Cognitive behavioral therapy helps children with obsessive-compulsive disorder

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"When CBT is combined with medication, treatment is more effective than medication alone. Health professionals need to consider this therapy - particularly in view of the controversy about prescribing psychotropic medications to children and teens," said O'Kearney, director of clinical training for psychology at the Australian National University, in Canberra.

This review appears in the October 18 issue of The Cochrane Library, a publication of The Cochrane Collaboration, an international organization that evaluates research in all aspects of health care. Systematic reviews draw evidence-based conclusions about medical practice after considering both the content and quality of existing medical trials on a topic.

OCD is can start at a very early age - review participants were as young as 7 years old. The disorder affects an estimated 0.5 percent to 4 percent of children and adolescents.

"Symptoms include repeated hand washing, checking behaviors, orderliness and various rituals that are not age-appropriate," O'Kearney said. "Children with OCD can also show generally high levels of anxiety that is managed by the need to perform particular behaviors. These children may be frustrated if their rituals are interrupted. In children, however, the compulsions are sometimes not experienced as distressing to carry out."

But in the big picture, OCD is often associated with significant disruption and impairment of the child's family, social and academic life, and it can impact psychosocial development. Children and teens who struggle with this problem also have heightened risk for clinically significant psychiatric and psychosocial problems as adults.

Cognitive behavioral therapy, which has been shown to work for adults, now appears to benefit children as well. The treatment includes a variety of techniques to help children challenge some of their unhelpful thoughts about threat, danger or the importance of controlling thoughts.

Exposure with response prevention technique is a core aspect of contemporary CBT treatment. Children with compulsive washing, for example, would be required in a graded way to touch objects that they fear lead to contamination, and prevent the washing, which neutralizes their fear.

O'Kearney said he was surprised to find so few high-quality studies that evaluated the effectiveness of pediatric CBT. The final review comprised four studies of randomized controlled trials or quasi-randomized trials, and three of these suggested at least some risk of bias.

In all, the studies looked at 222 children and adolescents ranging in age from 7 to 18 years, with about an equal number of boys and girls. The participants were Australian, Dutch or American. CBT interventions ranged from 12 hours to 30 hours.

There was no direct assessment of negative effects in these CBT studies, which were funded entirely by The Australian National University. The low drop-out rate of participants suggests that CBT may have been an acceptable approach to families involved, the researchers say.

Carol A. Mathews, M.D., with the department of psychiatry at the University of California, San Francisco, called the systematic review "excellent" and said it represents an important step forward in the understanding of the effectiveness of various types of treatment for pediatric OCD. Pediatric OCD is frequently underdiagnosed and undertreated, she said, and this could be because of limited treatment options parents have for their children.

"This study shows convincingly that CBT is superior to placebo, not only in reducing the number of OCD symptoms, but also in effecting remission in many cases. The study also shows that CBT plus medication is more effective than medication alone in children - an important confirmation of what has been believed clinically, but never proven," said Mathews, who was not involved with the study.

"The results of this paper provide clinicians and parents with an additional effective treatment option - CBT or CBT plus medication - a treatment that involves only about 14 to 21 hours, in general," Mathews said.

"Probably the most important issue related to our findings is that while the evidence suggests that CBT is as effective as medication, relatively few children and adolescents get CBT treatment," O'Kearney said. "Part of this is because of access and part is because primary care doctors often prescribe medicine before they refer patients to CBT. Hopefully this review will make them think more about this practice."

O'Kearney said that although attempts have been made to use telephone and computer-assisted delivery to increase access, "overall, there need to be more trained CBT therapists skilled in treating pediatric OCD."

Center for the Advancement of Health