Group family-based cognitive behavioral therapy for pediatric obsessive compulsive disorder: Global outcomes and predictors of improvement
Introduction
Mounting evidence supports the efficacy of cognitive behavioral therapy (CBT) featuring exposure and response prevention (ERP) as a first line treatment for pediatric obsessive-compulsive disorder (OCD) (Freeman et al., 2014a, Watson and Rees, 2008). Despite this, specific implementation of CBT can vary significantly and evidence is less clear regarding which specific approaches and factors are most likely to lead to success. In addition, access to this effective treatment remains a concern (Blanco et al., 2006, Goetter et al., 2014). Group-based CBT may help address some limitations associated with treatment accessibility by increasing the patient-to-provider ratio. This allows more patients to be seen in less provider time, reducing per patient treatment cost (Anderson and Rees, 2007, Fals-Stewart et al., 1993). While a group approach may limit individualization, it affords unique benefits over individual approaches, including symptom normalization, peer modeling and support, group motivation, and cross-participation in exposure completion (Himle et al., 2003). Group approaches have generally demonstrated comparable efficacy to individual approaches (Jonsson and Hougaard, 2009, Jonsson et al., 2011) and therefore represent a meaningful, alternative delivery method that may improve availability and accessibility of CBT.
The inclusion of family members in CBT has been suggested as an important component of effective pediatric OCD treatment. Specifically, family inclusion allows clinicians to address common family-level barriers to symptom reduction (e.g., accommodation, dynamics) and utilize parents as support for children's homework completion. As a result, family inclusion to individual treatment has been well supported (Barrett et al., 2004, Freeman et al., 2014b, Lewin et al., 2014, Merlo et al., 2009, Piacentini et al., 2011, Storch et al., 2007, Storch et al., 2016). Despite these benefits, family involvement has been understudied in conjunction with group-based treatment approaches (Freeman et al., 2014a). Thus far, two open trials (Farrell et al., 2012, Farrell et al., 2010) have found positive results in examining group family-based CBT (GF-CBT) protocols for youth with OCD, and one randomized controlled trial (Barrett et al., 2004) found that GF-CBT had equivalent outcomes to individual family-based CBT. While encouraging, these GF-CBT studies included relatively minor parental involvement compared to what is typically observed in studies of individual family-based CBT. Given the potential benefits, expanding the extent of parental/family involvement in GF-CBT is warranted. Mendlowitz et al. (1999) found that when anxious children and parents participated in simultaneous treatment groups, reductions in severity were superior to group treatment for children or parents alone. To date, only one 14-participant study examined a group treatment for pediatric OCD that placed equal emphasis on youth and parents (Jacqueline and Margo, 2005). The results indicated generally positive outcomes and supported further research to explore the overall benefits associated with this approach.
As discussed above, well-controlled trials have established that CBT is an efficacious treatment for reducing the severity of OCD symptoms in youth (Freeman et al., 2014a). However, continued efforts are needed to better establish the effectiveness of CBT in treating this population, which includes building evidence of treatment benefit under more naturalistic conditions (e.g., open/flexible inclusion/exclusion criteria) and establishing benefits that reach beyond symptom reduction to include broader functional improvements. Examining treatments in this light allow for greater generalizability of outcomes as well as a better understanding of the full scope of treatment benefit, which will increase our ability to compare the full impact of variations in CBT delivery. For example, research is lacking with respect to treatment impacts on coercive and disruptive behaviors, which are common in youth with OCD and contribute to overall severity (Lebowitz et al., 2015). A better understanding of global outcomes can speak to the meaningfulness of treatment, guide decisions regarding primary treatment targets, and advocate for psychosocial treatments as first-line approaches.
Despite strong empirical support for CBT, improvements in outcomes are still necessary, as many OCD-affected youth do not respond to CBT and the majority of youth complete treatment with at least some remaining symptoms (Pallanti and Quercioli, 2006). Identifying factors associated with response represents a first step towards developing and testing modifications that may improve the efficacy of treatment. Preliminary evidence suggests that a number of factors, such as symptom severity, family accommodation, comorbid externalizing disorders such as attention deficit-hyperactivity disorder (ADHD) and oppositional defiant disorder (ODD), and homework success, may impact treatment outcomes (Barrett et al., 2005, Garcia et al., 2010, Keeley et al., 2008, Merlo et al., 2009, Park et al., 2014, Storch et al., 2008); however, predictors have not yet been examined in the context of comprehensive GF-CBT.
In light of these gaps in the literature, the current study examined a GF-CBT protocol featuring extensive parental involvement, evaluating its efficacy across a wide range of outcome measures and exploring factors associated with improvement. Specifically, the following aims and hypotheses were set:
To examine the efficacy of GF-CBT in reducing OCD symptom severity as well as in improving the overall lives of youth and families as reflected by functional impairment, coercive/disruptive symptoms, family accommodation, and family functioning. We hypothesized that GF-CBT would be associated with large improvements across these outcomes from baseline to post-treatment.
To examine the short-term maintenance of GF-CBT outcomes across domains. We hypothesized that youth outcomes would not significantly differ between post-treatment and one-month follow-up.
To explore potential predictors of symptom improvement following GF-CBT. Based on prior literature, it was hypothesized that reduced treatment improvement would be associated with greater baseline OCD severity and family accommodation (Barrett et al., 2005, Garcia et al., 2010, Piacentini et al., 2002), the presence of comorbid ADHD and ODD (Garcia et al., 2010; Storch et al., 2008), and lower homework success (Mausbach et al., 2010, Park et al., 2014), while gender and age were not expected to be associated with treatment improvement (Garcia et al., 2010, Piacentini et al., 2002).
Section snippets
Participants and procedures
The present study was approved by the University of British Columbia Research Ethics Board. The present study was a 12-week, open trial examining GF-CBT for OCD-affected youth recruited from patients referred to the British Columbia Children's Hospital Provincial OCD Program (POP), a hospital-based outpatient specialty program for the assessment and treatment of youth with OCD, between 2011 and 2016. Youth screened at the POP (age range 7–18 years), who had a primary diagnosis of OCD and were
Participant characteristics
Participant characteristics are reported in Table 1. The present study included 85 youth aged 8–18 years (M = 13.9, SD = 2.49); 46% were male (n = 39), and 79.8% were Caucasian (n = 67). Mothers of 75 (88%) participants and fathers of 29 (34%) participants completed the questionnaires. Average CY-BOCS symptom severity at baseline was in the high moderate range (23.36; SD = 4.98).
Treatment outcomes
Paired t-tests indicated that youth who completed treatment demonstrated significant reductions in symptom severity
Discussion
The results of the present study provide further evidence for the effectiveness of CBT in treating pediatric OCD including when treatment is delivered via a group family-based approach. While the present study cannot establish why a group-based treatment remains effective despite a shift from individual focus, results are consistent with growing literature suggesting that less direct interventions, such as group treatment (Farrell et al., 2012, Freeman et al., 2014a), online or telehealth
Conclusions
Overall, the results of the present study corroborate the effectiveness for CBT as an empirically supported treatment for youth with OCD and provide specific evidence that a group family-based version of CBT is globally beneficial for youth with OCD and their families. Despite the strength of this evidence, continued efforts are needed to ensure that youth have the highest chance of improvement and long-term success. As the field continues to move forward, the results described here suggest
References (52)
- et al.
Group versus individual cognitive-behavioural treatment for obsessive-compulsive disorder: a controlled trial
Behav. Res. Ther.
(2007) - et al.
Cognitive-behavioral family treatment of childhood obsessive-compulsive disorder: long-term follow-up and predictors of outcome
J. Am. Acad. Child Adolesc. Psychiatry
(2005) - et al.
Cognitive-behavioral family treatment of childhood obsessive-compulsive disorder: a controlled trial
J. Am. Acad. Child Adolesc. Psychiatry
(2004) - et al.
Comorbidity and treatment response in pediatric obsessive-compulsive disorder: a pilot study of group cognitive-behavioral treatment
Psychiatry Res.
(2012) - et al.
Cognitive-behavioral treatment of childhood obsessive-compulsive disorder in community-based clinical practice: clinical significance and benchmarking against efficacy
Behav. Res. Ther.
(2010) - et al.
Predictors and moderators of treatment outcome in the Pediatric Obsessive Compulsive Treatment Study (POTS I)
J. Am. Acad. Child Adolesc. Psychiatry
(2010) - et al.
Stepped care for obsessive-compulsive disorder: an open trial
Behav. Res. Ther.
(2010) - et al.
An open trial of videoconference-mediated exposure and ritual prevention for obsessive-compulsive disorder
J. Anxiety Disord.
(2014) - et al.
Child-focused treatment of pediatric OCD affects parental behavior and family environment
Psychiatry Res.
(2015) - et al.
Clinical predictors of response to cognitive-behavioral therapy for obsessive-compulsive disorder
Clin. Psychol. Rev.
(2008)
Family-based exposure and response prevention therapy for preschool-aged children with obsessive-compulsive disorder: a pilot randomized controlled trial
Behav. Res. Ther.
Cognitive-behavioral group treatments in childhood anxiety disorders: the role of parental involvement
J. Am. Acad. Child Adolesc. Psychiatry
Treatment-refractory obsessive-compulsive disorder: methodological issues, operational definitions and therapeutic lines
Prog. Neuropsychopharmacol. Biol. Psychiatry
Controlled comparison of family cognitive behavioral therapy and psychoeducation/relaxation training for child obsessive-compulsive disorder
J. Am. Acad. Child Adolesc. Psychiatry
Open trial of cognitive behavior therapy for childhood obsessive-compulsive disorder
J. Anxiety Disord.
Children's Yale-Brown Obsessive Compulsive Scale: reliability and validity
J. Am. Acad. Child Adolesc. Psychiatry
Test-retest reliability of anxiety symptoms and diagnoses with the Anxiety Disorders Interview Schedule for DSM-IV: child and parent versions
J. Am. Acad. Child Adolesc. Psychiatry
Family-based cognitive-behavioral therapy for pediatric obsessive-compulsive disorder: comparison of intensive and weekly approaches
J. Am. Acad. Child Adolesc. Psychiatry
Impact of comorbidity on cognitive-behavioral therapy response in pediatric obsessive-compulsive disorder
J. Am. Acad. Child Adolesc. Psychiatry
The children's Yale-Brown obsessive-compulsive scale: psychometric properties of child- and parent-report formats
J. Anxiety Disord.
Validation of two global impression questionnaires for incontinence
Am. J. Obstet. Gynecol.
Internet-based cognitive behaviour therapy for obsessive-compulsive disorder: a randomized controlled trial
Psychol. Med.
Treatment of obsessive-compulsive disorder by U.S. psychiatrists
J. Clin. Psychiatry
Family accommodation in obsessive-compulsive disorder
Am. J. Psychiatry
A comparison of behavioral group therapy and individual behavior therapy in treating obsessive-compulsive disorder
J. Nerv. Ment. Dis.
Cited by (22)
Family accommodation as a predictor of treatment outcome in outpatient intensive cognitive behavioral therapy of adult obsessive compulsive disorder
2022, Journal of Obsessive-Compulsive and Related DisordersLongitudinal trajectory and predictors of change in family accommodation during exposure therapy for pediatric OCD
2021, Journal of Anxiety DisordersFamily profiles in pediatric obsessive-compulsive disorder
2020, Journal of Obsessive-Compulsive and Related DisordersCitation Excerpt :Of those who completed baseline assessments, 75% completed assessments post-CBT and 55% completed assessments at follow-up. Additional details on the treatment group approach and its primary outcomes for participants enrolled between 2011 and 2016 are described in Selles, Belschner, et al. (2018). Demographic information regarding the treatment sample in the current study is presented in Table S1.
Mindfulness-based skills training group for parents of obsessive-compulsive disorder-affected children: A caregiver-focused intervention: Mindfulness for parents of OCD-affected children
2020, Complementary Therapies in Clinical PracticeCitation Excerpt :Interventions directly targeting parents of OCD-affected youth are scarce [10], although there is a clear need for support in this population [5,7,11]. Noting this, the pediatric OCD research community has been calling for interventions to help parents deal with their own and their child's emotional distress [5,10] and to support their child in achieving better treatment outcomes [12,13]. The impairment experienced by family members is partially a consequence of parental involvement in their child's OCD symptoms, also known as family accommodation [14–16].
Avoidance, Insight, Impairment Recognition Concordance, and Cognitive-Behavioral Therapy Outcomes in Pediatric Obsessive-Compulsive Disorder
2020, Journal of the American Academy of Child and Adolescent PsychiatryFamily involvement and treatment for young children with Obsessive-Compulsive Disorder: Randomized control study
2019, International Journal of Clinical and Health Psychology