S P,E C I A L ART I C L E

Cognitive-Behavioral Psychotherapy for Childrenand Adolescents with OCD: A Review and

Recommendations for Treatment

JOHN S. MARCH, M.D., M.P.H.

ABSTRACT

Objective: To critically review the published literature on cognitive-behavioral psychotherapy for obsessive-compulsive

disorder (OGD) in children and adolescents. Method: The psychiatric and psychological literature was systematically

searched for "studies" applying cognitive-behavioral principles to children and adolescents with OGD. Results: Thirty­

two investigations, most of them single case reports, were identified. Despite manifold differences in terminology and

theoretical framework, all but one showed some benefit for cognitive-behavioral interventions. Graded exposure and

response prevention form the core of treatment; anxiety management training and OGD-specific family interventions

may play an adjunctive role. Poor compliance, inadequately documented and inconsistently applied treatment, and

lack of exportability were recurrent problems. Conclusions: Abundant clinical and emerging empirical evidence suggest

that cognitive-behavioral psychotherapy, alone or in combination with pharmacotherapy, is an effective treatment

for OGD in children and adolescents. Future research in this area will need to focus on comparisons of cognitive­

behavioral psychotherapy to other treatments, on component analyses, and on the application of exportable protocol­

driven treatments to divergent patient populations. J. Am. Acad. Child Ado/esc. Psychiatry, 1995, 34, 1:7-18. Key

Words: obsessive-compulsive disorder, behavior therapy, cognitive therapy, follow-up studies, treatment, children

and adoiescents.

Obsessive-compulsive disorder (OCD) is more com­mon than once thought, affecting approximately 0.5%to 1.0% of children and adolescents at any given time(Flament et al., 1988). Since one third to one halfof adults develop the disorder during childhood oradolescence (Rasmussen and Eisen, J990), childhood­onset OCD also is an important predictor of adultmorbidity. Cognitive-behavioral psychotherapy (CBT)has been shown to be an effective treatment for OCDin adults (Baer, 1992; Marks et al., 1988), where it isoften combined with pharmacotherapy (Greist, 1992).

Accepted january 26, 1994.Dr. March is with the Program in Child and AdolescentAnxiety Disorders,

Division of Child Psychiatry, Department of Psychiatry, Duke University

Medical Center, and the Department ofPsychology: Socialand Health Sciences,at Duke University.

This work was supported in part by a NIMH Scientist Development Awardfor Clinicians (I K20 MH00981-01) to Dr. March.

Correspondence to Dr. March, Department ofPsychiatry, DUMC Box 3527,

Durham, NC 21110. InterNet: jsmarch@acpub.duke.edu.0890-8567/95/3401-0007$03.00/0© 1995 by the American Academy

of Child and Adolescent Psychiatry.

J. AM. ACAD. CHILD ADOLESC. PSYCHIATRY, 34:1, JANUA'!ty 1995

Although empirical support remains weak, CBT alsomay be the psychotherapeutic treatment of choice forchildren and adolescents with OCD (Rapoport et al.,1992). Nonetheless, clinicians routinely complain thatpatients will not comply with behavioral treatments andparents routinely complain that clinicians are poorlytrained in the application of CBT to child patientswith OCD.

This article reviews the current status of CBT forchildren and adolescents with OCD, addressing empiri­cal documentation, acceptability of treatment, and ex­portability, among other issues, and concludes bymaking specific recommendations regarding cognitive­behavioral interventions for young persons with OCD.

COGNITIVE-BEHAVIORAL PSYCHOTHERAPY

FOR OCD IN ADULTS

As illustrated by recent lay publications (Baer, 1991;Foa and Wilson, 1991), CBT has become the psycho­therapeutic treatment of choice for adults with OCD.Treatment generally involves a three-stage approach

7

MARCH

co nsis ting of informatio n gathering, therapist-assistedexposure and response prevention (E/RP), and home­work assignme nts. The seco nd element, therapi st­assisted exposure, often can be eliminated in favorof patient-di rect ed homework. Compo nent ana lysessugges t that expos ure is th e active ingre dient of treat­ment (Em melkam p et al., 1989). Relaxa tio n has beenshown to be an inert compo nent of behavioral treat­ment for O CD, and sometimes it is used as an activeplaceb o (Marks, 1987). Simi larly, cog ni tive interven­tions probably are less importan t than E/RP in reducing

OCD sympto ms (Emmelkamp and Beens, 1991). Bothgraded exposure and flooding procedures have shownem pirical and clinical support (M arks, 1987). Pre­dictors of a successful response to behavior therapyinclude th e presence of overt rituals, the desire to

elimi na te sympto ms, ability to mon ito r and reportsym ptoms, absence of complicati ng comorbid co ndi­tions, an d willingness to coo perate with treatmen t (Foaand Emrnelkamp, 1983). Behavior therapy is oftensuccessfully combined with ph arm acotherap y wi th aserotonin reuptake inhibito r (G reist, 1992 ). Further­mo re, since antiexposure instructio ns (in wh ich patientsare enco urage d not to resist th eir obsessions and ritu als)atte n uate th e effectiveness of drug trea tme nt (M arkset al., 1988), the combina tion of d rug and behavioraltherapies may be the treatment of choice for O CD inpa tients req uiring medication (Greist, 1992) .

COGNITIVE-BEHAVIORAL PSYCHOTHERAPY FOR

OCD IN YOUNG PERSONS

Method

Us ing MEDLINE, PsychLit, the Obsessive-Compul­sive In formation Center at the Dean Foundation inM ad ison , W isconsin, and an informal survey of profes­sional colleagues, the psychiatric and psych ologicalliteratu re was systema tically searched for published andunpubl ished reports that explici tly or im plici tly appliedcog ni t ive-behavio ral prin ciples and th erap ies to O CDin chi ldre n and adolescents. Reference lists of selectedarticles were scanned for mor e recent or omitt ed papers.Excluded from consideration were arti cles conce rni ngthe so-called O C spectr um disorders (such as tr ichotil­lomania), "com pulsive" behaviors manifesting as im­p ulse disorders (such as stealing), or repetitive beha viors(such as com pulsively flipping light swi tches) in men­tally reta rded chi ldren.

8

Types of Investigations

T hirty-two art icles describ ing th e no npharmacologi­cal treatment of OCD in one or more ch ild andado lescent subjects were identified (Table 1). T h isrepresents a substantial inc rease from th e 13 art iclesidentified by Wolf an d Rapop ort in their 1988 reviewof th is to pic (Wolff and Rapoport , 1988) and reflectsthe na ture of the literat ure searc h rather than a profu­sion of recent reports. Twenty-five of the 32 investiga­tions are case reports, as defin ed by insubstantialdescriptions of assessment, treatmen t, and outcomewith little or no accompan ying qu antitative data. O nepresents an case series of systematically assessed childrenand ado lescents treated with a newly developed, proto­col-driven treatment (March et al., 1994). The re­maining investigati on s are single case studies, definedas any report that provides a quanti tative baselineassessme nt plus either assessme nt across multiple sym p­to m domains (mult iple baseline design) or treatments(such as an ABAB design). No published investiga tio ns

used contrasting group designs compari ng treatments orcomponents of treat ments, and th ere were no systematicreplicat ion studies.

Assessment Issues

Diagnosis and Symptom Profile. Accura te assessme ntis essential to the skillful application and evalua tionof behavioral t reat m ents (Thyer, 19 91 ) , but was no t

a strength of the cited investigatio ns taken as a who le.O nly 2 of 32 articles used struc tu red interviews toidentify subjects as hav ing OCD (Francis, 1988; Kear­ney and Silverman, 1990). Severa l others used scalarmeasures, such as the M audsley O bsessional Inventory(Stern berge r and Burns, 1990) and Leyton Obsession alInventory (Berg et al., 1988), that assess OCD butare not truly diagnostic. One used the Yale-BrownObsessive Com pulsive Scale (March et al., 1994), whichis currently considered the inst rument of choice forrating O CD sympto ms (Goodma n et al., 1989). Mostinvestigat ions relied instead on rathe r haph azard clinicaldesc ript ions to cha racterize sym ptomatology in individ­ual subjec ts. Similarly, just th ree of th e reviewed investi­gations assessed comorbidity using either categorical orscalar meas ures (Fra ncis, 1988; Kearney and Silverman,1990; March et al., 1994), altho ugh severa l mentionedtic d isorders or dep ression as factors complicating treat­ment. Since corn orbidir y may pred ict the nature and

J. AM. ACAD. C H IL D ADOL ESC. PSY CH IATRY, 34 : 1 , JANUARY 19 9 5

outcome of treatment (Dar and Greist, 1992), failureto systematically assess comorbid conditions is a criti­cal deficiency.

Demographics and Severity. Both males and femalesare represented in the treated population as are youngerchildren to older adolescents (age range 6 to 18 years).Other demographic variables, such as ethniciry or socio­economic status, were generally not well documented.Nine of the 32 investigations focused on hospitalizedchildren or adolescents, most of whom were hospital­ized for long periods. All were hospitalized with severeOCD as the primary indication. However, other thancomments about "severe" OCD, no study of hospital­ized children and only one outpatient study (Marchet al., 1994) provided quantitative measures of symp­tom severity, although Bolton et al. (1983) linkedseverity to time occupied by OCD in a global fashion.This is a notable deficiency, since children and adoles­cents with OCD vary widely with respect to the impactof the disorder on level of functioning. Moreover,severely ill patients who improve markedly with treat­ment may nonetheless fail to normalize so that globalimprovement and clinical status must be judgedindependently.

Outcome Measures. Most of the cited investigationsrelied on unsubstantiated parent reports to documentwhat happened during treatment. Six of 32 investiga­tions, all single case studies, systematically monitoredthe process and outcome of treatment using measuresthat sampled specific symptom domains, such as wash­ing versus avoidance; functional domains, such as homeor school; or symptomatic distress during exposure,such as subjective units of discomfort. A few of thehospital-based investigations used symptom counts byhospital staff (see, for example, Bolton et aI., 1983).Two others used self-report checklists, such as thefrequency of hand washing, rather than direct observa­tional measures (Ong and Leng, 1979; Stanley, 1980).Since reliable and valid assessment of outcome acrosstime is a key feature ofwell-designed treatment outcomestudies, the lack of adequate assessments alone relegatesa great deal of the work in this area to hypothesisgeneration.

Treatments

Careful specification of treatments is a prerequisiteto the empirical evaluation of treatment efficacy. Levelof detail and conceptual clarity varied widely between

J. AM. ACAD. CHILD ADOLESC. PSYCHIATRY, 34:1, JANUARY 1995

COGNITIVE-BEHAVIORAL TREATMENT OF OCD

investigations; however, cited investigations were ap­proached using consistent behavioral terminology. Forexample, when O'Connor (1983) encouraged his pa­tient's parents not to attend to reassurance seeking,this intervention was termed extinction, even thoughO'Connor conceptualized it in the language of systemicfamily therapy. Of the 32 investigations, only one(March et aI., 1994) used a treatment protocol docu­mented in manual form. Most of the cited investiga­tions, including the single case studies, used multiplebehavioral treatments, mixing and matching behavioraltherapies with nonbehavioral interventions, such asfamily therapy or supportive psychotherapy, dependingon the needs of the particular child.

For heuristic purposes, treatment approaches havebeen divided into exposure-based treatments, anxietymanagement training, operant treatments, and nonbe­havioral psychotherapies.

Exposure-Based Treatments

Exposure. As applied to OCD, the exposure principledepends on the fact that anxiety usually attenuatesafter sufficient duration of contact with the fearedstimulus (Dar and Greist, 1992). Thus a child withcontamination fears must come into and remain incontact with "contaminated" objects until his or heranxiety decreases substantially. Repeated exposure isassociated with lessened anxiety across exposure trialsuntil the child no longer fears contact with a particularphobic stimulus. Exposure can be implemented in agradual (sometimes termed graded) fashion or throughflooding, with exposure targets under either therapistor patient control. In graded exposure, the child rankshis or her OCD symptoms from the easiest to hardestto resist, in the process generating a stimulus hierarchythat serves as the focus for organizing E/RP. In contrastto graded exposure, which begins at the easy end ofthe stimulus hierarchy, flooding involves prolongedexposure to the most anxiety-provoking stimuli on thehierarchy in order to shorten treatment and maximizebenefit (Dar and Greist, 1992).

Counting satiation (described below) as exposure,slightly more than one half of the cited investigations(17 of 32) included a formal exposure procedure,although all relied on naturalistic in vivo exposure.Most applied exposure in a graded fashion, with targetschosen or suggested by the therapist rather than bythe patient. While two investigations used flooding to

9

.... TABLE 1 Articles Reporting Implicit o r Expl icit App lica tio n of CBT to OCD0

Study Subject Characteristics Design Behavior T herapy Other Th erapies Results Author's Conclusions

Weiner, 1967 l S-yr-old male with fear of harm CR Graded RP None "Essentially symptom free.. RP is effectiveto self and oth ers CT

Fine, 1973 8-yr-old male with touchinJ and CR EXT FT "Minimal rituals" FT is effectiverepeating rituals; 9-yr-ol male OP PSwith balancing and grooming E/RPrituals

Campbell, 1973 12-yr-old male with CR TS None No symptoms at 3-yr follow-up TS is effective, ruminations" after violent SATdeath of sister

Mills et al., 1973 l S-yr-old hospitalized male with SC Alternating RP FT Elimination of symtc toms; patient RP is effectivehistory of repeating rituals of relapsed 2 mo a er discharge;unknown dur ation part ial reduction in symproms

with RP

Hallam, 1974 IS-yr-old hospitalized female CR 9 mo after admission, PS and FT "Marked reduction in symptoms.. RP is effectivewith 3-yr history of S mo RP/EXT incompulsive reassurance seeking hospital

Friedmann and Silvers, 18-yr-old male with counting CR SAT? SST "M inimal rituals" Combination treatments are1977 and repeating rituals TS FT necessary

ORO

Yamagami, 1978 l S-yr-old hospitalized male with SC Graded RP Medication and PS Fear and rituals decreased with RP is effective3-yr history of contamination FL were not helpful application of RP; extinction offears and washing rituals OP fear sometimes lagged reduction in

rituals~

>- Ong and Leng, 1979 13-yr-old Chinese female with CR ElRP Diazepam Partial reduction in symJ.toms at 6 E/RP is effective3:: 6-mo history of contamination FL FT mo; relapse at 2 yr e ecrively

>- fears and washing rituals treated with CBT()

Green, 1980 I S-yr-old male with l -yr history SC OP MEDS Marked reduct ion in symproms at 6 CBT package is effective>-tJ of checking, touching, and SAT wk with benefit maint ained for 3() repeating rituals RP mo::r: Stanley, 1980 8-yr-old female with 6-mo CR RP followed by None Elimination of OC symptoms in 2 RP is effectiver- history of repeating rituals graded E/ RP wk with no return at 6 motJ

>- Hafner et al., 1981 l S-yr-old male with 7-yr history CR E/RP FT Marked reduction in OCD FT is beneficial, although processtJ of multiple rituals related to EXT symptoms associated with leadinJ, to improvement needs0r- contamination fears involving improvement in family clear efinition

'" his sister functioningV>()

Kellerman, 1981 12-yr-old male with "matricidal CR IS Hypnosis Elimination of symptoms in 6 Hypnosis augments CBT..,obsessions" SAT sessions over 10 wk with noV>

-< Parent al RP? recurrence at 2 yr()

::r: Clark, 1982 13-yr-old hospitalized male with SC Promp ting. shaping, MT Improved self-care behaviors in some CBT is temporarily beneficial:;-l S-yr history of primary pacing, modeling. but not all self-care tasks; fading

'" obsessional slowness fading produced prompt relapse.:-<

Dalton, 1983 9-yr-old male with washing and CR EXT FT as primary No symptoms at l- yr posttr eatment FT is beneficial\.»"'- checking rituals ORO treatment

RP

'> OPZ O'Connor, 1983 l O-yr-old male with 6-mo history CR EXT FT as primary No symptoms at conclusion of Systemic FT is effectivec>- of reassurance seeking SAT treatment treatment

'" ORO-<- Ownby, 1983 13-yr-old male with 3-mo history CR IS Elimination of symptoms over 12 CBT is effective<c<c of contamination fears and RP wk with no recurrence 16 moV>

washing and grooming rituals later

Zik

is,

1983

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mal

ew

ith6-

yrC

RE

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Eli

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ptom

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ple

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ions

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her

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1988

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tipl

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rent

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mpt

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ofO

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Fran

cis,

1988

lI-y

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dm

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with

aggr

essi

veC

SE

XT

Eli

min

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nof

sym

ptom

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nis

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Har

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1992

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dm

ultip

leri

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Mar

chet

aI.,

1994

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char

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DS

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ked

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with

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low

rela

pse

rate

s;su

cces

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scon

tinu

atio

n

Not

e:C

BT

=co

gniti

ve-b

ehav

iora

lps

ycho

ther

apy;

OC

D=

obse

ssiv

e-co

mpu

lsiv

edi

sord

er;

CR

=ca

sere

port

;SC

=si

ngle

case

stud

y;R

P=

resp

onse

prev

enti

on;

EX

P=

expo

sure

;FL

=fl

oodi

ng;

E/R

P=

-ex

posu

rean

dre

spon

sepr

even

tion;

EX

T=

extin

ctio

n;A

MT

=an

xiet

ym

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emen

ttr

aini

ng;

OP

=op

eran

tte

chni

ques

;SS

T=

soci

alsk

ills

trai

ning

;C

T=

cogn

itive

ther

apy;

TS

=th

ough

tst

oppi

ng;

-SA

T=

satia

tion;

HR

=ha

bit

reve

rsal

;O

RO

=di

ffer

entia

lre

info

rcem

ent

ofot

her

beha

vior

;PS

=ps

ycho

ther

apy;

MT

=m

ilieu

ther

apy;

FT=

fam

ilyth

erap

y;M

ED

S=

med

icar

ions

.

MARCH

treat adolescents with OCD (Bolton and Turner, 1984;Harris and Wiebe, 1992), young persons with OCDunderstandably abhor "therapeutic" surprises (Lenane,1989), and the intensity of miscalculated exposure isalmost alwayssurprising and aversive. Stated differently,a therapist's idea about what constitutes an appropriateE/RP target may not match the child's with respectto motivation to resist OCD or ability to tolerateanxiety. Thus what appears to be graded exposure tothe therapist may turn out to be flooding for the child.Failure in an exposure task generally reinforces anxiety,and not infrequently disrupts the therapeutic relation­ship. For this reason, Harris and Weibe (1992) recom­mended that young persons with OCD receive gradedE/RP, with targets for both under control of the patient.They did not, however, specify how the therapist canhelp patients choose appropriate E/RP targets. Werecently proposed using cartographic and story meta­phors to negotiate just such a mechanism (j.S. Marchand K. Mulle, "How J Ran OCD Off My Land''®:A Cognitive-Behavioral Program [or the Treatment ofObsessive-Compulsive Disorder in Children and Adoles­cents, unpublished) and demonstrated the effectivenessof this approach in a series of 15 patients (Marchet al., 1994).

Response Prevention. The response prevention princi­ple states that adequate exposure depends on blockingrituals or avoidance behaviors (Dar and Greist, 1992).Thus a child with contamination fears must not onlytouch "contaminated" objects but must refrain fromritualized washing until his or her anxiety attenuates.Since many phobic stimuli occur naturally throughoutthe day, response prevention targets can be selectedindependently of contrived exposure targets under theassumption that the child cannot avoid exposure. Forexample, a boy with doorway balancing rituals willinvariably need to go through doors. Not avoidingdoors, or refraining from executing balancing ritualsas he proceeds through them, is an example of anoncontrived response prevention strategy. Twenty-sixof the 32 investigations successfully used responseprevention (see Mills et al., 1973, for example). Ofthose that did not, some involved an OCD subtype,such as obsessional slowness, for which response preven­tion is not indicated or is difficult to implement. Mostinvestigations failed to explicitly separate exposure fromresponse prevention; many failed to distinguish re­sponse prevention selected voluntarily by the child

12

from that enforced by parents or hospital staff. Bothcan be effective, but the level of short-term distressand oppositional behavior associated with the latterstrategy is virtually always higher. In addition, it isoften difficult to train parents to interrupt or preventrituals, and constant supervision, necessary to preventsurreptitious washing, for example, is difficult to imple­ment outside hospital settings.

Extinction. Technically, response prevention is anextinction procedure, since blocking rituals or avoid­ance behaviors removes the negative reinforcementeffect of the rituals or avoidance. However, adoptingthe convention that exists in the literature, extinctionis defined here as the elimination of OCD-relatedbehaviors through removal of parental positive rein­forcement. For example, parents may reduce OC symp­toms by systematically ignoring compulsive reassuranceseeking (Hallam, 1974). Extinction often producesrapid effects and is readily monitored. On the otherhand, extinction (especially ignoring) is difficult toimplement when the child's behavior is bizarre or whenthe behaviors are frequent. Like response prevention,extinction can be effected with (or more commonlywithout) the child's consent. For example, Francis usedextinction to successfully treat an l l-year-old boy withaggressive obsessions and compulsive reassurance seek­ing (Francis, 1988). As with E/RP, we found thatplacing extinction targets under the child's controlled to increased compliance and improved outcomes(March et al., 1994).

Anxiety Management Strategies

Packaged anxiety management trammg (AMT) isan effective treatment for children with generalizedanxiety (Kendall, 1991), but has not yet been testedempirically in children and adolescents with OCD. Inadults, AMT is ineffective for OCD and has been usedas an active placebo (Marks, 1987). However, childrenwith OCD often have other anxiety disorders (Flamentet al., 1988), and AMT could benefit patients bytargeting comorbid conditions that might interfere withOCD treatment. Moreover, studies in adults haveshown that the level of anxiety during exposure isless important than exposure duration and consequentattenuation of anxiety (Marks, 1987). Thus AMT alsomay facilitate exposure through reducing the amplitudeof exposure-related anxiety (March et al., 1994).

J. AM. ACAD. CHILD ADOLESC. PSYCHIATRY, 34:1, JANUARY 1995

Relaxation and Breathing Training. Progressive mu s­cle relaxation and diaphragmatic breathing train inghave been successfully applied to child ren and ado les­cents with separation anxiety and overanxious disord ers(Kendall, 1991 ; T hyer , 199 1). Several of 32 investiga­tions mentioned relaxat ion , but only one specificallyimpl emented progressive muscl e relaxation or breathingtra ining (March et al., 1994) , and the role of thesestrategies in trea ting childre n and ado lescents withOCD remains un certa in.

Cognitive Therapies. Cognitive the rap ies for O CDinclude techniqu es based both in exposure, such assatiation, and in anxiety management, such as thoughtsto pping or cognitive restr uctu ring (N eziroglu andN eum an, 1990). Satiation is a form of massed pract icein which patient s repeat the ir obsessions vocally orin writing to induce exposure. Before impl ementingsatia tion, it is impor tant to distinguish obsessions fromment al ritu als that are appropriate targets for responseprevention. Satiation typically has been applied to

patients with primary obsessional O C D, and 6 ofthe 32 investiga tions successfully applied satiation to"obsessional" patients . Adjunctive hypn osis provedhelp ful in implementing satiation in a boy with aggres­sive obsessions (T aylor, 1985 ). In cont rast to satiationprocedures, which exaggerate obsessions, two investiga­tions formally used thought stopping- a techniquedesigned to interrupt rather than to challenge obses­sions-to treat obsessional adolescents (Ca m pbell,1973; Kellerma n, 198 1). As part of a multico mponentapproach to OCD treatm ent, thought stopping mayenable E/RP in some patients (Ma rch et aI., 1994). Incogn itive restructuring, the therap ist helps the pat ientdirectly challenge the reality of obsessions and thenecessity of compulsions (Emmelkamp and Beens,1991 ). Kearney and Silverma n used expos ure andrational em ot ive therapy to treat rituals and obsessions,respectively, in a single-subject, alternating-weeks de­sign. Exposure primarily reduced rituals; rat ional emo­tive therapy reduced obsessions (Kearney andSilverman, 1990 ). In our preliminary case series, cogni­tive restruc turing in the form of " bossing back O CD"seemed to benefi t patients primarily by facilitati ngcompliance with E/RP (March et al., 1994). Thusit remains unclear whether cogn itive therapy simpl yenco urages exposure or provides dir ect antio bses­sion al effeers.

J. A M . ACAD . C H I l. D AD O l. ESc:. PSYCHI AT RY, 34 : 1, JANUARY 19 9 5

C OGN IT IV E-BE H AV I O RA L T REAT M EN T OF Oe D

Habit Reversal. N egative affects, such as anxiety,guilt, or disgust , predict com pulsions, such as washin gin response to conta mination fears, that respond nicelyto E/RP. No t all OC symptoms involve negative affects,however. Some O CD pat ients, particularly those onthe boun dary with the tic disorders, exhibit "sensoryincompleteness"-the feeling that an act ion has to becompleted "enough" or "just so"-often accompaniedby stereorypic repeating rituals (Rasmussen and Eisen ,1992). For those pat ient s in who m O CD resembl es acomplex tic-like repeating ritual, habi t reversal proce­dures, such as those descr ibed for trichot illom an ia orT ou rette's syndrome (Baer, 1992; Vitulano et al.,1992), can sometimes be help ful alone or in combina­tion with response prevent ion. In habit reversal, patientsand their fami lies are taught thought stopping, visual­ization , relaxation, competing motoric responses, andrelapse prevention stra tegies. Although habit reversalis in wide use in subspecialty clinic anxiety programs,habit reversal procedures have received little empiricalattent ion in children or adolescents with OCD. Cli nica lexper ience suggests that habit reversal like E/ RP is lesspromising for tic disorders, which may be driven in partby abnormal processing of sensori motor infor mation(Kane, 1994; Leckma n er al., 1993) , than for symptomconstellations, such as trichotillomania (Swedo, 1993),that more closely resemble OCD.

Operant and Related Procedures

Operant Techniques. O perant proced ures are in the­ory defined by their effects. In clinical practice, however ,operant techniques reduce to the appli cation of rewardsand punishm ents plus negative reinforcement. Sincethere is no em pirical or clin ical sup port for the prop osi­tion that positive reinforcement affects OCD symptomsdirectly, many investigations used positive reinforce ­ment on an adju nctive basis to encourage exposure.For example, we rou tinely use pr izes for compl etingexposure tasks and reward ceremonies for masteringimp ortant steps along the way to eliminatin g OCD(March et al., 1994). Taking the opposite tack, severalinvest igat ions attem pted to impleme nt punishme nt(imposition of an aversive event) or response -cost (re­moval of a positive event ) procedures. Altho ugh onereport "showed" a reduction in OCD symptoms usingresponse-cost in the form of reducing privileges (Apteret al., 1984; see Lyon, 1983, for a similar example),methodological problems, the absence of replication,

13

MARCH

and abundant clinical evidence that punishment in­creases resistance to treatment preclude endorsementof aversive techniques for children and adolescents withOCD. Finally, none of the cited investigations usednegative reinforcement procedures, defined here as theremoval of an aversive event in order to increase adesired behavior. However, OCD is itself a negativereinforcer, so that a reduction in presumably aversiveOCD symptoms through spontaneous or planned ex­posure should produce an increase in adaptive E/RP.Consistent with this idea, Flament et al. noted thatchildren from the NIMH cohort who did well seemedto have spontaneously discovered saying "no" to OCD(Flament et al., 1990). As part of negotiating gradedexposure, we explicitly use the negative reinforcementvalue of OCD to encourage compliance with treatment(March et al., 1994).

Modeling and Shaping. Modeling, defined as demon­strating more appropriate or adaptive behaviors, isfrequently used during therapist-assisted exposure.Modeling can be overt (the child understands that thetherapist is providing a demonstration) or covert (thetherapist informally models a behavior). Closely relatedto modeling, shaping consists of positively reinforcingsuccessive approximations to a target behavior. Forexample, an AIDS-phobic child might be reinforcedfor coming closer and closer to an HIV-positive personbefore finally shaking hands (shaping/exposure), anaction that the child has seen the therapist take withoutharm on previous occasions (modeling). With childpatients, modeling helps reduce anticipatory anxietyas well as providing an opportunity for cognitive strate­gizing in the form of constructive self-talk (Thyer,1991). Obsessional slowness may represent a specificindication for modeling and shaping procedures sinceexposure has proven less useful than shaping proceduresin this population (Ratnasuriya et al., 1991). Clinically,children with primary obsessional slowness generallyrespond poorly to both behavioral and pharmacologicalinterventions, often relapsing when therapist-assistedshaping, limit setting, and temporal speeding proce­dures are withdrawn (Wolff and Rapoport, 1988). Andalthough Clark successfully used shaping proceduresto treat a 13-year-old boy with obsessional slowness(Clark, 1982), most clinicians and researchers agreethat this subtype is ripe for cognitive-behavioral innova­tion in both adults and youth (March et al., 1990a).

14

Diffirential Reinforcement of Other Behaviors andOvercorrection. Differential reinforcement of other be­haviors (ORO) depends on extinction (systematicallyignoring problem behaviors) while simultaneously rein­forcing more adaptive behaviors. Overcorrection in­volves substitution via massed practice of a moreadaptive for a less adaptive behavior in the same domainof functioning. In OCD, for example, a parent mightignore reassurance seeking around contaminationthemes (extinction) while paying more attention toschoolwork (ORO) and emphasizing a greater fre­quency of chores involving appropriate cleaning (over­correction). Both ORO and overcorrection implicitlyfoster response prevention. Of the cited investigations,the family therapy-oriented investigations in particularfavored ORO or overcorrection, although none de­scribed the interventions in behavioral terminology,and no study empirically validated either procedure.

Nonbehavioral Psychotherapeutic Techniques

A variety of psychotherapeutic techniques, not sys­tematically applied or conceptually linked, have beenbrought to bear on children and adolescents withOCD. Examples include individual and group psycho­therapies, hypnosis, and family therapy. Some, such asO'Connor's (1983) family treatment of OCD, containunacknowledged behavioral components. Others ex­plicitly combine treatment approaches. For example,Kellerman used hypnosis to implement thought stop­ping and E/RP to treat matricidal obsessions in a 12­year-old boy (Kellerman, 1981); we routinely use storymetaphors (White and Epston, 1990), like giving OCDa "nasty nickname" against which the child can dobattle, to support cognitive-behavioral interventions(March etal., 1994).

Individual and Group Psychotherapy. As it has inadults (Esman, 1989), psychodynamic psychotherapyhas proven disappointing as a treatment for OCD inchildren and adolescents (Hollingsworth et al., 1980).Nevertheless, many investigations included supportiveor psychodynamic psychotherapy as part of the treat­ment package. Often these interventions seemed aimedat increasing compliance with E/RP or at comorbidconditions, particularly personality dysfunction. Forexample, Apter et al. (1984) reported that their hospital­ized adolescent patients refused behavior therapy, butgot better with supportive psychotherapy and ward

J. AM. ACAD. CHILD ADOLESC. PSYCHIATRY, 34:1, JANUARY 1995

milieu therapy, suggesting that these additional mea­sures permitted implicit if not explicit application ofexposure-based treatments. Clinically, long-standingOCD often damages self-esteem and interferes withpeer relationships. Thus insight-oriented psychotherapymay become more important as the effects of OCDrecede with successful treatment. Social skills trainingalso may playa role in selected patients with OCD,especially those with comorbid nonverbal learning disa­bilities that interfere with the pragmatics of social­emotional communication (March et aI., 1990b;Voeller, 1990).

Family Therapy. While OCD is substantially herita­ble (Lenane et aI., 1990; Riddle er aI., 1990), familydysfunction is neither sufficient nor necessary clinicallyfor the genesis of OCD (Lenane, 1989). Nevertheless,families affect and are affected by the disorder. Typicalconcerns include parental or sibling involvement inrituals, difficulty dealing with sexual or aggressive obses­sions, and differences ofopinion about how to deal withOCD symptoms. As in schizophrenia, high "expressedemotion" in families may exacerbate OCD in affectedfamily members (Hibbs et aI., 1991). Moreover, OCDfrequently unsettles social and community interactions,including those with health care professionals who mayor may not understand the disorder (Hand, 1988).Thirteen of the 32 investigations cited here includedexplicit family interventions as part of treatment forOCD. While these interventions frequently focusedon implementing extinction or response preventionprocedures, several adopted systemic family therapyapproaches where OCD represented a metaphor forfamily dysfunction (Dalton, 1983; O'Connor, 1983).These investigations tended to encourage E/RP as a"paradoxical intervention," making it impossible todetermine how or whether the family interventionadded to conventional if implicit cognitive-behavioralapproaches. Until future research establishes a preferredcontext, CBT for OCD can be administered in anindividual or family setting, depending on the needsof the child. For most patients, the combination ofindividual sessions plus focused family work will provebest (March et al., 1994). Family therapy or maritalcounseling should be recommended as part of thechild 's treatment for OCD only if family dysfunctionor marital discord represents a constraint to the applica­tion of treatments directed specifically at OCD.

J . AM . ACAD . CHILD ADOLESC . PSYCHIATRY, 34:1, JANUARY 1995

COGNITIVE-BEHAVIORAL TREATMENT OF OCD

CONCLUSION

Abundant clinical and emerging empirical evidencesuggests that CBT, alone or in combination withpharmacotherapy, is an effective treatment for OCDin children and adolescents. Unlike other psychothera­peutic techniques that have been applied to OCD,CBT presents a logically consistent and compellingrelationship between the disorder, the treatment, andthe specified outcome. Moreover , the empirical litera­ture shows no support for the now discredited mythsofsymptom substitution, danger of interrupting rituals,uniformity of learned symptoms, and incompatibilitywith pharmacotherapy (Baer, 1992). And as Baer alsopoints out, CBT neither ignores thoughts nor discountsmeaning (Baer, 1992), although OCD symptomsthemselves perhaps are best seen as CNS hiccups devoidof intrinsic meaning. Finally, CBT is not simplistic.Helping patients make rapid and difficult behaviorchange over short time intervals takes considerable skillcoupled to highly focused treatment.

Ideally, young persons with OCD should first receiveCBT, and if not rapidly responsive, or if experiencingmarked depression, a selectiveserotonin reuptake inhib­itor . However, some physicians and their patients willprefer to begin with CBT in hopes of avoiding theneed for medication and the side effects that mayaccompany pharmacotherapy. Others will choose medi­cation first, trying to avoid the time, effort, expense,and anxiety associated with cognitive-behavioral inter­ventions. Still others will prefer to combine the twoapproaches.

Clinically, pharmacotherapy and CBT work welltogether, and many children with OCD likely requireor would benefit from pharmacotherapy (Rapoportet al., 1992). In our CBT caseseries, where the majorityof subjects also were treated with medication (Marchet aI., 1994), the average magnitude of improvementwas larger and relapse rates were lower than usuallyseen with medication alone (DeVeaugh et aI., 1992;Leonard et aI., 1989). Thus concurrent CBT, includingbooster treatments during medication discontinuation,may improve both short- and long-term outcome inmedication-responsive patients, including those forwhom ongoing pharmacotherapy proves necessary (Le­onard et aI., 1993).

It should be emphasized, however, that empiricaldocumentation regarding the efficacy of CBT in child

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subjects with OCD remains weak, especially whencontrasted with the robust empirical evidence favoringpharmacotherapy (Rapoport et al., 1992). For themost part, currently published investigations fail to (1)adequately define and assess inclusion/exclusion criteria,OCD symptoms, functional impairment, and com or­bid conditions; (2) apply reliable and valid measures oftreatment outcome that cross symptom and functionaldomains; (3) assess subjects pretreatment, posttreat­ment, and at follow-up; (4) use distinct levels of assess­ment, including, for example, neuroimaging,psychophysiology, behavior, and family methodologies;and (5) implement contrasting group designs, usingrandomized assignment or carefully specified single­subject designs. Moreover, only recently has the applica­tion ofCBT to OCD in young persons been adequatelydocumented in a treatment manual (March et al.,1994); thus replication studies and the exportation ofsuccessful techniques to clinical settings have beenimpeded.

Given these caveats, the following treatment recom­mendations regarding implementation of CBT foryoung persons with OCD currently seem reasonable(March and Mulle, in press; March et al., 1994; Wolffand Rapoport, 1988):

• It is generally preferable to describe OCD in amedical context, that is as a neurobehavioral disordet,

and not as a bad habit.• Giving OeD a "nasty nickname" against which the

child can do battle helps keeps the focus on OCDas the identified problem.

• In most subtypes of OCD, graded E/RP is thefoundation of treatment.

• With the admonition that the child must makeprogress, the choice of E/RP targets IS best left tothe child.

• Implementing AMT as a "tool kit" to use duringE/RP improves compliance with E/RP.

• While the focus of treatment must be on the child'sstruggle with OCD, involving family members inthe treatment process frequently is essential to a

satisfactory outcome.• Many, if not most, patients will require or would

benefit from concurrent pharmacotherapy with aserotonin reuptake inhibitor.

Future research in this area will need to focus onthe following areas. First, controlled trials comparing

16

medications, behavior therapy, and combination treat­ment to controls are necessary to determine whethermedications and behavior therapy are synergistic oradditive in their effects on symptom reduction. Second,follow-up studies will be necessary to evaluate the long­term benefit of CBT, including examining whetherbooster CBT reduces relapse rates in patients discontin­uing medications. Third, dismantling strategies arenecessary to examine the relative contributions of

specific treatment components to symptom reductionand treatment acceptability. A comparison of E/RP,anxiety management, and combination treatment is a

logical starting point. Fourth, CBT can be administeredas an individual- or family-based treatment, and com­parison of these two approaches will be necessary todetermine which is more effective in which children.Fifth, OCD subtypes, such as obsessional slowness,

primary obsessional OCD, and tic-like OCD, bedevilthe field and are ripe for behavioral innovation. Sixth,other putative predictors of treatment resistance, suchas nonverbal learning disabilities (March et al., 1990b)or family dysfunction (Hand, 1988), need to be exam­ined vis-a-vis their interactions with behavioral treat­ments. Finally, the application of protocol-driventreatments to different patient populations should in­crease generalizibility of results as well as provide arationale for exporting research-based treatments intoclinical settings to the benefit of children and adoles­cents with OeD.

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Call for Submissions

The new Clinical Perspectives Section of the Journal reflects an attempt to acknowledge for­mally the value of clinical observations, perspectives, wisdom, guidelines, and pearls.Submissions should be short (750 to 1,500 words), concise, clear, pithy, and focused.Clinical Perspectives reflects the Journal's continuing attempt to provide the latest informa­tion for clinical practice in addition to building a knowledge base for the field grounded onformal research. We encourage questions, comments, and submissions sent to MichaelJellinek, M. D., Assistant Editor, Clin ical Perspectives, Massachusetts General Hosp ital, 15Parkman Street-ACC 725, Boston, MA 02 114.

18 J . AM, AC AD , C H I LD AD O LESC. PSY C H IATRY, 34 : 1, JANU ARY 1995