Elsevier

Psychiatry Research

Volume 260, February 2018, Pages 116-122
Psychiatry Research

Group family-based cognitive behavioral therapy for pediatric obsessive compulsive disorder: Global outcomes and predictors of improvement

https://doi.org/10.1016/j.psychres.2017.11.041Get rights and content

Highlights

  • Eighty-five youth with OCD completed group, family-based, cognitive behavioral treatment.

  • Treatment was associated with large improvements in OCD severity and impairment.

  • Coercive/disruptive behaviors and family domains also improved with treatment.

  • Homework success was a significant predictor of treatment improvement.

Abstract

This open, uncontrolled study examined the efficacy of a group family-based cognitive behavioral therapy (GF-CBT) protocol in treating pediatric obsessive-compulsive disorder (OCD) and explored predictors of symptom improvement. Eighty-five OCD-affected youth aged 8–18 years (M = 13.9 years, SD = 2.49; 46% male) and their parent(s) participated in a weekly, 12-session GF-CBT program. Data from multiple perspectives were gathered at the beginning and end of treatment, as well as at one-month follow-up. A broad range of assessment measures were utilized to capture clinically-relevant domains and a number of potential predictor variables were explored. Paired t-tests indicated that treatment was associated with significant reductions in clinician- and parent-rated OCD severity (d = 1.47, 1.32), youth and parent-rated functional impairment (d = 0.87, 0.67), coercive/disruptive behaviors (d = 0.75), and family accommodation (d = 1.02), as well as improvements in youth-, mother-, and father-rated family functioning (d = 1.05, 0.50, 0.88). Paired t-tests also indicated that youth remained improved at one-month follow-up. Step-wise regression identified greater homework success as a significant predictor of symptom improvement. This study provides evidence that GF-CBT significantly improves a wide range of domains for youth/families that extends beyond OCD symptom severity and supports homework as a core treatment component.

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

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