Elsevier

Psychiatry Research

Volume 220, Issues 1–2, 15 December 2014, Pages 441-446
Psychiatry Research

A baseline controlled examination of a 5-day intensive treatment for pediatric obsessive-compulsive disorder

https://doi.org/10.1016/j.psychres.2014.07.006Get rights and content

Highlights

  • 22 children with OCD received intensive exposure and response prevention therapy.

  • Treatment included training parents to conduct ERP independent of a therapist.

  • Outcomes were assessed using a baseline control design.

  • OCD symptoms and parental accommodation improved from pre- to post-treatment.

  • Symptoms and accommodation continued to improve from post-treatment to follow-up.

Abstract

This study extends support for a 5-day intensive exposure and response prevention (ERP) treatment protocol for pediatric obsessive compulsive disorder (OCD). Twenty-two children with OCD received ERP treatment twice daily for 5 days. The treatment also emphasized teaching children and parents how to conduct ERP independently after they returned home. Symptoms were assessed at four time-points: Baseline, 4 weeks later at pre-treatment, one week after the intensive treatment 5-day treatment, and at 3 month follow-up. Changes on the primary outcome measure, clinician severity ratings on the Anxiety Disorders Interview Schedule for Children, and secondary measures, indicated that OCD symptoms remained stable from the evaluation to baseline and improved significantly from baseline to follow-up. Moreover, parental accommodation of OCD decreased significantly from baseline to post-treatment and from post-treatment to follow-up. These data suggest that the 5-day intervention demonstrates efficacy in reducing OCD symptoms and may initiate change in parent accommodation that continues to improve after the family returns home.

Introduction

Obsessive-compulsive disorder (OCD) occurs in approximately 1–2 of every 100 children and adolescents (Flament et al., 1988, Valleni-Basile et al., 1994, Valleni-Basile et al., 1996) and is associated with significant impairment in social, academic, and family functioning (Piacentini et al., 2003). Exposure and response prevention (ERP), the most well-researched psychosocial intervention for OCD (e.g., March and Leonard, 1996), has been demonstrated to be effective in children (Pediatric OCD Treatment Study (POTS), 2004, Abramowitz et al., 2005, Watson and Rees, 2008, Storch et al., 2013) and is considered a first-line treatment (American Academcy of Child and Adolescent Psychiatry, 2012). Despite its established efficacy, ERP is not widely available in community outpatient settings (Goisman et al., 1993, Valderhaug et al., 2004, Storch et al., 2007b) and efforts to disseminate empirically supported treatments have been met with considerable obstacles, such as the cost of training, the questionable influence of continuing education courses, and negative beliefs held by practitioners (Addis, 2002).

Until the quantity of specially trained mental health providers can be increased, other methods to expand the accessibility of effective treatments need to be pursued. One such alternative is to modify existing treatments to be administered in a time-limited period. By providing intensive treatment (i.e., daily sessions over a short timeframe), families may be able to travel to a specialty OCD clinic and reside in that location for the duration of treatment. Although an extended stay associated with intensive treatment adds additional costs, it may be more feasible than weekly office visits, or the only option for families that live at significant distance from a treatment center. It also may be more cost-effective in the long run compared to ongoing suboptimal or non-empirically supported treatment. In addition, providing treatment in an intensive format may actually increase its effectiveness, at least initially, by maximizing learning through massed practice, focusing the patient׳s attention on treatment, and allowing close monitoring of compliance (Schmidt and Bjork, 1992, Storch et al., 2007b). However, one drawback is that massed learning may also be associated with greater return of fears (Abramowitz et al., 2003, Storch et al., 2007b). Thus, specific research into intensive formats for ERP is necessary.

The currently existing intensive protocols that provide daily ERP for OCD over three to four weeks have been found to be of comparable effectiveness to treatment delivered once or twice a week (Franklin et al., 1998, Abramowitz et al., 2003, Storch et al., 2007b). Franklin et al. (2001) suggested that intensive ERP may be the treatment of choice for patients that have severe symptoms, have not responded to traditional treatment, or are not available for daily sessions. In the only randomized trial to date, Storch et al. (2007b) compared a 3-week program for pediatric OCD to 14 weekly sessions of ERP. In this study of 40 patients, intensive and weekly treatments were associated with equivalent decreases in the Children׳s Yale-Brown Obsessive Compulsive Scale (CY-BOCS; m=15.7 and 15.6, respectively). Similarly, in the largest study of intensive OCD treatment to date, Storch et al. (2008) found that a similar percentage of adults no longer met the criteria for OCD following a 3-week intensive treatment, 40.7%, and weekly treatment, 52.3%.

Despite the success of these intensive programs, a three- to four-week treatment protocol places a considerable burden on families staying away from home. Specifically, receiving specialty care outside one׳s home area involves travel expenses, missed school, missed work for one or both parents, lodging, and meals away from home. Such costs are substantial for the most researched treatment protocols that last 3 weeks (Storch et al., 2007b, Storch et al., 2008). To decrease these ancillary costs by at least two-thirds we developed a protocol to be administered twice daily over 5 days (Whiteside et al., 2008). Similar to some non-intensive protocols (e.g., Barrett et al., 2004), parents are included in every session, but with a specific emphasis on receiving hands-on training in exposures coaching to maximize generalizability and increase the likelihood that therapeutic tasks will be implemented after the intensive week. In addition, including parents directly targets family accommodation. Addressing accommodation is essential given that research has shown that it functions to maintain and potentially increase obsessive-compulsive symptom severity (Lewin et al., 2005).

An initial feasibility study of the 5-day treatment protocol suggested that the treatment was tolerable (i.e., 15 of the 16 patients participated in all sessions) and effective (Whiteside and Jacobson, 2010). Specifically, scores on the Children׳s Yale-Brown Obsessive Compulsive Scale (CY-BOCS) decreased significantly from pre-treatment to post-treatment (d=2.07) and from post-treatment to follow-up (d=0.91) with reductions comparable to those with standard weekly and 3-week intensive ERP protocols (i.e., Storch et al., 2007b). However, this initial study had several limitations, including being uncontrolled, having the majority of the patients treated by a single therapist, and relying on child- and parent-report at follow-up.

Demonstrating the effectiveness of a 5-day treatment protocol would have a number of benefits. First, since seeking intensive treatment away from home requires considerable costs to the family (e.g., travel, lodging, time away from school and work) reducing the duration to a single work week will substantially decrease the burden of receiving care. Second, the successful integration of ERP and training parents to be exposure coaches would provide additional support for a model of using parents to increase the efficiency and effectiveness of standard weekly treatment for OCD and related anxiety disorders.

The present study provides a more rigorous examination of the efficacy of the intensive 5-day treatment for pediatric OCD than has been previously conducted. Patients were recruited from two geographically different sites and treated by multiple therapists. Data was collected at baseline, after a four-week waiting period, one-week after the intensive treatment, and 3-months after the intensive treatment. It was hypothesized that pediatric OCD symptoms would remain stable during the waiting period, decrease moderately following the week of intensive treatment, and continue to decline after the children returned home. With regards to secondary outcomes, it was expected that participants would experience improvements in OCD-related impairment, reduced family accommodation, and reduced anxiety and depressive symptoms.

Section snippets

Participants

Participants included 22 children and adolescents seen across two sites (Mayo Clinic, n=14, and Fordham University n=8). Participants learned of the intensive treatment from a variety of sources including other providers, professional organizations, and/or listings on websites (e.g., Mayo Clinic, The International OCD Foundation, clinical trial registries). Fig. 1 provides a full accounting of recruitment and eligibility.

The youth consisted of 15 males and 7 females ages 7 to 18 (m=12.59,

Results

All the 22 participants who began the 5-day intensive treatment completed all 10 sessions. Two participants declined to participate in follow up data collection. Descriptive statistics and effect sizes for differences between all time points can be found in Table 1. There were no differences in age or sex between sites. There was no effect of age on outcome. Site differences at the baseline assessment were observed for ADIS CSR ratings [t(20.0)=2.27, p=0.035, d=1.13], but not for any other

Discussion

The current study increases support for the efficacy of a 5-day intensive treatment for pediatric OCD. As in the previous feasibility study (Whiteside and Jacobson, 2010), youth and their parents were able to tolerate and benefit from the 10 h of ERP over 5 consecutive days. The current study extends the previous findings by increasing the methodological rigor of the assessments, demonstrating change with multiple therapists across two sites, and including a baseline control period.

One weakness

References (54)

  • S.H. Spence

    A measure of anxiety symptoms among children

    Behaviour Research and Therapy

    (1998)
  • E.A. Storch et al.

    Family-based cogntive-behavioral therapy for pediatric obsessive-compulsive disorder: comparison of intensive and weekly appraoches

    Journal of the American Academy of Child & Adolescent Psychiatry

    (2007)
  • E.A. Storch et al.

    Predictors of functional impairment in pediatric obsessive-compulsive disorder

    Journal of Anxiety Disorders

    (2010)
  • E.A. Storch et al.

    Cognitive-behavioral therapy for obsessive--compulsive disorder: a non-randomized comparison of intensive and weekly approaches

    Journal of Anxiety Disorders

    (2008)
  • E.A. Storch et al.

    Psychometric evaluation of the Children׳s Yale-Brown Obsessive-Compulsive Scale

    Psychiatry Research

    (2004)
  • E.A. Storch et al.

    Randomized, placebo-controlled trial of cognitive-behavioral therapy alone or combined with sertraline in the treatment of pediatric obsessive-compulsive disorder

    Behaviour Research and Therapy

    (2013)
  • L.A. Valleni-Basile et al.

    Frequency of obsessive-compulsive disorder in a community sample of young adolescents

    Journal of the American Academy of Child and Adolescent Psychiatry

    (1994)
  • L.A. Valleni-Basile et al.

    Incidence of obsessive-compulsive disorder in a community sample of young adolescents

    Journal of the American Academy of Child and Adolescent Psychiatry

    (1996)
  • S.P. Whiteside et al.

    Five-day intensive treatment for adolescent OCD: a case series

    Journal of Anxiety Disorders

    (2008)
  • S.P. Whiteside et al.

    An uncontrolled examination of a 5-day intensive treatment for pediatric OCD

    Behavior Therapy

    (2010)
  • V.M. Wuthrich et al.

    A randomized controlled trial of the cool teens CD-ROM computerized program for adolescent anxiety

    Journal of the American Academy of Child and Adolescent Psychiatry

    (2012)
  • J.S. Abramowitz et al.

    Exposure and ritual prevention for obsessive-compulsive disorder: effects of intensive versus twice-weekly sessions

    Journal of Consulting and Clinical Psychology

    (2003)
  • M.E. Addis

    Methods for disseminating research products and increasing evidence-based practice: promises, obstacles, and future directions

    Clinical Psychology: Science and Practice

    (2002)
  • A.M. Albano et al.

    Anxiety Disorders Interview Schedule for DSM-IV Child Version: Clinical Manual

    (1996)
  • American Academcy of Child and Adolescent Psychiatry

    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)
  • J. Barnard et al.

    Small-sample degrees of freedom with multiple imputation

    Biometrika

    (1999)
  • D.C. Beidel et al.

    Behavioral treatment of childhood social phobia

    Journal of Consulting and Clinical Psychology

    (2000)
  • Cited by (34)

    • Brief intensive cognitive behavioral therapy for children and adolescents with OCD: Two international pilot studies

      2021, Journal of Obsessive-Compulsive and Related Disorders
      Citation Excerpt :

      Special emphasis was placed on teaching child and parents to conduct exposure exercises independent of the therapist. Results from their multiple baseline controlled study in which 22 children with OCD (7–18 years) participated, provided support for the efficacy of this treatment (CY-BOCS effect size d = 1.37) (Whiteside et al., 2014). Farrell et al. (2016) increased the length of sessions and decreased the number of sessions.

    • Cognitive behavioral therapy in children with anxiety disorders

      2021, Diagnosis, Management and Modeling of Neurodevelopmental Disorders: The Neuroscience of Development
    • Concentrated exposure and response prevention for adolescents with obsessive-compulsive disorder: A replication study

      2018, Journal of Obsessive-Compulsive and Related Disorders
      Citation Excerpt :

      If impairing OCD-symptoms can be treated within a shorter time frame and with less drop-out, this might be more cost-effective in the long run compared to standard ERP treatment. Evidence suggests favorable outcomes of treatment delivered over three weeks (14 daily 90-min sessions; Storch et al., 2007) and five days (two 50-min sessions a day; Whiteside et al., 2014). Furthermore, Farrell et al. (2016) found that ERP could be successfully delivered in two weekly sessions of 3.5 h followed by 4 one-hour sessions of e-therapy.

    View all citing articles on Scopus
    View full text