4 8 14

Week

ERP

RT

Treatment Response Rate UCLA STUDY

Intent to Treat

p < .05

40

54

17

3

21

39

0

10

20

30

40

50

60

PBO LA - RT SER CBT LA - CBT COMB

Pe

rce

nt

Re

sp

on

se

Excellent Responder POTS and UCLA Studies

(CY-BOCS < 10)

Storch et al. (2007): Families receiving intensive FCBT showed greater

reduction in family accommodation compared to those receiving weekly

treatment.

Merlo et al. (2009): In a partially-overlapping sample of children receiving

FCBT through one of two separate open-label studies, decreases in

family accommodation over the course of treatment predicted reduced

symptom severity and OCD-related impairment post-treatment.

Piacentini et al. (under review): FCBT was associated with a marginally

greater reduction in parent-reported accommodation of OCD symptoms

(p=.05). Reduction in family accommodation temporally preceded

improvement in OCD severity across treatment groups and child

functional status for FCBT only

Family Accommodation as Outcome Mediator

Effectiveness of CBT for Child OCD Valderhaug, Larsson, Gotestam, & Piacentini, 2006

28 Norwegian youth

treated in community

clinics by community

practitioners.

60.6% response rate

post-tx

68.8% response rate

at 6 mo FU

Franklin al. (1998)

14 Ss age 10-17 nonrandom assignment to outpatient (16wks) or

intensive (18 days) CBT. Groups didn’t differ post-tx

Storch et al. (2006)

40 Ss age 7-17 randomized to 14 sessions outpatient (14 wks) or intensive

(3wks) CBT c/ family component. Intensive > outpatient post-tx but not at 3

mo FU

Excellent response rates to intensive CBT, but differences in baseline

severity differences (sicker kids in intensive tx) complicate comparison

with outpatient samples.

Intensive CBT for Child OCD

Limited available data suggests treatment outcome not

related to gender or ethnicity, but this has not been

systematically evaluated in controlled trials.

Diversity in Child OCD Treatment Research

Classification of Psychosocial Treatments for OCD in Children and Adolescents

Treatment Citation

Well-Established Treatments

None —

Probably Efficacious Treatments

Individual CBT POTS (2004)

Individual CBT + sertraline POTS (2004)

Possibly Efficacious Treatments

Family-Focused Individual CBT Barrett et al. (2004)

Family-Focused Group CBT Barrett et al. (2004)

Experimental Treatments

Group CBT Multiple authors

Barrett et al., JCCAP, 2008

For more information, please go to the main website and browse for workshops on this topic or check out our additional resources.

Additional Resources Online resources: 1. National Institute of Mental Health: http://nimh.nih.gov/health/topics/obsessive-compulsive-disorder-ocd/index.shtml 2. Society of Clinical Child and Adolescent Psychology website: http://effective childtherapy.com

Books: 1. Albano, A. M., March, J.S., Piacentini, J. (1999). Obsessive-compulsive disorder. In in R. T., Ammerman, M. Hersen, & C. G. Last (Eds.), Handbook of prescriptive treatments for children and adolescents (pp. 193-213). Needham Heights: Allyn & Bacon. 2. Franklin, M.E., Freeman, J., & March, J.S. (2010). Treating pediatric obsessive-compulsive disorder. In J.R. Weisz & A.E. Kazdin. (Eds.), Evidence-based psychotherapies for children and adolescents (pp. 80-92). New York: Guilford Press.

Peer-reviewed Journal Articles: 1.Barrett, P.M., Farrell, L., Pina, A.A., Peris, T.S. & Piacentini, J. (2008). Evidence-based psychosocial treatments for child and adolescent obsessive–compulsive disorder. Journal of Clinical Child & Adolescent Psychology, 37 (1), 131-155. 2. Garcia, A.M., Sapyta , J.J., Moore, P.S. Freeman, J.B., Franklin, M.E., March, J.S., Foa, E.B. (2010). Predictors and moderators of treatment outcome in the pediatric obsessive compulsive treatment study (POTS I). Journal of the American Academy of Child & Adolescent Psychiatry 49 (10), 1024-1033. 3. Geller, D.A., Biederman, J., Stewart, S.E., Mullin, B., Martin, A., Spencer, T. & Faraone, S.V. (2003). Which SSRI? A meta-analysis of pharmacotherapy trials in pediatric obsessive-compulsive disorder. American Journal of Psychiatry, 160, 1919-1928. 4. Peris, T.S., Bergman, R.L., Langley, A., Chang, S., McCracken, J.T., & Piacentini, J. (2008). Correlates of accommodation of pediatric obsessive-compulsive disorder: Parent, child, and family characteristics. Journal of the American Academy of Child and Adolescent Psychiatry. 47 (10), 1173-1181 5. Piacentini J., Bergman L., Keller M., & McCracken J. (2003). Functional impairment in children and adolescents with obsessive-compulsive disorder. Journal of Child and Adolescent Psychopharmacology, 13, S61–S69.

http://nimh.nih.gov/health/topics/obsessive-compulsive-disorder-ocd/index.shtml







Full Reference List Keynote: Evidence-based Treatment of Obsessive Compulsive Disorder in Children and Adolescents Websites: National Institute of Mental Health: http://nimh.nih.gov/health/topics/obsessive-compulsive-disorder-ocd/index.shtml Books: Albano, A. M., March, J.S., Piacentini, J. (1999). Obsessive-compulsive disorder. In in R. T., Ammerman,

M. Hersen, & C. G. Last (Eds.), Handbook of prescriptive treatments for children and adolescents (pp. 193-213). Needham Heights: Allyn & Bacon.

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Peer-reviewed Journal Articles: Abramowitz, J., Franklin, M., Street, G., Kozak, M., & Foa, E. (2000). Effects of comorbid depression on

response to treatment for obsessive-compulsive disorder. Behavior Therapy, 31, 517-28. Allsopp, M. & Verduyn, C. (1990). Adolescents with obsessive-compulsive disorder: a case note review of

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Barrett, P., Healy-Farrell, L., & March, J.S. (2004). Cognitive-behavioral family treatment of childhood obsessive-compulsive disorder: A controlled trial. Journal of the American Academy of Child & Adolescent Psychiatry, 43 (1), 46-62.

Barrett, P.M, Farrell, L., Dadds, M., & Boutler, N. (2005). Cognitive-behavioral family treatment of childhood obsessive-compulsive disorder: long-term follow-up and predictors of outcome. Journal of the American Academy of Child and Adolescent Psychiatry, 44, 1005–1014.

Barrett, P.M., Farrell, L., Pina, A.A., Peris, T.S., & Piacentini, J. (2008). Evidence-based psychosocial treatments for child and adolescent obsessive–compulsive disorder. Journal of Clinical Child & Adolescent Psychology, 37 (1), 131-155.

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Foa, E., Abramowitz, J., Franklin, M., & Kozak, M. (1999). Feared consequences, fixity of belief, and treatment outcome in patients with obsessive-compulsive disorder. Behavior Therapy, 30, 223-231.

Franklin, M., Kizak, M.J., Cashman, L.A., Coles, M., Rheingold, A.A., Foa, E. (1998), Cognitive behavioral treatment of pediatric obsessive compulsive disorder: An Open Clinical Trial. Journal of the American Academy of Child & Adolescent Psychiatry, 37 (4), 412-419

Garcia, A.M., Sapyta , J.J., Moore, P.S., Freeman, J.B., Franklin, M.E., March, J.S., Foa, E.B. (2010). Predictors and moderators of treatment outcome in the pediatric obsessive compulsive treatment study (POTS I). Journal of the American Academy of Child & Adolescent Psychiatry 49 (10), 1024-1033.

Geller, D.A., Biederman, J., Stewart, S.E., Mullin, B., Martin, A., Spencer, T. & Faraone, S.V. (2003). Which SSRI? A meta-analysis of pharmacotherapy trials in pediatric obsessive-compulsive disorder. American Journal of Psychiatry, 160, 1919-1928.

Geller, D., Hoog, S., Heiligenstein, J., Ricardi, R., Tamura, R., et al. (2001). Fluoxetine treatment for obsessive–compulsive disorder in children and adolescents: A placebo-controlled clinical trial. Journal of the American Academy of Child & Adolescent Psychiatry, 40, 773-779.

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Liebowitz, M., Turner, S., Piacentini, J., Beidel, D., Clarvit, S., et al. (2002 ). Fluoxetine in children and adolescents with OCD: A placebo-controlled trial. Journal of the American Academy of Child & Adolescent Psychiatry, 41, 1431-1438.

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Peris, T.S., Bergman, R.L., Langley, A., Chang, S., McCracken, J.T., & Piacentini, J. (2008). Correlates of accommodation of pediatric obsessive-compulsive disorder: Parent, child, and family characteristics. Journal of the American Academy of Child and Adolescent Psychiatry. 47 (10), 1173-1181

Piacentini, J., Bergman, R. L., Chang, S., Langley, A., Peris, T., Wood, J.J., McCracken, J. (2011). Controlled Comparison of Family Cognitive Behavioral Therapy and Psychoeducation/Relaxation Training

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Piacentini, J., Bergman, L., Keller M., & McCracken J. (2003). Functional impairment in children and adolescents with obsessive-compulsive disorder. Journal of Child and Adolescent Psychopharmacology, 13, S61–S69.

Piacentini, J., Peris, T.S., Bergman, R.L., Chang, S., & Jaffer, M. (2007), Functional impairment in childhood OCD: Development and psychometrics properties of the Child Obsessive-Compulsive Impact Scale-Revised (COIS-R). Journal of Clinical Child and Adolescent Psychology, 36, 645–653.

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