A preliminary study of cognitive-behavioral family-based treatment versus parent training for young children with obsessive-compulsive disorder

Highlights

• Efficacy of Cognitive-Behavioral Family Treatment vs. Parent Training is examined.

• Participants were very young children with obsessive-compulsive disorder.

• Exposure-response prevention was therapist- or parent-assisted in each condition.

• Both interventions were effective in improving primary and secondary outcomes.

Abstract

Background

Cognitive-Behavioral Family-Based Treatment (CBFT) is the standard of care in young children with OCD. Developmental considerations, parent desires, and cost-effective advantages motivate research to explore the relative efficacy of parent-only interventions. The main goal in this study was to test the effectiveness and feasibility of a parent only intervention for OCD in young children, comparing, in a preliminary fashion the relative efficacy of reducing obsessive-compulsive symptoms through two treatment conditions: 1) an individual CBFT for early OCD involving both parents and children, and 2) the family component of the intervention involving only individual Parent Training (PT).

Methods

Twenty treatment-seeking families from two private outpatient clinics in Spain were alternately assigned to one of the two treatment conditions. Participants had a primary diagnosis of OCD and a mean age of 6.62 years (65% males). Interventions were conducted by the same therapist and the assessments were administered by independent clinicians who were blind to the experimental conditions of the participants. Assessment time-points were pretreatment, posttreatment, and 3-month follow-up (including diagnosis, symptom severity, global functioning, family accommodation, externalizing and internalizing symptoms, and satisfaction measures).

Results

The two ways of implementation, involving child and parents (CBFT) or involving only parents (PT), produced clinical improvements and were well-accepted by parents and children. The CBFT condition was superior to the PT condition in reducing externalizing problems.

Limitations

reduced sample size and absence of randomization were the main limitations of this study.

Conclusions

these results suggest, in a preliminary manner, that the need to have the child present at session with the clinician could be decreased for some children, as well as the overall feasibility of working only with parents for the implementation of CBT for OCD in very young children.

Introduction

Pediatric obsessive-compulsive disorder (OCD) is a debilitating psychological condition associated with interference in child's recreational, academic, social and family activities, as well as producing considerable time lost due to symptom engagement (Valderhaug and Ivarsson, 2005). Epidemiological studies of OCD suggest that children and adolescents have a lifetime prevalence of 1–2% (Rapoport et al., 2000, Zohar, 1999) that runs a chronic course in the absence of treatment (Stewart et al., 2004).

The best established psychological treatment for pediatric and adult OCD is cognitive-behavioral therapy (CBT) with exposure response prevention (ERP) as the core component (Rosa-Alcázar et al., 2008; 2015). The effectiveness of ERP has been demonstrated in children with OCD (McGuire et al., 2015), showing superiority to pharmacological monotherapy (Sánchez-Meca et al., 2014) and active psychotherapy control conditions (e.g., relaxation therapy; Freeman et al., 2014; Piacentini et al., 2011).

The standard of care in very young children with OCD is Cognitive-Behavioral Family-Based Treatment (CBFT), which includes the same core components of CBT (ERP and complementary techniques such as psychoeducation, cognitive training, and relapse prevention), but with significant family involvement and less focus on cognitive therapy (American Academy of Child and Adolescent Psychiatry Committee on Quality Issues, 2012, Freeman et al., 2014). Parent involvement in treatment for children with OCD, especially young children, is of particular importance for several reasons. First, poor functioning and high levels of distress, conflict, and blame have been observed in relatives of children with OCD (Peris et al., 2008). Second, family accommodation of OCD symptoms (e.g., participation in rituals, providing reassurance, or modifying routines) is ubiquitous (Caporino et al., 2012, Storch et al., 2007) and has important implications in the course and maintenance of a child's OCD, namely preventing the child from experiencing habituation of anxiety and learning that feared consequences typically do not occur (Storch et al., 2007). Also, family accommodation predicts poor treatment response (Barrett et al., 2005; Merlo et al., 2009, Peris et al., 2012). For example, Rudy et al. (2014) reported that family accommodation predicted symptom severity and remission status in children with OCD after receiving an intensive CBFT program. Finally, parents desire to be engaged in their child's intervention and to learn how to help their child cope more effectively (Salloum, 2014; Storch, 2014).

Considering these reasons, CBFT for OCD includes parent-focused techniques such as psychoeducation, problem solving, instructions for addressing family accommodation, and training in contingency management with the goal of establishing a parents-as-cotherapist model (e.g., Barrett et al., 2004; Freeman et al., 2008; Lewin et al., 2014a; Storch et al., 2007). Indeed, a recent meta-analysis on the effectiveness of pediatric OCD treatment found that higher levels of parent involvement in treatment (parents attending all treatment sessions, and trained to assist with ERP exercises) predicted better results relative to CBT with more limited family involvement (Rosa-Alcázar et al., 2015).

Building on positive findings in case studies/series (e.g., Comer et al., 2014; Ginsburg et al., 2011), the efficacy of CBFT in young children with OCD has been tested in several studies. Freeman et al. (2008) conducted the first randomized controlled trial (RCT) in 42 children with OCD ages 4-8 years old. A 12-session CBFT protocol – including child-friendly psychoeducation, ERP, cognitive training and a family-focused component (instructions to reduce accommodation, exposure guidance training and problem solving) – was significantly more effective than relaxation training for treatment completers. In the intent-to-treat analysis, a moderate effect (d =.53) and a 50% remission (CY-BOCS score ≤12) rate for CBFT condition was present, which did not significantly differ from the relaxation training condition. Lewin et al. (2014a) demonstrated the efficacy of CBFT in a RCT which included 31 children with OCD between 3 and 8 years old who were randomized to family-based ERP or treatment as usual (TAU). Findings reflected a significant group effect favorable to ERP relative to TAU (d =1.69) on obsessive-compulsive symptom severity with 58.8% (versus 0% in TAU) of the sample achieving clinical remission (CY-BOCS score ≤12). Group differences in favor of ERP were found for all secondary measures including impairment, family accommodation, and parent-reported child anxiety. Finally, Freeman et al. (2014) reported on the efficacy of CBFT in a multicenter RCT, where CBFT was superior to family-based relaxation training in reducing obsessive-compulsive symptoms (d =.84) and functional impairment (d =.42) in 127 children (4–8 years) with OCD. Clinical response defined as the percentage of children much or very much improved on the Clinical Global Impressions-Improvement Scale (CGI-I; Guy, 1976) was 72% in the CBFT condition versus 41% in FB-RT condition.

The success of parent inclusion in enhancing the efficacy of CBT relies in part on the parent learning to be the child's therapy ‘coach’– with an emphasis on assisting the child with exposure exercises and reducing family accommodation. Through this process, parents become co-therapists and assist with the treatment process by implementing therapeutic tasks outside of clinic, monitoring/facilitating homework, and implementing reinforcement protocols (Taboas et al., 2015). According to Choate-Summers et al. (2008) children under seven years old present with developmental differences from older youth (e.g., difficulties in identification and expression of symptom patterns, inability to distinguish obsessional thoughts from other cognitions, and their connection to compulsions, lower level of insight, etc.) that often obstruct their active participation in treatment. This, along with the parent's desire to help their child directly (Salloum et al., 2014) suggest parent training as a potentially effective and well-accepted approach by which to treat OCD in youth. In this sense, Lebowitz (2013) reported preliminary findings on a manualized parent-only intervention focused in reducing family accommodation among six children with OCD (10–13 years old). Results showed significant improvements in obsessive-compulsive symptoms, family accommodation and disruptive behavior.

When family inclusion is adequately implemented (focused on exposure and family accommodation), the question about the relative contribution of having young children with OCD in sessions emerges. Moreover, treating OCD in young children by working only with parents may have several advantages. These include delivering the intervention in the child's natural settings, limiting disruption of children's activities (e.g. school, time with peers, etc.), and fostering parental skill development which may contribute to reduced relapse. Therefore, the main purpose of this study is to test the effectiveness and feasibility of a parent only intervention for OCD in young children, comparing, in a preliminary fashion, the relative effectiveness of reducing obsessive-compulsive symptoms, family accommodation, externalizing/internalizing behaviors and functional impairment through two treatment conditions: 1) an individual CBFT protocol for early OCD involving both parents and children, and 2) the family component of the same protocol involving only individual Parent Training (PT).