Elsevier

Journal of Anxiety Disorders

Volume 42, August 2016, Pages 85-94
Journal of Anxiety Disorders

Brief intensive CBT for pediatric OCD with E-therapy maintenance

https://doi.org/10.1016/j.janxdis.2016.06.005Get rights and content

Highlights

  • There were significant reductions on almost all measures following two sessions exposure therapy with e-therapy maintenance.

  • The majority of the sample were reliably improved. At post-treatment, 60% were in remission, and at 6-months follow-up this increased to 70%.

Abstract

Cognitive behaviour therapy (CBT), incorporating exposure and response prevention (ERP), has received strong empirical support for the treatment of paediatric OCD, and moreover, is considered the first line treatment of choice (Geller & March, 2012). However, despite the availability of effective treatments for this chronic and debilitating disorder, only a small proportion of youth receive these evidence-based approaches. The present study aimed to examine the effectiveness of an intensive ERP-based treatment for youth OCD, using a multiple baseline controlled design. Children and youth (N = 10; aged 11–16 years) with a primary diagnosis of OCD were randomly assigned to a 1- or 2-week baseline monitoring condition followed by the intervention. The efficacy of the intensive treatment, involving 1 session psychoeducation, 2-sessions ERP plus e-therapy maintenance was examined across parent- child- and clinician-rated measures at post-treatment and 6-month follow-up. Overall, there were significant reductions across time on almost all measures (except self-report anxiety), and moreover, the majority of the sample (80%) were considered reliably improved, and meeting clinically significant change. At post-treatment, 60% were in remission of symptoms, and at 6-month follow-up this increased to 70%. These findings provide strong support for intensive, time-limited approaches to ERP-based CBT for children and youth with OCD.

Introduction

Obsessive Compulsive Disorder (OCD) in childhood is a relatively common (Zohar, 1999), yet severe and debilitating condition, characterised by widely varying symptoms and diverse comorbidity (Farrell, Waters, Milliner, & Ollendick, 2012). Further, it is associated with significant impairments at home (Cooper, 1996; Piacentini, Bergman, Keller, & McCracken, 2003; Valderhaug & Ivarsson, 2005), with peers (Allsopp & Verduyn, 1990; Storch, Ledley et al., 2006; Weidle, Jozefiak, Ivarsson, & Thomsen, 2014), and at school (Honjo et al., 1989; Toro, Cervera, Osejo, & Salamero, 1992). Cognitive behaviour therapy (CBT) that incorporates exposure and response prevention (ERP), either alone or in combination with pharmacotherapy (e.g., selective serotonin reuptake inhibitor; SSRI) has received strong empirical support (Geller & March, 2012; The Pediatric OCD Treatment Study (POTS) Team, 2004). However, despite the availability of effective treatments for this disorder only a small proportion of children and youth receive these evidence-based approaches.

CBT for OCD is difficult to access for a variety of reasons including a lack of trained therapists, clinician and patient beliefs about CBT (e.g., reluctance to engage in exposure therapy; Young, Ollendick, & Whiteside, 2014), geographical and financial barriers and the time intensive nature of treatment (Goisman et al., 1993, Marques et al., 2010; Turner, Heyman, Futh, & Lovell, 2009). For example, existing programs typically require children to attend 10–16 weekly 1 h sessions, which can be challenging for families in terms of managing the time commitment, especially when health service opening hours frequently coincide with children’s school hours and parents work hours (Booth et al., 2004). Indeed, research with adults suggests the majority of patients simply do not receive treatment, or they take medication alone or receive alternative (e.g., non-CBT) psychological treatments (Blanco et al., 2006; Goodwin, Koenen, Hellman, Guardino, & Struening, 2002; Marques et al., 2010). Consequently, there is a need to provide more cost- and resource-efficient ERP-based treatments in order to increase their accessibility. Intensive approaches offer a number of advantages over traditional treatments, including; more rapid relief and recovery from symptoms, provision of a service to families living outside the geographical location who would not otherwise have access to a trained expert practitioner, and various efficiencies in regards to costs of treatment, particularly for families engaging in less than optimal treatment approaches (Farrell and Milliner, 2015, Whiteside et al., 2014).

In the only randomised controlled trial of intensive CBT for paediatric OCD to date, Storch et al. (2007) compared the relative efficacy of 14 sessions (90 min) of CBT delivered daily over a period of 3-weeks, to 14 sessions (90 min) of CBT delivered weekly, in a sample of 40 youth aged 7–17 years. At 3-month follow-up, intensive CBT was found to be as effective as weekly, however at post-treatment, children in the intensive treatment condition had lower global severity, as well as increased rates of remitters and responders. Subsequently, Storch, Lehmkuhl et al. (2010) delivered the same 3-week (14 session) approach to a sample of 30 children and youth who were partial or non-responders to at least two previous trials of pharmacotherapy for OCD. Children experienced a 54% reduction in their symptom severity, which was maintained at 3-month follow-up. Furthermore, approximately half of the children achieved remission. Taken together, these initial studies provide support for intensive CBT delivered daily over 3 weeks. However, given the potential for significant expense due to short-term relocation to access these specialised treatments for remote families, as well as the potential burden of parental leave from work, and children missing school, a 3-week approach may still present feasibility challenges.

In an effort to reduce this time burden, Whiteside and colleagues developed a novel 5-day intensive CBT that incorporated 10 sessions (2 × 50–75 min sessions/day). In an initial case series, reductions in OCD symptoms were observed for 3 adolescents with OCD (Whiteside, Brown, & Abramowitz, 2008). In a subsequent study with 16 youth (10–18 years), significant reductions were observed in OCD severity rom pre- to post-treatment, and symptoms continued to decline out to 5-months follow-up (Whiteside & Jacobsen, 2010). Most recently, Whiteside et al. (2014) evaluated the effectiveness of the 5-day program in a controlled baseline trial (N = 22, 7–18 years). During the baseline, OCD symptoms remained relatively stable; however, they were observed to improve significantly following the 5-day treatment. At 3-month follow-up, 65% of the sample was diagnosis free, and parent accommodation was also reported to decline.

While the aforementioned studies provide preliminary support for intensive CBT, they continue to follow a 1-h session model, delivered either once weekly or intensively across 1- to 3-weeks. An alternative, more concentrated model to treatment aimed at circumventing time and costs associated with accessing treatments, as well as potentially enhancing exposure therapy outcomes, has been recently proposed by Farrell and Milliner (2015) and involves even fewer CBT sessions; however, for a longer duration (e.g., 2 exposure sessions of up to 3.5 h). This alternate format stems from the work of Öst (1989), and later Ollendick and Öst (Ollendick et al., 2009) who developed the one session treatment (OST) approach for specific phobia in adults and children. A similar approach has also been piloted for the treatment of social phobia in children (Donovan, Cobham, Waters, & Occhipinti, 2015; Gallagher, Rabian, & McCloskey, 2004) providing further support for the feasibility and effectiveness of brief, intensive 3-h exposure sessions with children. The basis for the approach is that concentrated, prolonged exposure may provide greater opportunities for the extinction of fear through more continuous exposure to feared stimulus, and thus allowing for greater consolidation of learning (Farrell & Milliner, 2015). Inhibitory learning models of exposure therapy (see Bouton and King, 1983, Craske et al., 2008) highlight the importance of patients acquiring new learning during exposure therapy, which can be readily accessed in different contexts and over time. Moreover, an important associated outcome of inhibitory learning is that of developing fear tolerance during exposure therapy, which is arguably more essential than habituation (Abramowitz, 2013). Whilst currently un-tested, we propose that fewer sessions of longer duration may provide an alternative model of intensive treatment for OCD, providing a more concentrated dose of exposure, and as such opportunity for inhibitory learning. Three-hour sessions provide a more efficient model, but may also provide a stronger dose of exposure, relative to existing 1-h sessions of CBT, which may only allow for up to ∼30 min a week/session of exposure (taking into consideration the opening and closing of hourly sessions – that is, reviewing homework, challenges, re-teaching the model of exposure, and reviewing and setting homework sessions – may consume at least 30 min).

Farrell and Milliner (2015) described this treatment approach with an 11-year-old boy who presented with severe OCD (CYBOCS score = 30). Treatment consisted of an education session, 2 × 3.5 h massed ERP sessions, followed by 3 × 45 min weekly e-therapy (Skype) sessions. Following treatment, the boy displayed significant improvements on various measures of OCD severity. Delivering a small number of web-based or telephone CBT sessions (Storch et al., 2011, Turner et al., 2009) following intensive sessions, allows participants the flexibility to return home, but may also assist in the generalisation of treatment gains across contexts within the home. Indeed, both web (14 weekly sessions; Storch et al., 2011) and telephone (14 weekly sessions; Turner et al., 2009) delivered CBT treatments have been found to be effective in preliminary trials for paediatric OCD.

The present study aimed to examine the effectiveness of a novel concentrated dose of CBT treatment for youth OCD, using a multiple baseline controlled design, given that such a design is supported by the evidenced based treatment movement (Task Force on Promotion and Dissemination, 1995) and allows for the systematic evaluation of the efficacy of innovative treatments in a controlled manner (Jarrett & Ollendick, 2012; Oar, Farrell, Waters, Conlon, & Ollendick, 2015). Treatment involved the combination of 1 session psychoeducation, 2 session of intensive exposure therapy combined with web-based maintenance, based on the rationale that fewer in person sessions would reduce the time and cost burden to families, and moreover, that prolonged exposure sessions may be an effective, alternative model of delivery for exposure therapy. Children and youth (aged 11–16 years) with a primary diagnosis of OCD were randomly assigned to a 1- or 2-week baseline monitoring condition followed by the intervention. It was hypothesised that OCD symptoms would remain stable during the baseline periods and then improve significantly following intensive CBT. Moreover, it was predicted that significant reductions would be observed from pre- to post-treatment on clinician ratings of OCD severity, diagnostic status, and self-reported OCD, anxiety and depression symptoms. Finally, it was expected that post-treatment gains would be maintained at 6-month follow-up.

Section snippets

Participants

Prospective participants were recruited from the community via advertising in local papers, as well as radio announcements, and by referrals into the program by general practitioners. Potential participants were initially screened (N = 27) for inclusion on the basis of presence of obsessive-compulsive symptoms. Children who were not considered appropriate, due to the absence of sufficient OCD symptoms, were referred elsewhere (n = 13). Exclusion criteria included psychosis, intellectual disability,

Overview of analyses

Single-case data were examined via visual inspection of the participant’s ratings across baseline, treatment and follow-up periods in line with recent guidelines for reporting single-case data (i.e., SCRIBE Statement; Tate et al., 2016). Stability over the baseline was examined by way of t-tests (for 1-week baseline) or ANOVA (for 2-week baseline). A series of repeated measures ANOVAs were conducted followed by component pairwise comparisons, to examine participant changes over time on the

Discussion

This study evaluated the effectiveness of a novel approach to intensive therapy for children and adolescents with OCD. Specifically, this study examined the preliminary efficacy of a novel 2-session intensive ERP-based CBT program, combined with e-therapy maintenance (3 weeks) using a multiple-baseline design to establish stability of symptoms over a no-treatment waiting period, relative to change in symptoms following intensive therapy, plus e-therapy maintenance, at post-treatment and out to

Conclusions

Overall, the study provides favourable evidence for novel intensively delivered exposure therapy plus response prevention, combined with e-therapy maintenance for children and youth with OCD. The outcomes offer promise for more efficient models of treatment delivery and importantly, more rapid improvements for children who are often severely impaired. The potential of this novel approach is that it may provide an even more efficient and cost effective means of accessing specialist clinic-based

Acknowledgements

This study was funded by the Griffith University and Gold Coast Hospital Foundation Collaborative Research Fund.

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