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The present chapter summarizes our current knowledge of obsessive compulsive disorder (OCD) in children and adolescents. The review begins with coverage on the nature of OCD such as the prevalence, age of onset, comorbidity and course and outcome. Following a brief discussion of the key challenges in assessing OCD, it then moves to systematic description of some etiological models, including biological/genetic, autoimmune model, neurochemical model, and key individual, family, and social factors influencing risk and resiliency. The subsequent part of the review describes evidence-base treatment strategies and efficacy, and factors that have been reported to influence treatment outcome. The review concludes with brief discussion on the recommendations for best practice when working with children and adolescents with OCD.
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T.P. Gullotta et al. (eds.), Handbook of Adolescent Behavioral Problems: Evidence-Based
Approaches to Prevention and Treatment, DOI 10.1007/978-1-4899-7497-6_13,
© Springer Science+Business Media New York 2015
Introduction
Obsessive-compulsive disorder (OCD) is one of
the most debilitating disorders which commonly
emerge during childhood and adolescence
(Pauls, Alsobrook, Goodman, Rasmussen, &
Leckman, 1995 ). As reported by the World
Health Organization ( 2000 ), OCD is among the
top ten causes of disability worldwide. OCD
was previously thought as rare in children and
adolescents, but recent epidemiological studies
have estimated that between 1 and 4 % of young
people in the general population are affected by
this disorder. However, these prevalence rates
may be an underestimation because OCD often
goes undetected (Flament et al., 1988 ) or mis-
diagnosed (Chowdhury, Frampton, & Heyman,
2004 ). OCD is associated with signifi cant dis-
tress and impairment in family, social, and
academic functioning (Piacentini, Bergman,
Keller, & McCracken, 2003 ). If left untreated,
OCD that begins early in life tends to be chronic
and disrupt social, education and emotional
development (Laidlaw, Fallon, Barnfather, &
Coverdale, 1999 ).
As the name implies, OCD comprises two
main components: obsessions and compulsions.
Obsessions are recurrent, unwanted and intru-
sive thoughts or images which cause signifi cant
anxiety or distress. Because of the intrusiveness
and unpleasant nature of its contents, obsessions
are often considered as “ego-dystonic” (Riggs &
Foa, 1993 ). Obsessions are accompanied by feel-
ings of intense anxiety, distress and feelings of
catastrophe, leading to repetitive behaviour (i.e.,
compulsions) which is aimed at neutralizing and
reducing anxiety or sense of perceived threat.
Core features of obsessions are (a) recurrent and
persistent thoughts, urges or images, which are
experienced as intrusive and unwanted; (b) the
individual attempts to ignore or suppress these
thoughts, urges or images, or to neutralize them
with other thought or action (i.e., compulsions).
Compulsions are repetitive behaviour (e.g., hand
washing) or mental acts (e.g., counting) which
are performed to respond to an obsession, and
are to prevent or reduce anxiety or distress, or
to prevent the occurrence of a dreaded event.
These behaviours or mental acts are not logi-
cally related to what they are meant to neutral-
ize or prevent, or are excessive. It is this cycle
of compulsion in response to obsession which
C. A. Essau , Ph.D., C.Psychol., F.B.Ps.S. (*)
Department of Psychology , University of Roehampton,
Whitelands College , Holybourne Avenue , London , UK
e-mail: C.Essau@roehampton.ac.uk
B. U. Ozer , Ph.D.
Psychological Counselling and Guidance , University
of Bahcesehir, Department of Educational Sciences ,
34353 Istanbul , Turkey
e-mail: blguzun@gmail.com
13
Obsessive-Compulsive Disorder
Cecilia A. Essau and Bilge Uzun Ozer
236
could cause a negative reinforcement (as it tem-
porarily reduces anxiety) which maintains OCD
symptoms.
Several changes have taken place in the classi-
cation of OCD in DSM-5 (American Psychiatric
Association [APA] 2013 ). First, OCD was clas-
sifi ed in DSM-III to DSM-IV-TR under anxi-
ety disorders. In DSM-5, OCD is included in a
chapter on obsessive-compulsive and related dis-
orders because of the relatedness of these disor-
ders in terms of their diagnostic validators (e.g.,
symptoms, neurobiological substrates, familiar-
ity, course of illness and treatment response),
similarities in clinical features (e.g., repetitive
behaviours) and clinical utility. It was further
argued that it is the obsessions and compulsions,
and not anxiety which form the main feature of
OCD (Stein et al., 2010 ). It is also unclear as to
the extent to which anxiety in OCD is the result
of obsessions or compulsions (Nutt & Malizia,
2006 ). The removal of OCD from the anxiety
disorders category is not without controversy.
Several authors argued that OCD should not be
removed from anxiety disorder category because
of its high comorbidity rates with various types
of anxiety disorders, and that they respond to
the same treatment. Second, in order to have a
more precise defi nition of obsession, the term
“impulses” has been replaced by “urges”. Third,
unlike the earlier versions of DSM which include
some insights that obsessions and compulsions
are excessive or unreasonable is one of the cri-
teria for the diagnosis of OCD, in DSM-5, hav-
ing insight is the basis for specifi ers. These
three specifi ers are “good or fair insight”, “poor
insight”, and “absent insight/delusional beliefs”.
DSM-5 also has a tic-related specifi er.
For the OCD diagnosis to be made in DSM-5
(APA, 2013 ), the following criteria must be
made: (a) the presence of obsessions, compul-
sions, or both; (b) obsessions or compulsions are
time-consuming (i.e., it takes at least one hour
a day), or cause signifi cant distress or impair-
ment in important areas of functioning such
as in social and occupational domains; (c) the
obsessive- compulsive symptoms are not attribut-
able to the physiological effects of a substance or
another medical conditions; (d) The disturbance
is not better explained by symptoms of other
mental disorders.
The same criteria of OCD can be applied to
children, adolescents and adults. The only crite-
rion which has been adjusted to young children is
related to their inability to articulate the aim of
their repetitive behaviour or mental acts.
Prevalence, Age of Onset
and Comorbidity
Epidemiological studies have estimated OCD to
affect 2–4 % of adolescents and 1 % of children
in the general population, making it to be one of
the most common psychiatric disorders affecting
individuals in these age groups (Essau, Conradt, &
Petermann, 2000 ; Rapoport et al., 2000 ; Valleni-
Basile et al., 1994 , 1996 ; Zohar, 1999 ). However,
these rates may be underestimated because OCD
is often undetected due to young people’s ten-
dency to be secretive of their intrusive thoughts
and repetitive behaviour (Cameron, 2007 ) and
to parent’s diffi culty in recognizing OCD symp-
toms. In clinical setting, it may be related to the
lack of recognition by the professional due to
the diversity of presenting OCD symptoms and
a failure to include assessment tool to screen for
OCD (Rasmussen & Eisen, 1990 ).
The prevalence of OCD has been reported to
vary across gender and age groups. Specifi cally,
at prepubertal years, signifi cantly more boys than
girls are affected by OCD, with boys to girls ratio
being 3:2. During adolescence, this gender differ-
ence tends to disappear (Geller et al., 1998 ;
Rasmussen & Eisen, 1992 ).
Although the content of obsession and com-
pulsions differs across individuals and age
groups, certain themes seem to be common such
as those related to cleaning, symmetry, forbidden
thoughts and harm (APA, 2013 ). Among young
children, the most common obsessive themes are
that of contamination, exactness and symmetry
(Geller et al., 1998 ; Masi et al., 2005 ; Swedo,
Rapoport, Leonard, Lenane, & Cheslow, 1989 ),
and the most common compulsions are ordering,
checking, hoarding, repeating and reassurance
seeking (Masi et al., 2005 ; Swedo et al., 1989 ).
C.A. Essau and B.U. Ozer
237
Among older children and adolescents, the most
common obsessions are fear of contamination,
harm to signifi cant others, self-preoccupation
with lucky and unlucky numbers or thoughts with
sexual or religious content (Thomsen, 1999 ); the
most common compulsions are cleaning rituals
(e.g., washing), checking, counting, straighten-
ing, touching, hoarding (Masi et al., 2005 ; Swedo
et al., 1989 ), silent prayers or counting (Franklin
et al., 1998 ). Although children and adolescents
present with obsession and compulsion, young
children tend to report only compulsion due to
their cognitive development and their ability to
identify and express their thoughts (Wever &
Rey, 1997 ). DSM-5 recognizes this developmen-
tal difference by stating that children may be
unable to describe the intention of behaviour or
mental acts.
OCD has an early onset, with up to 80 % of
adults with OCD reported the occurrence of their
rst OCD symptoms before the age of 18 years
(Pauls et al., 1995 ). Other studies among adults
reported the age of onset of OCD to be bimodal,
with the fi rst onset being in the puberty and the
second one in early adulthood (Geller et al.,
1998 ). Among studies in children and adoles-
cents, the mean age of onset for OCD is usually
about 10.4 years, with ages ranging from 6.9 to
12.5 years (Geller et al., 1998 ; Stewart et al.,
2004 ). OCD is associated with a wide range of
impairment at various life domains. Children
with this disorder have signifi cant academic and
social diffi culties, as well as diffi culties in family
relations (Piacentini et al., 2003 ; Storch et al.,
2010 ). As reported in several studies, young peo-
ple with OCD have trouble making new friends
and keeping friends, or in having friends over at
their home either during day time or for sleeping
over (Storch et al., 2006 ; Valderhaug & Ivarsson,
2005 ). In most cases, these impairments are
directly related to the amount of time that these
young people spend in doing the rituals (American
Psychiatric Association, 2000 ). Severe forms of
OCD have also been linked to increased victim-
ization (Storch et al., 2006 ; Ye, Rice, & Storch,
2008 ). A recent study (Kim, Reynolds, & Alfano,
2012 ) indicated that children with OCD were less
socially competent and that they tend to be more
socially isolated and refrain from doing activities
where peers could see their OCD symptoms. This
is related to their concerned of being seen as odd
(Swedo et al., 1989 ).
Impairment was signifi cantly predicted by
severity of OCD and depressive symptoms, family
accommodation and insight (Storch et al., 2010 ).
Interestingly, some of these factors predicted
impairment in certain domains. Specifi cally,
poorer insight predicted impairment at home and
social activity, but not in school. It was argued that
children with higher compared to lower insight
were able to hide their rituals when they were
with friends and by doing so, their interpersonal
relationship was not impaired. In explaining for
the association between impairment and family
accommodation, the authors argued that family
involvement in their child’s ritual reinforced the
child’s behaviour and limit the child’s opportu-
nity to develop and apply problem-solving skills
to cope with anxiety- provoking situations. Of all
the OCD symptom dimensions, those related to
contamination/cleaning and aggressive/checking
were signifi cantly linked with impairment, pos-
sibly given the diffi culty in avoiding their triggers
(Storch et al., 2010 ).
In a study by Storch et al. ( 2008 ), children
with low insight were found to have more severe
OCD symptoms, more repeating compulsion,
more internalizing symptom and higher levels of
family accommodation. Lewin et al. ( 2010 )
recently examined the relationship between
insight and intellectual functioning and perceived
control among children and adolescents who
attended a community medical centre-based
OCD specialty program. Adolescents who had
low insight were found to have lower level of
intellectual functioning compared to those with
high insight. It was argued that these adolescents
who were more concrete in their thinking tend to
be more likely to believe that the “danger” are
experienced through obsessive beliefs is real
which in turn make them more likely to adhere to
their obsessive-compulsive beliefs.
OCD comorbid frequently with a wide range
of psychiatric disorders such as with anxiety,
depressive and eating disorders, tic disorder,
ADHD and conduct disorder (e.g., Langley,
13 Obsessive-Compulsive Disorder
238
Lewin, Bergman, Lee, & Piacentini, 2010 ; Storch
et al., 2010 ). As reported by Storch et al. ( 2008 ),
about 74 % of the young people with OCD also
met the criteria of one or more psychiatric disor-
ders. The comorbidity rates however vary across
studies due to methodological differences. For
example, in the Pediatric OCD treatment study
(2004), 80 % of the children had at least one psy-
chiatric comorbid disorders. In other clinical set-
tings, as high as 80 % of the youth with OCD has
been reported to have comorbid depressive disor-
ders and up to 70 % and 60 % have anxiety and
tic disorders, respectively (Flament et al., 1990 ;
Geller, Biederman, Griffi n, Jones, & Lefkowitz,
1996 ). The presence of comorbid disorder was
related to lower treatment response and lower
remission rates, and to higher relapse rates
(Geller et al., 2003 ; Storch et al., 2008 ).
Course and Outcome of OCD
OCD that begins in childhood tends to have a
chronic course (Geller, 2006 ) and is associated
with an increased risk for a wide range of psychi-
atric disorders in adulthood (Wewetzer et al.,
2001 ). The remission rates of those with a
childhood onset OCD have been reported to
range from 40 to 59 % (Stewart et al., 2004 ). Poor
long- term outcomes of OCD were associated by
an early age of onset, poor response to medica-
tion treatment, presence of comorbid tic disorder,
and an inpatient hospitalization for OCD (Masi
et al., 2010 ; Stewart et al., 2004 ).
Bolton, Luckie, and Steinberg ( 1995 ) exam-
ined the course of OCD among adolescents who
were treated for the disorder using family and
behaviour therapy. At a follow-up period of 9–14
years, the recovery rate was 57 %, which was also
associated with good social adjustment. None of
the adolescents who recovered were taking medi-
cation. In a recent study by Micali et al. ( 2010 ),
41 % of the children who received a diagnosis of
OCD still receive the same diagnosis at a 9-year
follow-up assessment. About 69.8 % of the par-
ticipants received a wide range of Axis I ICD-10
diagnosis at follow-up, with GAD (25–40 %)
being the most common, followed by depressive
disorders (15.9 %) and tic disorder (15.9 %).
Approximately 66.4 % of the participants did
receive professional help for their OCD since dis-
charge from the specialist clinic and half of them
are still receiving treatment; most of the treatment
was pharmacological in nature (42 %). Predictors
for the stability of OCD at follow-up was dura-
tion of OCD at baseline, while as the presence of
comorbid tourette syndrome or tics at baseline
reduces the risk of OCD persistence. In a study
by Bloch et al. ( 2009 ) about 44 % of the partici-
pants with a childhood onset OCD experienced
remission at a follow-up evaluation conducted
on average of 9 years later. About 60 % of the
patients continued to take SSRI and 31 % no lon-
ger using this medication. The presence of comor-
bid chronic tic disorder seemed to infl uence the
remission time. Specifi cally, 62 % of the patients
with childhood OCD with comorbid chronic tic
disorder, compared to 22 % of those without any
comorbid chronic tic disorder had remitted.
More recently, Fernández de la Cruz et al.
( 2013 ) examined the stability of OCD symptoms
in a group of paediatric from a clinical setting
who were examined twice over an average of 5
years. Findings indicated that 60 % of the par-
ticipants maintained their symptoms between
baseline and follow-up. Symptom categories that
were related to forbidden thoughts, hoarding and
symmetry remained stable, whereas aggressive
obsessions, cleaning and compulsions disap-
peared completely at follow-up. The strongest
predictor for the presence of symptom dimen-
sions at follow-up was the same dimension at
baseline. Overall, this fi nding showed that the
content of OCD symptoms were relatively stable.
Assessment
Assessing OCD in children and adolescents is
complicated because of the heterogeneity nature
of the disorder and the high comorbidity rates
between OCD and other psychiatric disorders. In
young children, this is further hampered by their
cognitive development. Some of the ritualistic
behaviour is part of normal development and as
such they tend to be self-limiting, rarely distressing,
C.A. Essau and B.U. Ozer
239
and tend to change with developmental stage.
As reported by Evans et al. ( 1997 ), some of the
ritualistic behaviour which fi rst appears includes
the need to arrange things “just right” or in sym-
metrical pattern. These behaviours generally
peak between the ages of two and fi ve (Evans &
Leckman, 2006 ), and are related to developmen-
tal milestones that involve mastery and control
(Gesell, 2007 ). These behaviours are followed by
concerned with dirt and germs, and the urge to
collect and store objects.
Therefore, having a reliable and valid instru-
ment for assessing OCD is crucial for both
research and clinical practice. Some of the most
commonly used instruments with their psycho-
metric properties are shown in Table 13.1 . Some
of these instruments have been developed to
screen for OCD, while others are used to estab-
lish symptom severity and treatment plan
(Overduin & Furnham, 2012 ).
Biological/Genetic factors
Family studies conducted over the past few
decades have reported the rates of OCD to be
signifi cantly higher in fi rst degree relatives of
patients with OCD than relatives of healthy con-
trols. For example, Hanna, Himle, Curtis, and
Gillespie ( 2005 ) compared the prevalence of
OCD among fi rst and second relatives of children
with OCD and healthy controls. The result
showed signifi cantly higher lifetime prevalence
of OCD among fi rst degree relatives (22.5 %)
compared to control relatives (2.6 %). Several
other studies have reported rates of OCD among
rst degree relatives to range from 17–23 % in
children probands (Chabane et al.,
2005 ; do
Rosario-Campos et al.,
2005 ). First degree rela-
tives of OCD patients also displayed the same
types of obsessions and compulsions (e.g., order-
ing, checking, symmetry) (Mataix-Cols et al.,
2004 ) as displayed by the OCD patients.
Family studies that have focused on the age
of onset of OCD had reported interesting fi nd-
ings. Specifi cally, OCD was more common in
relatives of probands with child onset of OCD,
compared to those with adult onset (Nestadt,
Samuels, Riddle et al., 2000 ). No cases of OCD
were found among relatives of patients whose
OCD began after the age of 18 years. This fi nding
led to the proposal that OCD that begin in child-
hood may have a stronger genetic component
than OCD that begins in adulthood. Although
Table 13.1 Examples of self-report measures of OCD symptoms in children and adolescents
Measure (Reference)
Informant
Age Items
Response
format (range) Domains assessed
Internal Consistency
Test-retest reliability,
and validity
Obsessive- compulsive
inventory-child version
(OCI-CV; Foa et al.,
2010 )
Child/adolescent
Age: 7–17 years
21 0 = Not at all;
3 = Very much
Doubting/checking,
obsessing, hoarding,
washing, ordering,
neutralizing
Internal consistency:
α = .81
Good convergent and
discriminant validity
Child Obsessive-
Compulsive Impact Scale
(COIS-C and COIS-P,
Piacentini et al.,
2003 )
Child and parent 56 1 = Not at all;
4 = Very much
School, social,
home/family
activities
Internal consistency:
α = .91
Good concurrent
validity, and test-retest
reliability
Children’s Obsessional
Compulsive Inventory
(CHOCI; Shafran et al.,
2003 )
Child/adolescent
Age: 7–17 years
32 0 = Somewhat;
2 = A lot
Obsession
Compulsion
α = 0.80–0.86)
Adequate convergence
validity
Good criterion validity
The Children Yale-Brown
Obsessive- Compulsive
Scale
(CY-BOCS; Scahill et al.,
1997 )
Child/adolescent
Age: 8–17 years
10 0 = None;
4 = Extreme
Obsession;
Compulsion
( α = 0.87–0.90)
Satisfactory convergent
and divergent validity
of the CY-BOCS-CR
13 Obsessive-Compulsive Disorder
240
these fi ndings provide support for the genetic
components of OCD, the way in which the genes
operate remains unclear (Walitza et al., 2011 ).
Furthermore, because shared environmental
infl uences were not controlled for in some stud-
ies the role of heritability may have been exag-
gerated (Abramowitz, Taylor, & McKay, 2009 ).
Unfortunately genetic relatedness cannot
tease apart similarity due to genetic from shared
environmental infl uences, because in addition to
sharing the genes, members of the same family
are likely to share the same family environment
(Zavos, Eley, & Gregory, 2013 ). Thus, twin stud-
ies are more useful than family studies in estimat-
ing the infl uence of genetic and environmental
factors in relation to OCD. In twin studies famil-
iarity into genetic and environmental components
is disentangled by comparing within-pair similar-
ity for monozygotic (MZ) twins and dizygotic
(DZ) twins who have in common their shared
environment but differ in their genetic related-
ness (Zavos et al., 2013 ). MZ twins share 100 %
of their genetic make-up whereas DZ twins share
on average half their segregating genes (Plomin,
Defries, McClearn, & McGuffi n, 2008 ).
Twin studies have suggested that genetic fac-
tors are implicated in the transmission of OCD
(van Grootheest, Cath, Beekman, & Boomsma,
2005 ). A study by Arnold and Richter ( 2007 )
found signifi cant greater concordance rates
for OCD in monozygotic (MZ) compared
one to dizygotic twins (DZ). Hudziak ( 2004 )
reported the presence of additive genetic (range:
45–58 %) and unique environmental infl uences
(range: 42–55 %) in OCD. However, a review of
over 70 years of twin research of OCD indicated
that only studies that used dimensional approach
and structural equation modelling to analyse the
data have convincingly showed obsessive-com-
pulsive symptoms are heritable in children with
genetic infl uences in the range of 45–65 % (van
Grootheest et al., 2005 ). Environmental factors
explain about 50 % of the “individual variation in
vulnerability to OCD” (Samuels, 2009 , p. 279).
In explaining this fi nding, it was argued that
environmental factors may activate OCD among
individuals who are genetically vulnerable in
developing this disorder.
The Autoimmune model
The autoimmune model postulates that some cases
of OCD are caused by a disruption in autoimmune
processes, called the cortico-striatal- thalamic-
cortical circuits (Swedo et al., 1993 ). This distinct
form of OCD is called Pediatric Autoimmune
Neuropsychiatric Disorders Associated with
Streptococcal Infections (PANDAS; Swedo
et al., 1998 ), which affect about 6 % of children
with OCD (Swedo, Leonard, & Rapoport, 2004 ).
Sydenham’s chorea (SC) occurs after streptococ-
cal infections (Swedo et al., 1997 ), leading to anti-
neuronal antibody- mediated response to Group A
beta-haemolytic streptococcal (GABHS) infection.
Following the fi rst report of PANDAS, Swedo
et al. ( 2004 ) investigated children in whom
GABHS triggered or potentiated symptoms of
OCD and tic disorder. The onset of symptom was
described as acute and dramatic, and in 72 % of
these patients, symptom onset was associated
with GABHS infection. However, in all the par-
ticipants, recurrence of at least one symptom was
preceded by GABHS infection within the fi rst six
weeks before the assessment. Some patients with
multiple recurrences of symptoms did not have
any signs of a streptococeal infection a month
before the assessment. The course of the disorder
has a relapsing-remitting pattern with the pres-
ence of comorbid problems including separation
anxiety, night time fears, cognitive defi cits, emo-
tional liability, oppositional behaviours and
motor hyperactivity. The presence of comorbid
symptoms especially that of ADHD tended to
make the GABHS infection worst.
Based on this study, Swedo et al. ( 1993 )
developed fi ve inclusion criteria for diagnosis
of PANDAS: (1) presence of OCD and/or a tic
disorder; (2) paediatric onset between 3 and 12
years of age; (3) episodic course of symptom
severity. The onset of symptoms is described
as sudden or by dramatic symptom exacerba-
tions during which the symptoms may appear to
“explode” in severity. Symptoms may decrease
between episodes and resolve between exac-
erbations; (4) symptom exacerbations must be
associated temporally with GABHS infection,
i.e., associated with positive throat culture and/
C.A. Essau and B.U. Ozer
241
or elevated anti-GABHS antibody titters; (5) dur-
ing symptom exacerbations, neurologic abnor-
malities are common, including adventitious
movements (e.g., choreiform movements) and
neurologic abnormalities (e.g., motor hyperactiv-
ity), or deteriorations in fi ne motor skills (e.g.,
deterioration in handwriting).
In the study by Murphy and Pichichero ( 2002 ),
all the children with PANDAS had a primary
diagnosis of OCD with an abrupt onset. Two of
them had recurrent tics. Almost all of the chil-
dren had an acute GABHS tonsillopharyngitis a
month before being diagnosed with OCD whose
OCD symptoms disappeared following treatment
with antibiotics. Recurrence of OCD was reported
in half of the children. Although the above stud-
ies have given support for the presence of
PANDAS, some authors (Singer & Loiselle,
2003 ) suggested the need to conduct prospective
epidemiological studies to examine the extent to
which the onset or exacerbation of OCD or tic
disorder is indeed triggered by GABHS.
Other Factors
Some studies have examined the impact of envi-
ronmental factors in the development of
OCD. Geller et al. ( 2008 ) examined the impact of
perinatal factors in the expression of OCD by
comparing youth with OCD with matched con-
trols (i.e., without OCD and ADHD). Among
children with OCD, the presence of sleeping
problems, and severe irritability in infancy pre-
dicted comorbid anxiety disorders, and perinatal
jaundice which needed treatment predicted
chronic tic disorder. Children who needed an
incubator in the postnatal period or need to be
hospitalized following mothers discharge and
excessive crying in infancy and whose mother
consumed medication and drug during pregnancy
had an increased risk of having comorbid
ADHD. Their result also showed maternal acci-
dents that require medical care during pregnancy
were associated with an early onset of OCD. The
authors argued that perinatal insult may have dis-
rupted development on migration of neuronal
elements in cortical-striatal-thalamic circuits.
Neurochemical model of OCD
The neurochemical model postulates that OCD is
caused by abnormality in specifi c serotonin
metabolism, hence, called the “serotonergic
hypothesis” (SH) of OCD (Gross, Sasson,
Chopra, & Zohar, 1998 ). The strongest support
for the SH comes from studies involving SSRI
which were developed for inhibition of the neu-
ronal uptake pump for serotonin (5HT).
This model has received support from neuro-
psychopharmacology research. Serotonin is the
main neurotransmitter implicated in OCD.
Clinical trials have demonstrated the superiority
of SSRIs to drug placebo in the treatment of OCD
in children and adolescents (March & Mulle,
1998 ). In fact, SSRIs are the only medication
which has been proven to be more effective than
placebo in children with OCD (Rapoport,
Leonard, Swedo, & Lenane, 1993 ). Five SSRI
which are known to alter the 5-HT system and
which are used for the treatment of OCD include
paroxetine, sertraline, fl uoxetine, citalopram and
uvoxamine.
Individual Factors Infl uencing
Risk and Resiliency
Cognitive models of OCD postulate that obsessions
and compulsions are the results of catastrophic
misinterpretation of intrusive thoughts (Allsopp
& Williams, 1996 ). The Obsessive- Compulsive
Cognition Working Group (OCCWG, 2001 ) has
identifi ed six domains of cognition that are impor-
tant for the development and maintenance of OCD
in adults. These include infl ated responsibility
(Salkovskis, 1996 ); over- importance of thoughts
(e.g., thought–action fusion) (Rachman, 1993 );
control of thoughts (e.g., thought suppression;
Clark & de Silva, 1985 ); and meta-cognitive beliefs
(Wells & Papageorgiou, 1998 ); overestimation of
threat; intolerance of uncertainty and perfectionism.
Three of these cognitive processes have been tested
in children and adolescents: (a) infl ated responsibil-
ity (Salkovskis, 1996 ), (b) thought–action fusion
(Clark & de Silva, 1985 ) and (c) meta-cognitive
beliefs (Wells & Papageorgiou, 1998 ).
13 Obsessive-Compulsive Disorder
242
I n ated Responsibility
According to the infl ated responsibility
(Salkovskis, 1996 ), individuals with OCD tend to
believe that they are mainly responsible for harm
or failing to prevent harm to themselves or oth-
ers. Consequently, they feel distressed at the pos-
sibility that they may cause harm, unless actions
are taken to prevent the harm from happening
by performing certain rituals and neutralizing
behaviour.
Studies that have examined the associa-
tion between infl ated responsibility and OCD
symptoms have produced inconsistent fi ndings.
Some studies have shown high level of infl ated
responsibility interpretations among children
with OCD compared to those without OCD
(Libby, Reynolds, Derisley, & Clark, 2004 ). For
example, in a study by Reeves, Reynolds, Coker,
and Wilson ( 2010 ), children were randomized
into three levels of responsibility: high, mod-
erate and low responsibility. The children were
asked to sort sweets onto those with and with-
out nuts and they were also told that these nuts
will be distributed to children, one of whom had
a nut allergy. Their fi ndings showed that OCD
behaviour such as hesitation, checking and time
taken were related to children’s level of respon-
sibility. Specifi cally, children in the high infl ated
responsibility group were slower, checked more
and were more hesitated; children in the moder-
ate responsibility group were in the mid-range
between the high and the low responsibility
groups. Responsibility attitudes were signifi cant
predictor of obsessive-compulsive symptoms
(Magnusdottir & Smari, 2004 ). Furthermore,
compared to TAF or meta-cognitive beliefs,
infl ated responsibility was a better predictor of
obsessive-compulsive symptoms (Matthews,
Reynolds, & Derisley, 2007 ).
However, other studies failed to support the
ndings on the association between OCD and
infl ated responsibility. For example, Barrett and
Healy-Farrell ( 2003 ) examined the role of infl ated
responsibility in children and adolescents with
OCD by using a behavioural avoidance task to
manipulate responsibility. This task involved a
situation which normally lead to compulsive
behaviour and infl ated perceptions of responsi-
bility. Their fi nding failed to fi nd any associa-
tions between infl ated responsibility and an
increased level of distress, avoidance and ritual-
izing behaviours.
Given the role of infl ated sense of respon-
sibility in the development and maintenance
of OCD, Salkovskis, Shafran, Rachman, and
Freeston ( 1999 ) have proposed fi ve pathways
that could explain for the origin of this cognitive
belief. These pathways include: (a) Children
may develop a broad sense of responsibility at
an early age: this may take place when the child
is required to perform important tasks for which
he/she is responsible for negative occurrence.
Such high sense of responsibility may lead to
feelings of conscientiousness and a sense of
responsibility. A failure to meet that responsi-
bility could lead to a “sense of failure, disap-
pointment and guilt” (Salkovskis et al., 1999 ,
p. 1060). These authors further claimed that
behaviour which is mostly linked to the sense of
responsibility is to prevent the anticipated mis-
haps. (b) Rigid codes of conduct and duty might
have been established within the family and
educational context in which the child feels the
need to follow a sense of responsibility. (c) The
sense of responsibility may have developed dur-
ing childhood as a result of being withheld from
it, or being treated as incompetent to cope with
responsibility by people around the child. For
example, parents may convey the message to
the child that since danger is near, it is better to
be safe. However, when negative events happen,
the child is criticized for not taking appropriate
actions to prevent the negative outcome from
happening. (d) A heightened sense of responsi-
bility follows a critical event and the individuals
believe that the occurrence of a negative out-
come is related to something that they did or did
not do. (e) Incident in which one’s thoughts or
actions is wrongly considered to have led to neg-
ative outcomes for self or others. This pathway
is characterized by misinterpretation of events
that are coincidentally linked, as is a case when
one’s own thoughts and a negative outcome for
others is causally related. An example is when
one wishes someone to be ill, and to discover
C.A. Essau and B.U. Ozer
243
that person is ill. These fi ve pathways tend to
overlap considerably in infl uencing responsibil-
ity, and not mutually exclusive.
Studies that examined Salkovskis et al.’s
model ( 1999 ) on the fi ve pathways to infl ated
responsibility are rare. Lawrence and Williams
( 2011 ) compared these pathways to responsi-
bility beliefs in a group of adolescents with and
without a history of OCD. Adolescents with a
history of OCD were found to report a higher
sense of responsibility for specifi c incidents
with a negative outcome before the onset of their
OCD compared to adolescents who have no his-
tory of OCD. It was argued that the combination
of infl ated sense of responsibility and the occur-
rence of specifi c incidents might interact with
each other and act as a vulnerable factor for the
development of OCD. A recent study by Farrell,
Hourigan, and Waters ( 2013 ) showed that moth-
ers of children with OCD were signifi cantly more
enhancing of their child’s responsibility than
mothers of children without any clinical diagno-
ses. Mothers of children with OCD also seemed
to implicate that the child was responsible for the
action that need to be taken to resolve the situa-
tion, compared to those in the non-clinical group.
This fi nding was interpreted as giving support
to the proposed pathway for the development
of dysfunctional infl ated responsibility beliefs
(Salkovskis et al., 1999 ).
Thought–Action Fusion
Thought–action fusion (TAF; Rachman, 1993 ) is
a cognitive bias in which thoughts and actions are
considered to be equivalent. It also misinterprets
intrusive thoughts as meaningful, personally sig-
nifi cant and are likely to have negative conse-
quences. Rachman ( 2003 ) identifi ed two types of
TAF, namely TAF-morality and TAF-likelihood.
TFA-morality is defi ned as a belief that an intru-
sive thought is about an unacceptable behaviour
which is morally equivalent to performing it.
TAF-likelihood refers to the belief that thinking
about a feared event will increase the probability
that the event will occur. Both beliefs generally
lead to high distress level, resulting in individuals
engaging in neutralizing behaviour in order to
prevent the feared events from happening.
Libby et al.’s study ( 2004 ) found TAF (i.e.,
likelihood other) to be signifi cantly higher in the
OCD groups of adolescents compared to those
with anxiety disorders and adolescents in the
non-clinical group. In a recent study by Evans,
Hersperger, and Capaldi ( 2011 ), the best predic-
tor of compulsive-like behaviour in 7–9 year olds
was physiological anxiety. Among 9–11 year
olds, TAF particularly the harm-avoidance sub-
scale, best predicted compulsive-like behaviour,
while as in the 11–14 year olds, the best predictor
was TAF-self. It was argued that as children
become older, they experience less TAF and per-
form less rituals behaviour. Other studies have
shown TAF to not being a specifi c marker for
OCD, but to a range of other mental disorders
such as with anxiety and depressive disorders
(Barrett & Healy-Farrell, 2003 ; Muris, Meesters,
Rassin, Merckelbach, & Campbell, 2001 ;
Simonds, Demetre, & Read, 2009 ). An exception
was a study by Libby et al. ( 2004 ) where TAF
was found to be signifi cantly higher in the OCD
groups of adolescents compared to those with
anxiety disorders and those without any anxiety
disorders.
Meta-cognitive Beliefs
These are beliefs about the importance and mean-
ing and/or dangerous consequences of intrusive
thoughts in the development of obsessional think-
ing (Wells, 1997 ). Beliefs about the need to con-
trol thoughts and/or do rituals are also considered
important. It further hypothesizes that neutraliz-
ing and avoidance behaviour increase the fre-
quency of intrusive thoughts through constant
monitoring, which in turn prevent the testing of
negative thoughts.
A number of studies among non-clinical sam-
ple of adolescents have found meta-cognitive
beliefs to signifi cantly correlate with obsessive-
compulsive symptoms (Cartwright-Hatton et al.,
2004 : Reynolds & Reeves, 2008 ). For example,
in a study by Matthews et al. ( 2007 ), OCD
symptoms correlated signifi cantly with infl ated
13 Obsessive-Compulsive Disorder
244
responsibility, TAF, and with meta-cognition.
Further analysis showed responsibility appraisal
to completely mediate the effect of TAF, and to
partially mediate the effect of meta-cognition.
Mather and Cartwright-Hatton ( 2004 ) examined
whether meta-cognition or infl ated responsibil-
ity to be a better predictor of OCD symptoms
in 13–17 year olds. They found responsibility
and meta- cognition to both correlate signifi -
cantly with OCD symptoms. After controlling
for age, gender and depression, meta-cognition
and not infl ated responsibility was a signifi cant
predictor of OCD symptoms. In another study,
Cartwright- Hatton et al. ( 2004 ) found meta-
cognitions to correlate signifi cantly with OCD
symptoms, and also with anxiety and depressive
symptoms. It was argued that meta-cognition
may be a general marker to a wide range of
psychopathology.
Family Factors Infl uencing Risk
and Resiliency
Familial factors such as family environment, par-
enting styles, parental cognitive bias, and paren-
tal accommodation of the child’s OCD symptoms
have been examined as possible risk factors for
the developmental and maintenance of OCD.
Family Environment
Families of children and adolescents with OCD
have been described as being distress (Peris et al.,
2008 ; Piacentini et al., 2003 ; Storch, Geffken
et al. 2007 ), and as having high family discord
and blame (Peris et al., 2008 ). These problems
were associated with the high level of disruption
to that family report (Piacentini et al., 2003 ). The
nding related to high level of hostility, blaming
response styles and disrupted interpersonal func-
tioning (Peris et al., 2008 ; Piacentini et al., 2003 )
could explain for the diffi culties that these fami-
lies have in various psychosocial functioning.
The quality of the family interactions in adoles-
cents with OCD was also characterized as having
less emotional support, warmth and closeness
compared to adolescents without any psychiatric
disorders (Valleni-Basile et al., 1995 ).
Parenting Rearing Styles
Parental styles which may be implicated in OCD
include parental control, overprotection, reject,
criticism, and lack of parental care (Waters &
Barrett, 2000 ). The latter includes warmth, affec-
tion and support that the parents show to their
children. Several authors argued that the associa-
tion between lack of parental care and obsessive
beliefs may be related to the parent–child attach-
ment (Doron, Kyrios, & Moulding, 2007 ; Yarbro,
Mahaffey, Abramowitz, & Kashdan, 2013 ).
According to the attachment theory (Bowlby,
1973 ), attachment forms the basis for the forma-
tion of cognitive working models about one’s
world, other and the self which in turn infl uence
the development of obsessive beliefs (Doron
et al., 2007 ). That is, the quality of children early
interaction with attachment fi gure could lead to
the development of belief that the world is threat-
ening and oneself as incompetent, all of which
could form the basis of obsessive thoughts
(Doron et al., 2007 ). A recent study by Yarbro
et al. ( 2013 ) showed an association between per-
ceived neglectful parenting and obsessive beliefs.
Another important fi nding was that attachment
anxiety (i.e., characterized by negative feelings
about the self and about others) partially medi-
ated the relationship between perceived neglect-
ful parenting and responsibility/threat estimation
and perfectionism/uncertainty. Overall, this fi nd-
ing seemed to suggest that perceived lack of
parental care is related to anxious attachment and
to distorted cognitions about the self and others
all of which contribute to cognitive vulnerabili-
ties for OCD (Yarbro et al., 2013 ).
Barrett, Shortt, and Healy ( 2002 ) compared
parent–child interaction in three groups of chil-
dren (i.e., children with OCD, children with
externalizing disorders and children without any
psychiatric disorders) when responding to hypo-
thetical situation that involved potential social
and physical threat. Children with OCD were
found to be less confi dent, less positive problem-
C.A. Essau and B.U. Ozer
245
solving and less warmth compared to children in
the other two groups. Compared to parents of
children in the other groups, parents of children
with OCD tended to be less confi dent in their
child’s ability, used less positive problem-solving
strategies, and less likely to reward their child’s
independence.
Parental Cognitive Bias
According to Hudson and Rapee’s model of gen-
eralized anxiety disorder ( 2004 ), parents with
high anxiety tend to have cognition which focused
on their child’s vulnerability and/or the danger-
ousness of the world. This cognitive bias makes
them being controlling and overprotective when
interacting with their child, which in turn signals
or reinforces the child’s perception that the world
is a dangerous and unpredictable place. Studies
which have examined the impact of parental cog-
nition on the child’s cognitive appraisal reported
that anxious children made more threat interpreta-
tion compared to non- anxious children (Shortt,
Barrett, Dadds, & Fox, 2001 ). Lester, Field,
Oliver, and Cartwright- Hatton ( 2009 ) similarly
found that anxious parents tended to interpret sit-
uations that they encounter as threatening to both
themselves and their child.
Farrell, Waters, and Zimmer-Gembeck ( 2012 )
examined the association of cognitive bias
(responsibility bias, thoughts-action fusion,
thought suppression, and meta-cognitive beliefs)
and maternal cognitive bias among children and
adolescents who have been referred for the treat-
ment of OCD. Their fi ndings showed a moderat-
ing effect of age between the child’s OCD
severity and child’s cognitive bias, and maternal
cognitive bias. The association between the
child’s maladaptive beliefs (child responsibility
and meta-cognitions) and OCD severity were sig-
nifi cant in the adolescent subsample, but not in
the younger child subsample. It was (Farrell
et al., 2012 ; Verhaak & de Haan, 2007 ) argued
that cognitive biases may be related to the way in
which adolescents attribute the meaning which
occurs following the perception of the need to
conduct a compulsive behaviour. They also found
a signifi cant positive correlation between the
child OCD severity and maternal cognitive bias
(maternal responsibility and thought suppres-
sion); however, no correlation was found with
adolescent OCD severity and maternal cognitive
bias. The authors (Farrell et al., 2012 ) argued that
mothers of adolescents may have denied the pres-
ence of their own symptoms in their child during
adolescence. Alternatively, increased cognitive
bias in adolescence could have an ameliorating
affect on mother’s own bias.
Family Accommodation
Family accommodation refers to the action taken
by family members either directly (e.g., partici-
pate in the child’s ritual) or indirectly such as by
changing family’s lifestyle in responding to the
child’s OCD symptoms, providing reassurance,
minimizing responsibilities, and providing assis-
tance with tasks (Waters & Barrett, 2000 ). The
main reasons for family accommodation include
an attempt in helping to stop the child’s rituals and
distress of both the affected child and the family
(Riddle et al., 1990 ). Among the most common
forms of family accommodation are verbal reas-
surance, facilitation of avoidance, and participa-
tion in the child’s rituals (Peris et al., 2008 ; Storch,
Geffken et al., 2007 ). For example, in a study by
Flessner et al. ( 2011 ), about 33.3 % of the parents
reported assisting their child in avoiding anxiety-
provoking situations daily. Parents who accom-
modated to their child’s OCD tended to have high
OCD symptoms themselves, high level of hostil-
ity, or global psychopathology (Peris et al., 2008 ).
Furthermore, family accommodation was signifi -
cantly correlated with child’s OCD symptoms and
low family organization (Peris et al., 2008 ).
Family accommodation seems to have impor-
tant impact on child’s treatment response and
course and outcome. Specifi cally, children’s posi-
tive response to cognitive-behavioural therapy
(CBT) was related to a decrease in parental accom-
modating to the child’s OCD (Merlo, Lehmkuhl,
Geffken, & Storch, 2009 ). It has been argued
that parental accommodation may be resistant to
ERP tasks as an increase in the child’s anxiety
13 Obsessive-Compulsive Disorder
246
may lead to parental anxiety which in turn could
comprise treatment compliance and/or adherence.
Furthermore, family accommodation may contrib-
ute to functional impairment (Peris et al., 2008 ;
Storch, Merlo et al., 2007 ) by reinforcing a child’s
rituals and/or avoidance behaviours.
Social and Community Factors
Infl uencing Risk and Resiliency
Children and adolescents with OCD, compared
to normal controls, reported more negative life
events both during the lifetime and a year before
the onset of the disorder, and that these events
were perceived as having more impact (Gothelf,
Aharonovsky, Horesh, Carty, & Apter, 2004 ).
The most common event experienced was related
to major illness or injury of a relative. Major ill-
ness or injury was the only event that differenti-
ated those with OCD from those with other types
of anxiety disorders and normal controls.
Findings on the association between OCD and
social class are inconsistent. In the British nation-
wide survey of child mental health, 74 % of the
children and adolescents with OCD were reported
to be from the lower social classes (Heyman
et al., 2003 ). However, Flament et al. ( 1988 )
found no signifi cant correlation between OCD
and socioeconomic status. Among children in
clinical setting (Hanna, 1995 ), a reverse trend
was found in that OCD seems to be widespread
among those in high social class. Most of the
children with OCD also come from families with
lower incomes and from larger families com-
pared to normal controls (Heyman et al., 2003 ).
Evidence-Based Treatment
Interventions for OCD
W h a t W o r k s
Behaviour Therapy: Exposure
and Response Prevention
The theoretical basis of exposure and response
prevention (ERP) is Mowrer’s 2-stage theory and
some early experiments by Rachman and his
colleagues. Mowrer’s theory (Mowrer, 1960 ) has
two stages: (a) acquisition of anxiety and fear; (b)
maintenance of this anxiety and/or fear.
According to Mowrer, anxiety is acquired when
neutral event becomes associated with fear when
paired with a stimulus that is increasingly dis-
tress provoking. Through conditioning process,
objects and thoughts acquired the ability to pro-
duce a conditioned response (e.g., fear or anxi-
ety). During the second stage, avoidance or
escape behaviour (i.e., compulsion) is developed
to reduce the anxiety evoked by conditioned
stimuli, which are maintained by reducing anxi-
ety (i.e., act as a negative reinforcement) (Riggs
& Foa, 1993 ). It is this negative reinforcement
that helps to maintain the presence of OCD
(Benito, Conelea, Garcia, & Freeman, 2012 ).
Consequently, in ERP, children are exposed to an
anxiety-provoking stimulus in a hierarchical
fashion, and at the same time being asked to
refrain from performing their compulsions.
Exposures can be either in vivo and/or imaginal,
and which must be long enough and repeated fre-
quently enough for anxiety habituation to take
place (Foa & Franklin, 2001 ); habitation involves
reducing anxiety response as a result of sustained
contact and repeated exposure to anxiety-
provoking stimulus (Benito et al., 2012 ). During
the ERP, the children learn that they do not need
to ritualize to reduce their anxiety and that the
obsessions are not catastrophic and with time,
their anxiety will eventually decline. Thus, they
learn that the feared situations they anticipate do
not materialize and there is no need for them to
protect themselves by ritualizing.
Although the fi rst case of ERP to treat OCD
was published in 1966 by Meyer, empirical study
that examined the effectiveness of this treatment
method was only published in 1983. Bolton,
Collins, and Steinberg ( 1983 ) were among the
rst to have examined the effectiveness of ERP
in children and adolescents who were hospi-
talized for OCD. They found that about 87 %
of the young people showed improvement at
post- treatment. A major limitation of this study
was the absence of standard treatment proto-
col. Furthermore, because these young people
received numerous other therapies, it was not
C.A. Essau and B.U. Ozer
247
possible to assess the specifi c effect of ERP. In
a study by Wever and Rey ( 1997 ), 68 % of the
adolescents who had ERP and SRI were remitted,
and 60 % of them showed a signifi cant decrease
in OCD symptoms at 4 weeks. About half of the
patients were no longer on medication and were
able to maintain their treatment gains for about
2 years. Adolescents who received SRI only
showed less and slower improvement when reas-
sessed at 6 months.
The use of ERP in children has been ques-
tioned as it is found to be aversive and challeng-
ing which could have explained for a high
drop-out rate, in the range of 20–40 % (Allsopp
& Verduyn, 1990 ; Bolton & Perrin, 2008 ).
Cognitive-Behavioural Therapy
Expert consensus guidelines have recommended
CBT as the treatment of choice for OCD in chil-
dren and adolescents (March, Frances, Carpenter,
& Kahn, 1997 ; National Collaborating Centre
for Mental Health, 2006 ). CBT consists of dif-
ferent components (i.e., psychoeducation, hier-
archy building, ERP, cognitive restricting, and
reward program) which are mostly conducted
in sequential manner. For example, the March
and Mulle ( 1998 ) treatment protocol has four
phases (Moore, Franklin, Freeman, & March,
2013 ). The fi rst stage focuses on psychoeduca-
tion about the nature of OCD, its behavioural,
cognitive and neurobiological underpinnings. By
focusing on OCD as a medical illness, it helps
to change the family process by identifying OCD
as the problem and not the child. This reframing
helps to form an alliance between the child and
the family and the therapist to deal with OCD
symptoms. OCD is described as a “brain hiccup”
which causes individuals to feel anxious in the
presence of certain thoughts or actions. During
the second stage, the concept of the cognitive
toolbox is introduced to the child and his/her
family. This involves teaching children the con-
cept of cognitive resistance (i.e., bossing OCD)
and self- administered positive reinforcement and
encouragement. These cognitive tools are meant
to prepare children to do exposure and response
prevention tasks. The third phase involves cre-
ating a map of the child’s OCD, which include
specifi c obsessions and compulsion, precipita-
tors of OCD symptoms, avoidance behaviour,
consequences, creation of stimulus hierarchy;
the children are then asked to rank order the lev-
els of distress that they anticipate to experience
when exposed to the obsessional trigger without
engaging in the ritual. During the exposure itself,
the children are exposed to the obsessional trig-
ger which they anticipate as producing the low-
est level of anxiety and without having to engage
in the compulsion. The fi nal phase of treatment
involves the implementation of CBT which com-
prises guided exposure and response prevention,
and homework assignments.
Following the publication of the treatment
manual by March and Mulle ( 1998 ), a consider-
able body of research has provided support for
the effi cacy and effectiveness of CBT in treating
OCD. As shown in Tables 13.2 , 13.3 and 13.4 ,
the remission rates for young people who had
participated in the CBT have been reported to
range from 40 to 85 % (Barrett et al., 2004 ;
Pediatric OCD Treatment Study [POTS], 2004 ),
and between-group effect sizes ranging from
0.99 to 2.84 (Barrett, Farrell, Pina, Peris, &
Piacentini, 2008 ).
Few studies had offered “intensive” CBT by
compressing the CBT sessions that are normally
delivered over a period of two to three months to
one to two weeks. The aim of doing this is to
overcome practical problems of attending treat-
ment such as having parents to take time off in
order to bring the child for treatment (Storch,
Geffken et al., 2007 ). The intensity of CBT deliv-
ery seems to impact the treatment outcome in
some studies but not in others. In a randomized
trial of intensive versus weekly family-based
CBT, a higher remission rate was obtained for the
intensive group (75 %) compared to the weekly
group (50 %) (Storch, Geffken et al., 2007 ). A
greater reduction in family accommodation of
OCD symptoms was also found in the intensive
group than the weekly group. However, no sig-
nifi cant group differences were found in any of
the outcome measures by three months after
treatment. Whiteside and Jacobsen ( 2010 ) exam-
ined the feasibility and effectiveness of the ERP
to anxiety-provoking stimuli over a 5-day period.
13 Obsessive-Compulsive Disorder
248
Table 13.2 Selected studies using cognitive-behavioural therapy for paediatric OCD
Studies Children characteristics Treatment protocol Outcome
March, Mulle, and
Herbel (
1994 )
Age: 8–18 years
(mean = 14.3 years).
Gender: 33 %
Setting: outpatient
Standardized protocol, consisting of psychoeducation,
anxiety management training, exposure relapse
prevention
3 parent sessions
3–21 sessions in children and adolescents
40 % patients in remission at post-test
60 % patients in remission at follow-up
Tolin ( 2001 ) Age: 5 years old
Gender: boy
A case study
Cognitive behaviour therapy including parent- and
teacher-directed extinction of compulsive reassurance
seeking and bibliotherapy with an age appropriate book on
OCD
Compulsive behaviour decreased and remained at a
low level during the treatment
Signifi cant reduction in OCD symptoms 1 and 3
months after treatment
Whiteside, Brown, and
Abramowitz (
2008 )
Age: 13–18 years
Gender: 2 females and a
male
A case series
Cognitive behaviour therapy including exposure and
response prevention (ERP)
10 sessions over 5 days
Substantial improvement in OCD symptoms and
overall functioning
56.1 % of reduction
Jacqueline and Margo
(
2005 )
Age: 8–14 years old
( M = 11.3)
Group Cognitive-Behavioural Treatment with family
involvement
14 week—90 min format
Signifi cant decrease in OCD symptoms (25 %): the
change was from moderate-severe to mild-moderate
Oline et al. (
2011 ) Age: 6–17 years old
( M = 12.36)
Gender: 33 % female
Setting: outpatient
ERT in an intensive outpatient community based
program
Up and down the Worry Hill Protocol
Signifi cant reduction in OCD symptom severity
regardless of age or gender
Whiteside and Jacobsen
(
2010 )
Age: 10–18 ( M = 13.13)
Gender: 7 females, 9 males
5 days of CBT based on ER
One 50-min (but sometimes as long as 75 minutes)
session in the morning, one in the afternoon
The child and parent were taught to carry out
exposures themselves
Signifi cant decrease in OCD symptoms from pre- to
post-treatment, and from post-treatment to 5 months
later
O’Leary, Barrett, and
Fjermestad (
2009 )
Age: 13–24 ( M = 18.4)
Gender: 53 % male
Individual or group cognitive-behavioural family-based
therapy for childhood OCD
Follow-up: 7 years after the treatment
79 % of individuals who had individual therapy, and
95 % of those who had group therapy, no longer met
the diagnosis of OCD
Barrett, Farrell, Dadds,
and Boulter (
2005 )
Age: 8–19 years
( M = 13.85)
Gender: 47.9 % male
14 weeks of manual-based CBT: participants received
either individual or group cognitive-behavioural family
therapy
70 % of individuals who had received individual
therapy, and 84 % of individuals who had received
group therapy, did not have an OCD diagnosis at the
time of follow-up
Cognitive- behavioural family therapy, regardless of
its mode of delivery is effective on a long-term basis
C.A. Essau and B.U. Ozer
249
(continued)
Studies Children characteristics Treatment protocol Outcome
Storch et al. (
2006 ) Age: 9–13 years
( M = 11.1 ± 1.4 year)
Gender: 4 males, 3 females
Participants suffered from OCD of the
Paediatric autoimmune neuropsychiatric disorders
associated with streptococcus
3 week intensive course of CBT. 6/7 participants were
taking selective serotonin reuptake inhibitor
medication(s) at presentation
6 participants responded to treatment, 3 of these 6
were deemed responders 3 months after treatment
Merlo et al. (
2009 ) Age: 6–18 years ( M = 12.8)
Gender: 55 % male
14 sessions of family-based cognitive-behavioural therapy
for OCD
Family-based CBT is associated with a considerable
reduction in family accommodation; this reduction is
associated with a positive response to treatment
Barrett, Healy-Farrell,
and March (
2004 )
Age: 7–17 years Participants were in 1 of 3 conditions: (1) individual
cognitive-behavioural family-based therapy (CBTF)
(2) group CBTF (3) a 4–6 week waitlist control
condition
Treatment: 14 weeks of manualized cognitive-
behavioural protocol and 2 booster sessions; parents
and siblings were involved
Signifi cant alteration in diagnosis and severity of
symptoms (statistically and clinically) for both
individual and group CBFT
No signifi cant differences between individual and
group CBFT
Benazon, Ager, and
Rosenberg (
2002 )
Age: 8–17 years old.
Gender: 16 male, 8 female
12-week open trial with manualized CBT After treatment, the symptoms of 10/16 participants
reduced by at least half, and 7 were symptomless
CBT may be helpful in treating paediatric OCD,
including without the use of medication
Farrell, Schlup, and
Boschen (
2010 )
Age: 7–17 years old
( M = 12.29)
Gender: 16 girls, 19 boys
12 weeks of weekly sessions of CBT administered either
individually or in small groups. Parent sessions took place
after each session
2 further sessions at 1 and 3 month(s) after treatment
63 % of the sample did not have an OCD diagnosis
after treatment
Franklin et al. (
1998 ) Age: 10–17 ( M = 14.1)
Gender: 10 males, 4
females
CBT using exposure and ritual prevention: 7 patients
received intensive treatment (averaging 18 sessions over 1
month); and 7 received weekly treatment (averaging 16
sessions during a period of over 4 months). 6 of the
patients received only the CBT, and 8 received CBT and
serotonin reuptake inhibitors
12/14 patients who participated in CBT had
improved by at least 50 % after treatment, and
continued to be improved at follow-up
Piacentini, Bergman,
Jacobs, McCraken, and
Kretchman (
2002 )
Age: 5–17 ( M = 11.8)
Gender: 60 % female
12.5 (on average) 1 h weekly sessions of manual-guided
open CBT treatment based on exposure plus response
prevention
78.6 % of participants were “positive responders” to
treatment
Storch, Geffken et al.
(
2007 )
Age: 7–17 ( M = 13.3 ± 2.7).
Gender: 22 female, 18 male
14 sessions (daily or weekly) of family-based CBT Intensive and weekly treatment were equally helpful
No signifi cant differences between the groups at the
3-month follow-up
13 Obsessive-Compulsive Disorder
250
Table 13.2 (continued)
Studies Children characteristics Treatment protocol Outcome
Thienemann, Martin,
Cregger, Thompson, and
Dyer-Friedman (
2001 )
Age: 13–17 ( M = 15.2)
Gender: 12 males, 6
females
14 weeks of group (5–9 patients) CBT; a 2 h session every
week
OCD symptoms of 9 patients ameliorated by 25 % of
more; 5 patients experienced an amelioration of
between 13–18 %; the symptoms of 3 subjects only
slightly altered; and the condition of 1 person
deteriorated
Valderhaug, Larsson,
Götestam, and Piacentini
(
2007 )
Age: 8–17 ( M = 13.3).
Gender: 50 % female
12 manual-guided sessions of CBT (both individual and
family)
Substantial improvements occurred; the average
reduction in symptoms was 60.6 % after treatment, and
68.8 % 6 months after treatment
Storch et al. (
2013 ) Age: 7–17 years Participants were provided with 1 of the 3 types of
treatment over 18 weeks: (1) Sertraline at the standard
dose and CBT (2) Sertraline titrated slowly but receiving 8
weeks (at the minimum) of the “maximally tolerated daily
dose” of it, and CBT (3) a placebo and CBT
Approximately 61.7 % of the participants responded
to treatment
No differences in pace of response between groups
Asbahr et al. (
2005 ) Age: 9–17.
Gender: 26 male, 14 female
12 weeks of treatment: patients received either sertraline
or group CBT
Relapse at 9 months after treatment was considerably
less in group CBT than sertraline group
Franklin, Tolin, March,
and Foa (
2001 )
Case study of a 12-year-old
boy with OCD
Intensive CBT with Exposure and Ritual Prevention: 2
assessment sessions and 11 treatment sessions were
provided 5 days a week. The patient was also on
medication during the time the CBT was administered
OCD symptoms signifi cantly reduced after 11
exposure and ritual prevention sessions
3 months after treatment the boy was found to have
no OCD symptoms or depression symptoms
C.A. Essau and B.U. Ozer
251
Table 13.3 Selected studies using medication for paediatric OCD
Studies Children characteristics Treatment protocol Outcome
Alderman, Wolkow,
Chung, and Johnston
(
1998 )
Age: 6–17 years old ( M = 12.8 ± 2.7)
Gender: 33 male, 28 female
The participants suffered from major
depression, OCD or both
Participants were given 50 mg sertraline. 1 week later
they commenced a 35 day course of sertraline—then
either they: (1) began with 25 mg/day, titrated to
200 mg/day through increases of 25 mg, or (2) they
began on 50 mg/day (the amount adults typically
commence with), gradually titrated to 200 mg/day,
through increases of 50 mg
No pharmacokinetic differences were seen
between the different titrations
Effi cacy measurements suggested symptoms of
both conditions decreased. Sertraline is possibly
valuable in treating young patients with major
depression or OCD
Cook et al. (
2001 ) Age: 6–18 ( M = 12.5)
Gender: 52 % male
Participants had undergone a 12-week, double-blind,
placebo-controlled sertraline course. They then
underwent an open-label sertraline course for 52 weeks
(they received 50–200 mg/day during this time)
At post-treatments, 72 % of the children (ages 6–12)
and 61 % of the adolescents (ages 13–18) fi tted the
response criteria
Geller et al. (
2001 ) Age: 7–17 (mean for the fl uoxetine
group: 11.4 ± 3.0; mean for the
placebo group: 11.4 ± 2.8)
Gender: 54 male, 49 female
Patients underwent a double- blind, placebo-
controlled study for 13 weeks
Patients were administered either fl uoxetine or a
placebo
Fluoxetine was signifi cantly more effective than
the placebo in reducing OCD symptoms
Fluoxetine 20–60 mg/day is useful for paediatric
OCD
Moore, Macmaster,
Stewart, and
Rosenberg (
1998 )
9-year-old boy Paroxetine (a selective serotonin reuptake inhibitor) for
12 weeks. Starting dose was 10 mg/day; this was
titrated to 20 mg/day
OCD symptoms improved signifi cantly; there was
also signifi cant modifi cation to the glutamate
resonance in the caudate
Riddle et al. (
2001 ) Age: 8–17 years old (mean age of
uvoxamine group was 13.4; mean
age of placebo group was 12.7)
Gender: in the fl uvoxamine group,
50.9 % of patients were male; in the
placebo group, 55.6 % of patients
were male
Participants rst underwent a 7–14 day “single-blind,
placebo washout/screening period”. Then, for 10
weeks, they either took 50–200 mg/day of fl uvoxamine
or a placebo. Participants who had not responded after
6 weeks were allowed to stop the double- blind part of
the study and commence a long-term, open-label
uvoxamine trial
Fluvoxamine was signifi cantly more successful
than the placebo in ameliorating OCD symptoms:
42 % of fl uvoxamine patients and 26 % of
placebo patients were responders
Fluvoxamine had positive effect quickly, to be
well tolerated and to be helpful for short-term
treatment of OCD
Rosenberg, Stewart,
Fitzgerald, Tawile, and
Carroll (
1999 )
Age: 8–17
Gender: 9 boys; 11 girls
12 week open-label trial of paroxetine (10–60 mg/daily) The medication seemed effective: the average score
of the CY-BOCS reduced from 30.6 ± 3.5 to
21.6 ± 6.8
13 Obsessive-Compulsive Disorder
252
Table 13.4 Selected studies using other psychological interventions for paediatric OCD
Studies Children characteristics Treatment protocol Outcome
Comer et al. (
2012 ) Age: 4–8 years old.
( M = 5.4 years)
Gender: 6 females, 9 males
12 sessions of anxiety-based modifi cation of Parent–Child
Interaction Therapy (this modifi ed version is the CALM
Program: coaching approach behaviour and leading by
modelling)
All treatment-completers were considered “global
treatment responders”. One participant did not show
“full diagnostic improvements”, and one did not show
“meaningful functional improvements”
Owens and Piacentini
(
1998 )
8-year-old boy with OCD and
comorbid disruptive behaviour
problems
ERP
Twelve 45 min sessions (attended by the boy and his
mother) over 4 months
The boy also completed homework about 5 days a
week, also involving exposure plus response prevention
A contingency management program was also used
(during the sessions and at home) to control his
disruptive behaviour
Post-treatment assessment (2 and 6 months
afterwards) suggests signifi cant improvement in
symptoms
Bolton and Perrin
(
2008 )
Age: 8–17 ( M = 13.2)
Gender: 6 female, 14 male
One group of participants received exposure plus response
prevention administered intensively over a 5-week period,
without medication being administered at the same time.
The second group were assigned to a waitlist condition
Signifi cant improvement in the group receiving the
exposure plus response prevention, in comparison with
the controls. This improvement remained 14 weeks
after the treatment
Simons, Schneider,
and Herpertz-
Dahlmann (
2006 )
Age: 8–17. The mean age of
the ERP group was 13.39; the
mean age of the MCT group
was 14.53. Gender: 7 males, 4
females
Participants were assigned to have either meta-cognitive
therapy (MCT) or ERP (Exposure with ritual
prevention).
Participants received manualized treatment each week,
for up to 20 sessions
OCD symptoms improved signifi cantly in both groups.
The CY-BOCS score went down from 20 to 1 in the
ERP group, and from 26 to 6 in the MCT group
( z = –2.032, p = 0.042)
MCT is a potential alternative to ERP
De Haan, Hoogduin,
Buitelaar, and Keijsers
(
1998 )
Age: 8–18. Gender: 50 %
female
Participants were placed in 1 of 2 conditions for 12 weeks
in this parallel design: (1) behaviour therapy; (2) open
Clomipramine (the average dosage given was 2.5 mg/kg)
Children in both conditions signifi cantly improved.
On the CY-BOCS, behaviour therapy brought
about more signifi cant therapeutic changes;
however the LOI-CV did not yield signifi cant
differences between the two groups
C.A. Essau and B.U. Ozer
253
The 15 children with OCD and their parents were
taught to do ERP at home. Results showed sig-
nifi cant reduction in OCD symptoms from pre- to
post-treatment, which was maintained at 5-month
follow-up. Overall this fi nding provided further
support for the feasibility of an intensive treat-
ment for OCD in children and adolescents.
In order to understand how and for who
works, increasingly more studies have examined
the mediators and moderators of CBT in paediat-
ric OCD. Factors that were associated with poor
CBT treatment outcome included baseline sever-
ity of obsessions and OCD-related academic
diffi culties, whereas age, gender, medication
status, or the presence of comorbid disorders did
not have any impact on the treatment outcome
(Piacentini et al., 2002 ).
In addition to examining the effectiveness
of CBT in reducing OCD, studies have also
examined the impact of CBT in changing young
people’s subjective distress during and after the
treatment. As recent fi ndings by Kircanski, Wu,
and Piacentini ( 2013 ) showed signifi cant reduc-
tion in subjective distress among young people
during CBT for OCD. Decrease in child dis-
tress between sessions, throughout and at post-
treatment was predicted by severity of OCD,
psychosocial impairment and the presence of
internalizing symptoms (i.e., withdrawn behav-
iour and social problem) at pre-intervention.
Higher obsession scores and social impair-
ment predicted greater decrease in distress at
post- treatment, and OCD-related functional
impairment predicted lesser decrease in distress
throughout the CBT. These ndings empha-
size the importance of continually examining
between-session change in subjective distress
and using this information to guide and enhance
treatment (Kircanski et al., 2013 ).
Few studies have examined the feasibility and
transportability of CBT for paediatric OCD when
delivered in routine-based clinical setting.
Valderhaug et al. ( 2007 ) examined the effective-
ness of CBT in three community clinics in
Norway among 8–17 year olds with OCD. At
post and 6-month follow-up assessment periods,
there was 60.6 and 68.8 % reduction in CY-BOCS
ratings, respectively.
CBT and Medication
The Pediatric OCD Treatment Study (POTS,
2004 ) is the largest study to date that has exam-
ined the effi cacy of CBT alone, sertraline alone,
or CBT and sertraline, or pill placebo among the
treatment for young people with OCD. A total of
11 young people completed the 12 weeks treat-
ment. Result showed that the most effective form
of treatment for paediatric OCD is the combina-
tion of CBT and sertraline where remission rate
of 54 %. Remission rates for CBT alone, sertra-
line alone, and for placebo were 39.3 %, 21.4 %
and 3.6 %, respectively. In the POTS II study
(Franklin et al., 2011 ), 7–11 year olds with OCD
were randomly assigned to 1–3 treatment strate-
gies: medication management alone, medication
management and instructions in CBT, or medica-
tion management plus CBT. Compared to the
other two treatment strategies, medication man-
agement combined with CBT was found to be the
most superior. The rate of responders was 68.6 %
in the medication management and CBT group,
compared to 34.0 % in the medication manage-
ment and instructions in CBT group, and 30.0 %
in the medication management alone.
Asbahr et al. ( 2005 ) compared the effi cacy of
group-based CBT to that of SSRI in Latino chil-
dren and adolescents. At post-test signifi cant
improvement was found in both treatment condi-
tions with no signifi cant group difference, con-
ducted 9 months later. However, patients in the
CBT group had lower relapse rate than those in
the SSRI group.
What Might Work
Given the role of family in the development
and maintenance of OCD, several studies have
involved parents in CBT. It was argued that get-
ting parents involved in the treatment could be
helpful because it helps to reduce family involve-
ment in the compulsions as well as to support
the child in doing the ERP (Barrett et al., 2004 ).
Barrett et al. ( 2004 ) compared the effi cacy of the
individual cognitive- behavioural family-based
therapy (CBFT) and group CBFT. No signifi -
cant group differences were found between these
13 Obsessive-Compulsive Disorder
254
two treatment conditions at post, 3-months and
6-months follow-up. Seven years after the treat-
ment (O’Leary et al., 2009 ), 87 % of the children
were found to have no longer met the diagnosis
of OCD. This study provided support for the
long-term gain of CBFT for children with OCD.
The study by Simons et al. ( 2006 ) was among
the fi rst studies to have examined the effi cacy
of meta-cognitive therapy (MCT) for the treat-
ment of paediatric OCD. In this study, 11 chil-
dren and adolescents with OCD were randomly
assigned to either the MCT or the ERP groups.
None of them received pharmacotherapy for
their OCD. MCT involves the appraisal of dys-
function meta-cognitive appraisal (e.g., thought–
action fusion) and meta-cognitive process (e.g.,
selective attention). Obsessional thoughts are
normalized and are accepted as they are. MCT
also uses thought control experiments, behav-
ioural experiments, and socratic dialogue to help
young people change their meta-cognitive strate-
gies and appraisals which may be responsible in
maintaining their OCD symptoms (Simons et al.,
2006 ). In illustrating how to use the MCT, the
authors gave an example of an adolescent with
bad commanding and blasphemous and “just
right” thoughts, and whose compulsions involved
touching and licking the fl oor and furniture. The
dysfunctional thought–commandment fusion that
the adolescent used was “if I think …, I have to
do it”. Some of the ways in which the adoles-
cent were taught to handle the thoughts were
suppressing, evoking and accepting. The ado-
lescent also used meta-cognitive reframing and
thought- imperative defusion (e.g., you cannot do
everything that you think of). The result showed
that both treatment approaches were shown to
produce signifi cant reduction in OCD symptoms
severity. These positive effects were found after
13 sessions of ERP and after 9 sessions of MCT,
which were maintained two years after the treat-
ment begin.
What Doesn’t Work
Empirical data to support the benefi t of psy-
choanalytic psychotherapy for OCD symptoms
are currently not available (Heyman, 2005 ).
Therefore, the National Institute for Health and
Clinical Excellent (NICE, 2005 ) does not recom-
mend it to be used in young people with OCD.
Psychopharmacology and OCD
In the UK, the selective serotonin reuptake inhib-
itors (SSRIs) are recommended as a last choice of
treatment for children, and should only be used in
treating individuals with moderate and severe
OCD, or after unsuccessful treatment with psy-
chological therapy (NICE, 2005 ). Furthermore,
the NICE cautions the use of the SSRIs because
of their unknown effect on the child’s develop-
ment, as well as their side effects such as appetite
suppression and nausea. Despite this warning and
because of their wide availability, medication is a
common form of treatment with adolescents with
OCD. Of all the available medications, serotonin
reuptake inhibitors, which work through their
action on serotonin neuro-transmission are the
most common (Tables 13.2 , 13.3 , and 13.4 ).
Numerous trials that have examined the effec-
tiveness of various SSRIs (i.e., sertraline, fl uox-
etine, fl uvoxamine and paroxetine) have reported
their effectiveness in reducing OCD symptoms
when compared to placebo (Geller et al., 2004 ;
March & Mulle, 1998 ; Riddle et al., 2001 ). A tri-
cyclic (i.e., clomipramine) has also been reported
to be effective among children and adolescents
with severe level of OCD (Leonard et al., 1989 ).
A meta-analysis of paediatric pharmacotherapy
trials showed both SSRIs and clomipramine to
have signifi cant and modest effect sizes (Geller
et al., 2003 ). However, when comparing these
two groups of medication, clomipramine com-
pared to SSRIs, was reported to have larger effect
size (Geller et al., 2003 ).
The Prevention of OCD
Despite the availability of evidence-based effec-
tive treatment for OCD, about 50.8 % of children
had not received any treatment for OCD prior
to clinic attendance (Chowdhury et al., 2004 ).
C.A. Essau and B.U. Ozer
255
Among those who received treatment, most of
them (42 %) received medication alone (i.e.,
SSRI or clomipramine), 7 % received CBT in
combination with medication, and 9 % received
other treatments (i.e., analytical psychother-
apy, family therapy, and cranio-facial therapy).
Factors related to low mental health services uti-
lization were: lack of resources available locally,
long waiting lists to see the primary care thera-
pists, clinician’s lack of awareness of evidence-
based practice. These fi ndings underlined the
importance of prevention.
W h a t W o r k s
There are no available studies on the prevention
of OCD.
What Might Work
Due to the low rate of mental health services
utilization, a long waiting list, and to the fact
that OCD is frequently unrecognized or mis-
diagnosed, it is important to fi nd strategies to
make effective intervention accessible to those
with OCD or to those with high risk of develop-
ing OCD (Chowdhury et al., 2004 ). One such
effort is to provide interventions in school set-
tings that could prevent the development of
OCD. Prevention programs may be universal,
selected, or indicated (Mrazek & Haggerty,
1994 ). Universal intervention is directed at the
whole population. Selective intervention involves
children who have been identifi ed as at risk of
psychological problems, whereas indicated inter-
vention targets children who have been identi-
ed as having mild to moderate symptoms of a
disorder. A universal approach to prevention in
schools teaches children generic skills that may
be used in a number of everyday situations; it also
helps to promote learning and healthy develop-
ment. Essau, Conradt, Sasagawa, and Ollendick
( 2012 ) recently evaluated the effectiveness of the
FRIENDS (Barrett, Lowry-Webster, & Turner,
2000 ), an Australian cognitive-behaviour therapy-
based program, in reducing anxiety symptoms
among children. Children who participated in the
FRIENDS program showed signifi cantly fewer
anxiety symptoms than children in the control
group at 12-month follow-up. Within the anxi-
ety disorder symptoms, OCD showed signifi cant
differences at both 6- and 12-month follow-ups.
A study using the FRIENDS program in the
UK (Stallard, Simpson, Anderson, Hibbert, &
Osborn, 2007 ) has similarly found a signifi cant
reduction in the OCD symptoms among young
people who participated in this program.
What Doesn’t Work
There are no available studies which report pre-
ventive program that does not work.
Recommended Best Practice
OCD is a chronic and disabling condition
which is characterized by the presence of
intrusive thoughts and/or repetitive behaviours
(APA, 2013 ). It is associated with psychosocial
impairments in various life domains, and if left
untreated, the OCD and its associated impair-
ment tend to persist into adulthood. Despite
these impairments, a high percentage of those
with OCD either did not, or had long delays
in receiving effective treatments (Hollander &
Wong, 1998 ), possibly due to lack of access to
these treatments. The reason for this limited
access included the fact that it is not widely used
by mental health professionals; among adults
with OCD some of the reasons for not participat-
ing in CBT were cost (57 %), available of insur-
ance coverage (38 %) and time (31 %) (Marques
et al., 2010 ). This has led to other alternative
way to deliver CBT which makes it more acces-
sible and less time-consuming and costly. One
such alternative is the use of “stepped care”
approach.
The Clinical Practice Guideline, a guideline
commissioned by the NICE in the UK ( 2006 )
recommended the use of “stepped care” for
OCD. The “stepped care” approach starts by
delivering the least intensive intervention (e.g.,
13 Obsessive-Compulsive Disorder
256
self-help) and only move to the more intensive
therapy if it is not effective (Haaga, 2000 ). This
seems to be a useful approach given the number
of young people with psychiatric disorders,
including OCD, who are in waiting list to see a
mental health professional. The main focus of
each of the steps is: (a) Step 1 involves providing
information about OCD and its impact on the
children and their families. Such information
could be provided by various public organiza-
tions. (b) Step 2 involves recognition and assess-
ment of OCD by health or mental health
professionals. At this stage, treatment options
will be discussed and referral is made at the
appropriate levels. (c) Step 3 involves providing
initial treatment of OCD by mental health pro-
fessional such as guided self-help and CBT
(including ERP). (d) Step 4 follows due to poor
response to initial treatment (CBT, including
ERP). At this stage, a combined treatment of
CBT (including ERP) and medication (e.g.,
SSRI, alternative SSRI or clomipramine) should
be considered. (e) Step 5: young people whose
OCD is associated with signifi cant comorbidity,
or severe psychosocial impairment and/or treat-
ment resistance are referred to specialist and
multidisciplinary care where they will receive
CBT (including ERP) in combination with SSRI
or alternative SSRI or clomipramine. (f) Step 6:
young people whose OCD is associated with
severe self-neglect or severe distress need to be
reassessed and their treatment options discussed.
In most cases, these young people are referred
for inpatient care or intensive treatment pro-
grams. Treatment generally includes a combina-
tion of medication (e.g., SSRI or clomipramine)
and CBT (including ERP).
In adults, about one-third of patients
responded to lower intensity guided self-help and
that two- thirds received the higher intensity treat-
ment (Gilliam, Diefenbach, Whiting, & Tolin,
2010 ; Tolin, Diefenbach, & Gilliam, 2011 ).
Furthermore, a standard treatment condition
was found to be as effective as the stepped care
program; they differ only in their cost of deliv-
ery in that the stepped care program was found
to be more cost-effective than standard treatment
(Tolin et al., 2011 ).
Studies have also demonstrated some evi-
dence that adults who received CBT that were
delivered by telephone showed similar positive
outcome and satisfaction level as when the CBT
sessions were delivered face to face (Lovell et al.,
2006 ). CBT delivered by telephone were about
30 min shorter than when CBT sessions were
delivered face to face. This translated to about
40 % saving in therapist’s time, thus, reducing
the cost involved. Turner, Heyman, Futh, and
Lovell ( 2009 ) examined the feasibility and out-
come of using telephone in delivering CBT to
young people with OCD. Half of these adoles-
cents were taking SSRI at the time of referral.
CBT sessions were conducted once a week with
young people and their parents at an agreed time.
Intervention was based on a CBT treatment man-
ual that is commonly used among young people
who receive face-to-face CBT in a clinical set-
ting. The participants were given a workbook
with work sheets for them to record their assign-
ment. The fi ndings showed telephone-
administered CBT to be an effective way of
delivering CBT to young people. Specifi cally,
about 70 % of them achieved remission of their
OCD. Participants rated telephone CBT to be
convenient, fl exible, and less stressful than the
traditional CBT.
Given the wide availability of computer and
other information technology several computer-
based prevention and early intervention programs
have been developed for anxiety and depressive
disorders. According to a systematic review of
the literature on internet interventions for child
and adolescent anxiety and depression by Calear
and Christensen ( 2010 ), four internet-based pro-
grams have been developed and evaluated
(BRAVE-ONLINE, Project CATCH-IT,
MoodGYM and Grip op je dip online). Evaluation
studies on these programs reported signifi cant
reductions in anxiety and depressive symptoms at
post-intervention and at follow-up. Another
progress is the use of handheld computer-assisted
CBT for various anxiety disorders among adults
(Clough & Casey, 2011 ). Given its widespread
use among young people, handheld technology
(e.g., mobile phones) could make it an excellent
devise to deliver CBT. To our knowledge, no
C.A. Essau and B.U. Ozer
257
computer-based prevention programs have been
developed specifi cally for paediatric OCD.
However, given the high comorbidity between
OCD and anxiety, psychological intervention that
focuses on anxiety and its role in OCD is an
important starting point for a successful CBT to
treat OCD (Heyman, 2005 ) .
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13 Obsessive-Compulsive Disorder
... Globally, people from diverse age groups, genders and ethnic backgrounds are coping with OCD. While the precise etiology of OCD remains elusive, a complex interplay of neurological, genetic, environmental, and psychological factors perhaps contributes (Agarwal and Srivastava, 2022;Essau and Özer, 2015;Goodman et al., 2014;National Institute of Mental Health, 2022;Pampaloni et al., 2022;Taylor, 2011). Regrettably, OCD frequently remains under diagnosed, with an average duration of untreated disorder lasting 17 years. ...
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This chapter considers Obsessive-Compulsive Disorder (OCD) from developmental and evolutionary perspectives. It begins with a definition of obsessions and compulsions and a description of this diagnostic category. The chapter then examines several normal epochs of development that are characterized by obsessive-compulsive behaviors that resemble those encountered in OCD. It focuses on the phenomenology and natural history of OCD, and reviews the available genetic, epigenetic, neuropsychological, neurochemical, neuroendocrine, and neuroimaging data that bear on OCD and related normal phenotypes. The chapter further presents number of theoretical models of pathogenesis and the treatments they have engendered. It offers an integrative model that emphasizes evolutionary and developmental perspectives and describes its potential utility in providing a coherent, multidisciplinary framework for future work in this area.
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Epidemiologic studies show that by late adolescence OCD has a lifetime prevalence of 2% to 3%. The age of onset is earlier in boys than in girls, and has a first peak around puberty and another in early adulthood. The natural course of the disorder is fairly stable, with a complete remission rate of 10% to 15%, although fluctuations in symptom level may make short-term apparent outcome unreliable. Comorbid conditions include depression, movement disorders, and anxiety disorders. Although the prevalence of OC symptoms and of OCD are not different for boys and girls, there may be gender differences in the symptom types. The boundary of the diagnosis of OCD is not always easy to determine, and individuals may meet threshold and subthreshold criteria at different times.
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Important progress has been made in understanding the spectrum of obsessive-compulsive disorders; however, most advances in treatment have been directed at the compulsive element of the behaviour. It is estimated that for as many as one in three patients presenting with obsessive-compulsive disorder, the primary problem is the obsessions. Obsessions are repetitive, unwanted thoughts, images or impulses. This volume describes how to conduct the first, specific cognitive treatment for obsessions, and provides a comprehensive account of the underlying cognitive theory and supporting experimental evidence. The title discusses patient assessment procedures, provides a detailed explanation of the specific technique, anticipates possible patient reactions and suggests tactics for dealing with them, and explores methods for assessing progress. Throughout, there are helpful case studies to illustrate aspects of the technique and the title closes with a ‘tool kit’ of forms and charts to allow the therapist to plan and record treatment sessions.
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Obsessive-compulsive disorder is a severe and disabling clinical condition that usually arises in late adolescence or early adulthood and, if left untreated, has a chronic course. Whether this disorder should be classified as an anxiety disorder or in a group of putative obsessive-compulsive-related disorders is still a matter of debate. Biological models of obsessive-compulsive disorder propose anomalies in the serotonin pathway and dysfunctional circuits in the orbito-striatal area and dorsolateral prefrontal cortex. Support for these models is mixed and they do not account for the symptomatic heterogeneity of the disorder. The cognitive-behavioural model of obsessive-compulsive disorder, which has some empirical support but does not fully explain the disorder, emphasises the importance of dysfunctional beliefs in individuals affected. Both biological and cognitive models have led to empirical treatments for the disorder-ie, serotonin-reuptake inhibitors and various forms of cognitive-behavioural therapy. New developments in the treatment of obsessive-compulsive disorder involve medications that work in conjuction with cognitive-behavioural therapy, the most promising of which is D-cycloserine.
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