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Mind & Brain, the Journal of Psychiatry


CBT OUTCOME DATA IN CHILDREN AND ADOLESCENTS WITH OCD Similar to adults, CBT demonstrates strong efficacy in


children and adolescents with OCD (Cohen’s d1.45- 1.9821,32). In addition, CBT has demonstrated superior efficacy to other modes of treatment such as relaxation training.33 Enhanced treatment effects have been noted when the families of youth with OCD have been incorporated in psychotherapy. Empirical trials of family-based CBT for pediatric OCD have demonstrated robust effects over relaxa- tion training (Cohen’s d0.8534) and waitlist control (Co- hen’s d2.7420). It has been examined in group and individual family formats, with significant remission rates and maintenance of gains in both groups at an 18-month follow-up.19 Storch et al18 compared intensive (daily for 3 weeks) and weekly (once per week) family therapy for children with OCD finding that 75% of intensive participants and 50% of weekly participants achieved remission at posttreatment (within group Cohen’s d2.62 and 1.73); findings were maintained at 3-month follow-up. Incorporat- ing families into treatment may prove as one strategy of personalizing the intervention to dually address OCD and comorbid conditions.35


Integrating the family of a child with OCD in treatment can


help to target numerous factors maintaining a child’s symptoms. First, children may not have sufficient insight into the irrationality of obsessional thoughts and compul- sions. Poor insight has been associated with diminished CBT response in children and adolescents3639 and medication response among adults.40,41 As children spend a significant amount of time around their family, family members are able to provide opportunities and contingencies to enhance a child’s motivation to confront obsessional triggers and subsequently resist compulsions.42 Second, children may not be capable of the self-regulation necessary to fully engage in treatment. Thus, parents not only provide support for their children undergoing treatment, but also facilitate awareness and use of intervention strategies in naturalistic settings. Third, family members may unintentionally contribute to OCD symptom severity through accommodation. Although family members may help a child avoid feared stimuli, assist with symptoms, or provide reassurance to reduce the child’s distress and family conflict,38,39 such behaviors tend to contribute to overall pathology and worse CBT outcome.42 Thus, family accommodation of symptoms is a direct target in family-based CBT.43 Finally, the pattern of comorbidity may vary in youth with OCD relative to adults with increased rates of disruptive and inattentive behavior in the former.


TREATMENT CONSIDERATIONS


CBT for patients with comorbidity As many as 75% of adults with OCD have at least one


comorbid condition, with generalized anxiety disorder, major depressive disorder, social phobia, and panic disorder among


M&B 2011; 2:(1). July 2011 40


the most prevalent.3 Although some data suggests that certain comorbidities such as major depressive disorder,44,45 generalized anxiety disorder,45 and post-traumatic stress disorder,46 attenuate CBT response in adults, results remain mixed.3,4752 Inconsistency in findings may reflect the type and severity of comorbid conditions in clinical trials (ie, exclusion of individuals with schizophrenia, autism, bipolar disorder, substance abuse, or severe forms of depression).


Similar to adults, comorbidity in pediatric OCD samples is common with about 75% of youth exhibiting a comorbid disorder.12,41,53 The number of comorbid conditions has been associated with attenuated CBT and pharmacotherapy re- sponse12,35 and higher relapse rates.12 Among specific disorders, major depressive disorder has been linked to worse CBT response among adults and children, while comorbid disruptive behavior has been linked to lower response and remission rates in children. The presence of comorbid disruptive behavior is thought to attenuate treat- ment response as there is typically greater family accommo- dation, externalizing problems, and decreased resistance to OCD symptoms when compared to other comorbid or no comorbid conditions.41


MOTIVATIONAL FACTORS


Despite its efficacy, engaging in exposures is either too overwhelming for a small group of patients or may not result in complete symptom resolution.54 As a result, research has begun to modify psychotherapy to enhance motivation to engage in exposures or alternatively strengthen cognitive components of treatment. Motivational interviewing (MI) is a strategy that helps to prepare an individual for change and also increasing feelings of self-efficacy in making the desired change.55 Preliminary research has suggested that the inclu- sion of an MI course prior to CBT for OCD enhanced treatment response in children.55 and treatment adherence in adults.56 Cognitive therapy (CT) may also be appropriate.57,58 Cognitive therapy directs individuals to confront the irra- tional, obsessional thoughts (ie, contamination, illness, misfortune, catastrophe, etc.) with logical reasoning. Indivi- duals are encouraged to focus on the statistical likelihood of the feared outcomes actually occurring, or times in the past when s/he was unable to engage in a ritual and the feared outcome did not occur. Cognitive therapy has shown promising initial results in adults, but likely is not superior to exposure-based CBT in terms of overall response.5861 The efficacy of CT may also be attenuated in individuals who engage in cognitive rituals such as counting, self-reassurance, or other mental rituals. Further, clinicians must be cognizant of patients who engage in CT exercises to reduce OCD- induced anxiety such that CT exercises function as rituals (ie, ritual replacement). Consequently, CT in the absence of ERP is rarely indicated. Instead, concurrent administration of an SRI during a course of psychotherapy may be indicated to enhance motivation to engage in exposures and improve treatment outcomes.


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