The Clinician's Guide to Cognitive-Behavioral Therapy for Childhood Obsessive-Compulsive Disorder

Eric A. Storch, Joseph F. McGuire, Dean McKay

• Publisher: Academic Press
• Year: 2018
• Print ISBN: 9780128114278
• eBook ISBN: 9780128114285
• Topic: Psychology
• Subtopic: History & Theory in Psychology
• Index: Psychology

The Clinician's Guide to Cognitive-Behavioral Therapy for Childhood Obsessive-Compulsive Disorder brings together a wealth of experts on pediatric and adolescent OCD, providing novel cognitive behavioral strategies and considerations that therapists can immediately put into practice. The book provides case studies and example metaphors on how to explain exposure models to children in a developmentally appropriate manner. The book also instructs clinicians on how to use symptom information and rating scales to develop an appropriate exposure hierarchy. The book is arranged into two major sections: assessment and treatment of childhood OCD and special considerations in treating childhood OCD.Each chapter is structured to include relevant background and empirical support for the topic at hand, practical discussion of the nature and implementation of the core component (such as exposure and response prevention, cognitive therapy, psychoeducation and more), and a case illustration that highlights the use of a particular technique.- Provides the strong theoretical foundation required to successfully implement treatment- Highlights the use of particular intervention techniques through case studies- Provides CBT strategies for anxiety, tic disorders, trichotillomania, ADHD and disruptive behaviors- Includes strategies for treatment of patients who are initially non-responsive to CBT- Encourages individualization of evidence-based and clinically-informed principles for each patient- Reviews what to do if/when OCD remits and/or returns- Provides details on differentiation OCD symptoms from anxiety and other psychopathology

Chapter 1

Introduction

Eric A. Storch⁎; Joseph F. McGuire^†,‡; Dean McKay^{§ ⁎} University of South Florida, St. Petersburg, FL, United States
^† Johns Hopkins University, Baltimore, MD, United States
^‡ University of California, Los Angeles, CA, United States
^§ Fordham University, New York, NY, United States

Abstract

This chapter provides an overview of the book in terms of content, use, and purpose.

Keywords

Obsessive-compulsive disorder; Children; Treatment; Cognitive behavioral therapy; Assessment; Family

Pediatric obsessive-compulsive disorder is a debilitating condition that affects approximately 1% of children worldwide at any time (Zohar, 1999). This condition confers great impairment across home, social and family domains (Piacentini, Bergman, Keller, & McCracken, 2003), and negatively impacts quality of life (Lack et al., 2009). Without intervention, symptoms tend to persist over time and escalate in severity (Bloch et al., 2009), often presenting with other cooccurring problems (Storch et al., 2008). Fortunately, there are two effective treatments that have been widely studied: cognitive behavioral therapy (CBT) that involves exposure and response prevention, and medication management with serotonin reuptake inhibitors (SRI). Although both interventions are effective, evidence suggests that CBT alone or together with SRI medications is the most effective treatment approach (Franklin et al., 2015; McGuire et al., 2015) with the specific approach depending on the severity of the child's condition as well as other clinical factors (AACAP, 2012).

Despite the strong efficacy of CBT, dissemination and access to treatment is a particular problem. Many children do not receive this form of psychotherapy at all or have to wait long periods until proper diagnosis and treatment is provided (Marques et al., 2010). Even when CBT is available, there may be considerable variability in its implementation due to the knowledge base and experience of the available providers. To address this critical dissemination gap, substantial efforts have been made. Training institutes (e.g., International OCD Foundation's Behavior Therapy Training Institute) have been designed with the goal of broadening the base of providers with expertise in CBT for childhood OCD. A second approach has involved developing treatment manuals that are published and made widely available. In this regard, several manuals have been published building on the initial seminal work by March and Mulle (1998), Freeman and Reinecke (1993), Piacentini, Langley, and Roblek (2007). These manuals provide structured, evidence-based treatment approaches for helping children with OCD and their families overcome the condition. While the linear nature of these texts is a strength and therapeutic concepts well described, it may be difficult for texts of this nature to go into great detail about a particular topic. For example, what are the exact words that one can say when providing education to a child and their family? Or, how exactly does one create a detailed hierarchy for the multitude of problems a child experiences? And, how might one contend with the myriad of clinical complexities that so often occur in this population (e.g., resistance, comorbidity)? With this in mind, we sought to compile a group of leading experts in the field of childhood OCD to write about—in a practical, “how to” fashion—conducting many of the skills essential to treating children with OCD.

We have divided the book into two overall sections: (1) assessment and treatment of childhood OCD and (2) special considerations in working with this population. The first section starts with chapters dealing with diagnosing OCD and comorbid problems, as well assessing the presence and severity of obsessive-compulsive and comorbid symptoms using evidence-based assessment instruments. Next, a chapter on psychoeducation for children and their family members details how to discuss with families theoretical models of OCD, the treatment model, and nature of treatment. Clear examples are given as to how to convey this information in a ready-to-use format. Following this, the core of the CBT treatment approach is described across two chapters. There is an in-depth discussion on how to create an exposure hierarchy with multiple examples detailing this approach for varied symptoms. The chapter after discusses designing and implementing successful exposures for a variety of symptom presentations. Real-world examples are given as well as tips for implementing creative, child-oriented exposure, and response prevention tasks. Following this, a chapter discusses cognitive therapeutic approaches to complement exposure work. Detailed examples are provided to facilitate this treatment approach and integrate it within an exposure-based treatment model. The next chapter focuses on working with families in the context treatment. Earlier models of treatment seem to isolate the child with more limited family involvement. Our belief, in contrast, is that family should be intimately involved in treatment with a default position of including the parents in sessions as clinically appropriate so that they can learn how to implement therapeutic skills (Storch et al., 2007). We have found this to be not only very effective but also widely acceptable to family members who often typically want to be readily engaged in their child's care and understand how to best help them. To this end, this chapter discusses methods of integrating family members into treatment. There is a special focus on targeting family accommodation, which is a ubiquitous construct when working with children with OCD (Caporino et al., 2012), as well as how to enhance compliance with treatment. A chapter on relapse prevention strategies is included in which a clear relapse prevention plan is articulated to optimize the chance therapeutic gains are maintained. Importantly, this chapter also addresses the sensitive topic what to do if the child that you are working with experiences relapse. A clear, well laid out plan is included for implementation. Finally, a chapter on medication management for childhood OCD is included given the efficacy of this approach. This chapter highlights evidence-based pharmacotherapy practice as well as when to consider medication management combined with CBT.

The second section of the book has a variety of chapters that go into further detail necessary for the complexity of working with this population. The purpose of this section is to spend time discussing critical features related to working with children with OCD. The section starts with discussing common myths and misconceptions in treating childhood OCD including misperceptions about exposure therapy, symptom return, and multiple other aspects. Next, a chapter focused on understanding OCD within school settings and how to manage it within school is provided. This chapter provides clear examples for ensuring that the child is ultimately successful in school, and the more severe cases are able to return to school effectively. The next chapter focuses on addressing significant family accommodation. As noted, virtually all families engage in some level of accommodation of the child's symptoms. This chapter talks about addressing accommodation, especially when such behaviors are entrenched and significant. This chapter is also unique in presenting a treatment model for what to do when a child is unwilling to engage in addressing their symptoms (Lebowitz, Omer, Hermes, & Scahill, 2014). Two chapters are included to discuss working with challenging patients and families. The focus of these chapters addresses increasing motivation through reinforcement systems and working with family member issues such as parental anxiety. The second chapter describes how to manage the most commonly cooccurring conditions such as comorbid anxiety, disruptive behavior, and attentional problems to name several. Following this chapter, a chapter on working with young children with OCD is included given the frequency with which symptoms onset in early childhood. The core treatment components of exposure and response prevention remain the same, but the application of this and other therapeutic concepts can differ in many ways. This chapter focuses on describing how to work with a young child and her/his family in addressing OCD. The final chapter presents an algorithm for managing the patient's care should they not be responsive to the initial trial of CBT and/or a first-line medication.

We anticipate that this book could be used in many ways. For practitioners who are newer to treating childhood OCD, this book can serve as a practical, “how to” manual for addressing symptoms in an affected child. We believe that the core of treatment includes exposure and response prevention; after conducting a thorough assessment over one to two sessions followed by providing psychoeducation over a session, the bulk of treatment will consist of exposure and response prevention. Studies have suggested that 12–14 sessions of exposure and response prevention may not be sufficient to gain an optimal response and that additional sessions may help optimize outcome (Skarphedinsson et al., 2015); it is reasonable to expect that some children will get better in a relatively short period of time but that others will need a significantly longer course. In the present approach, cognitive therapy is a complementary technique to exposure and response prevention; we believe that the majority of treatment should focus on exposure therapy. As the child progresses in treatment, it would follow that sessions are tapered and a relapse prevention plan is set in place. For clinicians who are more experienced, this text may provide more detailed information on core treatment components or addressing clinical complexities.

In closing, it is our hope that this book contributes by providing individuals who are interested in conducting CBT for childhood OCD with a practical framework and resource for implementing the core elements of this intervention. Further, we hope that this book can be useful for parents of an affected child; perhaps as a complement to ongoing treatment, or as a reference to ensure that appropriate treatment is being provided. Ultimately, it is our central goal that CBT for childhood OCD becomes available to all children who are affected with this problem to improve their quality of life and happiness as well as that of their family.

References

AACAP. Practice parameter for the assessment and treatment of children and adolescents with obsessive-compulsive disorder. Journal of the American Academy of Child and Adolescent Psychiatry. 2012;51(1):98–113. doi:10.1016/j.jaac.2011.09.019.

Bloch M.H., Craiglow B.G., Landeros-Weisenberger A., Dombrowski P.A., Panza K.E., Peterson B.S., et al. Predictors of early adult outcomes in pediatric-onset obsessive-compulsive disorder. Pediatrics. 2009;124(4):1085–1093.

Caporino N.E., Morgan J., Beckstead J., Phares V., Murphy T.K., Storch E.A. A structural equation analysis of family accommodation in pediatric obsessive-compulsive disorder. Journal of Abnormal Child Psychology. 2012;40(1):133–143.

Franklin M.E., Kratz H.E., Freeman J.B., Ivarsson T., Heyman I., Sookman D., et al. Cognitive-behavioral therapy for pediatric obsessive-compulsive disorder: Empirical review and clinical recommendations. Psychiatry Research. 2015;227(1):78–92.

Freeman A., Reinecke M.A. Cognitive therapy of suicidal behavior: A manual for treatment. New York, NY: Springer Publishing Co; 1993.

Lack C.W., Storch E.A., Keeley M.L., Geffken G.R., Ricketts E.D., Murphy T.K., et al. Quality of life in children and adolescents with obsessive-compulsive disorder: Base rates, parent–child agreement, and clinical correlates. Social Psychiatry and Psychiatric Epidemiology. 2009;44(11):935–942.

Lebowitz E.R., Omer H., Hermes H., Scahill L. Parent training for childhood anxiety disorders: The SPACE program. Cognitive and Behavioral Practice. 2014;21(4):456–469.

March J.S., Mulle K. OCD in children and adolescents: A cognitive-behavioral treatment manual. New ...

Table of contents

• Cover image
• Title page
• Table of Contents
• Copyright
• Dedication
• Contributors
• Chapter 1: Introduction
• Chapter 2: Diagnosing Childhood OCD
• Chapter 3: Psychoeducation for Children, Parents, and Family Members About Obsessive-Compulsive Disorder and Cognitive Behavior Therapy
• Chapter 4: Assessment of Children With OCD
• Chapter 5: Developing Exposure Hierarchies
• Chapter 6: Developing and Implementing Exposure Treatment in Youth Obsessive-Compulsive Symptoms
• Chapter 7: Modifying Cognitions in the Treatment of OCD in Young People
• Chapter 8: Involving Family Members of Children With OCD in CBT
• Chapter 9: Medication Management of Childhood OCD
• Chapter 10: Relapse Prevention Strategies for Young People With OCD (After CBT)
• Chapter 11: Addressing Common Myths and Mistaken Beliefs in the Treatment of Youth With OCD
• Chapter 12: OCD in School Settings
• Chapter 13: Addressing Family Accommodation in Childhood Obsessive-Compulsive Disorder
• Chapter 14: Working With Challenging Young People and Families
• Chapter 15: Working With Young Children With OCD
• Chapter 16: Strategies to Manage Common Co-occurring Psychiatric Conditions
• Chapter 17: Managing a Child With OCD Who Is Treatment Refractory
• Index