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Cognitive-Behavioral Therapy of Obsessive Compulsive Disorder in Children and Adolescents



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Chapter 2
Cognitive-Behavioral Therapy of Obsessive-Compulsive
Disorder in Children and Adolescents
Irem Damla Cimen
Additional information is available at the end of the chapter
Provisional chapter
© 2016 The Author(s). Licensee InTech. This chapter is distributed under the terms of the Creative Commons
Attribution License (, which permits unrestricted use, distribution,
and reproduction in any medium, provided the original work is properly cited.
DOI: 10.5772/intechopen.70612
Cognitive-Behavioral Therapy of Obsessive-Compulsive
Disorder in Children and Adolescents
Irem Damla Cimen
Additional information is available at the end of the chapter
While obsessive-compulsive disorder (OCD) is present under the category of anxiety
disorders in DSM-IV TR, it is classied under “Obsessive Compulsive Disorder and
Related Disorders” in DSM 5. There is no dierent diagnostic system for children and
adolescents. OCD has serious adverse eects on family, school, and social lives of chil-
dren and adolescents, but adolescents with OCD often hide their symptoms and delay
seeking help due to several reasons such as inability to recognize their symptoms as
disease manifestations, embarrassment, fear of being stigmatized by other people, and
believing that what the experience is transient. The age of onset has signicance in terms
of the disease progression. Therefore it is very important to detect OCD at its early
stage, because the majority of the adult patients develop the disease during childhood
or adolescence.
Keywords: obsessive-compulsive disorder, child, adolescent, review, psychiatric disorders
1. Introduction
Obsessive thoughts and behaviors are mentioned since ancient times and mentioned on holy
books. In Middle Ages, it was thought that people who have religious and sexual unwanted
thoughts were taken over by the devil and to be punished by burning. In the seventeenth
century, Shakespeare dened a character called Lady Macbeth; she had contamination obses-
sion and hand washing compulsion. In the nineteenth century, Esquirol mentioned from a
case report named Matmazel F. Matmazel F was rubbing her ngers and washing her hands
constantly because she was thinking that she might be infected with something, and she
could not stop herself. Morel used the term of “obsession” rst time in 1866. In the twentieth
century, Janet stated that the sense of incompleteness is the base of obsessive-compulsive
© 2018 The Author(s). Licensee InTech. This chapter is distributed under the terms of the Creative Commons
Attribution License (, which permits unrestricted use,
distribution, and reproduction in any medium, provided the original work is properly cited.
disorder. Janet handled this disorder under the title of psikasteni and exhibited that rituals
could be improved by behavioral technics. S. Freud also stated the psychodynamic basis of
the disorder [1].
There are two basic classication systems in psychiatric disorders as the Diagnostic and
Statistical Manual (DSM) and the International Classication of Diseases (ICD). Obsessive-
compulsive disorder (OCD) has been included in ICD-5 rst time among adult mental dis-
orders in 1939, but for children OCD has been included in DSM-II among childhood mental
disorders in 1968 and in ICD-9 in 1978 [2–4]. In DSM-IV, dierences in childhood OCD
patients “like they could not know their obsessions and compulsions” are extremely unrea-
sonable were highlighted [5]. While obsessive-compulsive disorder (OCD) is present under
the category of anxiety disorders in DSM-IV TR, it is classied under “Obsessive Compulsive
Disorder and Related Disorders” in DSM 5 and hoarding compulsions separated from OCD
in DSM 5 into a new disorder, as “Hoarding Disorder.” But in the ICD 10 classication sys-
tem, OCD is located under “neurotic, stress-related, and somatoform disorders” [68].
Obsessive compulsive disorder and related disorders include:
• Obsessive-compulsive disorder (OCD)
Body dysmorphic disorder
Hoarding disorder
• Trichotillomania
• Excoriation (skin-picking) disorder
• Substance-/medication-induced obsessive-compulsive and related disorder
• Obsessive-compulsive and related disorder due to another medical condition
Other specied obsessive-compulsive and related disorders and unspecied obsessive-
compulsive and related disorders [8]
OCD is a disorder that is characterized by the presence of obsessions and/or compulsions [8].
Obsessions are intrusive and unwanted thoughts, urges, or images which are recurrent and
persistently experienced and caused anxiety or distress. Patients usually try to ignore or sup-
press these thoughts, urges, or images or try to neutralize them. Compulsions are behaviors
or mental acts which are repetitive and performed in response to an obsession or applied as
rigid rules. These behaviors or mental acts are performed in order to prevent or reduce anxi-
ety and distress or feared event or situations. These behaviors or mental acts are unrelated
with feared events in reality. For this to be diagnosed, it should take a lot of time, for example,
more than 1 h per day and cause clinically signicant distress or impairment in functioning
like social, occupational, or other important areas. Symptoms of OCD must not be related
with any substance’s physiological eects, medical conditions, or mental disorders. In DSM 5
diagnostic criteria, OCD could be specied as if with good or fair insight, with poor insight,
and with absent insight/delusional beliefs or tic related [8]. Although there is no dierent
diagnostic system for children and adolescents than the adults, it has been stated that young
Cognitive Behavioral Therapy and Clinical Applications28
children may not be able to articulate the purposes of their compulsive behaviors or cognitive
actions [8]. Children usually have less insight about the irrationality of their obsessions and
compulsions. And at some developmental stages of children, it is hard to distinguish some
normative behaviors from OCD. At this point, behavior’s impact in child or adolescent’s func-
tioning is important; normative behaviors usually do not aect functioning [9].
2. Etiology
The etiology of OCD is certainly unknown, but multiple factors like genetic, biological, cog-
nitive, and behavioral are found eective [10]. Also it involves interactions between genetic
and environmental factors [11]. Environmental factors such as traumatic life events and stress
were found to be eective in 50% of OCD cases [12, 13]. In a twin study, OCD concordance
was found approximately 90% in identical twins and 47% in dizygotic twins [14]. And in a
twin study, genetic factors were found related with OCD symptoms [15]. In early onset OCD
patients, OCD may be almost twice as high through the relatives as late onset OCD patients.
This shows that familiarity in early onset OCD patients is higher [16].
OCD is a neuropsychiatric disorder, and basal ganglia dysfunction has been associated with
obsessive-compulsive symptoms. In literature there are some studies that found associa-
tion between OCD and neurological disorders like epilepsy, brain injury, Touree’s syn-
drome, and Sydenham’s chorea [1619]. Repetitive behaviors in a patient with Sydenham
cores were rst described by Sir William Osler. During the course of Sydenham’s chorea,
usually obsessive-compulsive symptoms occur [18, 20]. In literature it was reported that
immunologically based group A beta-hemolytic streptococcal infection is an another etio-
logical factor. This disorder is called as Pediatric Autoimmune Neuropsychiatric Diseases
Associated to Streptococcal Infections (PANDAS). This disorder leads to an autoimmune
inammation in the striatum and other brain areas and shows some neurologic symptoms
like hyperactivity, choreiform movements, and tics. In addition to these, in a certain period,
increase of obsessive-compulsive symptoms is observed. This makes researchers to think
that Touree’s syndrome, Sydenham’s chorea, and OCD have a common etiology [21].
OCD’s neural basis is thought to include the circuits of the orbitofrontal cortex, striatum,
and thalamus and the neurotransmiers as serotonin, dopamine, glutamate, and gamma-
amino-butyric acid [22, 23].
In recent neuroimaging studies, amygdala and prefrontal cortex’s role has been found impor-
tant in mechanism of regulating emotional responses like fear and anxiety [24]. Some evi-
dences showed that there is a reward dysfunction in OCD [25]. Similar to addictive behaviors,
compulsive behaviors that cause relief from anxiety and have a rewarding eect were hypoth-
esized. Reward process has been associated with ventral striatal orbitofrontal circuitry and in
neuroimaging studies; it was shown that OCD patients had an altered metabolism in this area
frequently, and this results supported the hypothesis [26].
As psychoanalytic theory, unresolved oedipal complexes cause anxiety, and this takes place
a factor in OCD etiology. According to this theory, as a result of encountering anxiety, people
Cognitive-Behavioral Therapy of Obsessive-Compulsive Disorder in Children and Adolescents
have a regression to anal period, and some defense mechanisms are commonly used like iso-
lation, doing-undoing, reaction formation, and displacement [27].
There is a lile evidence about the cognitive mechanisms of OCD; it is thought that these
mechanisms are similar in adults and children. According to cognitive theory, the basis of
obsessions is catastrophic interpretation of unwanted and distressing thoughts, impulses, and
images. Obsessions are creating anxiety, and by rituals, ruminations, or avoidances, this anxi-
ety is tried to be reduced. For obsession treatment these misinterpretations must be corrected.
Also in a study, maternal cognitive biases are found more relevant with younger children’s
OCD severity; personal cognitive biases are more relevant in adolescents [28].
3. Epidemiology
People with OCD seek medical help when their daily functionality is seriously compromised
or they experience severe anxiety, and it has been reported that these individuals start seeking
professional help after an average of 7 years from the onset of these symptoms. It was found
that adolescents with OCD often hide their symptoms and delay seeking help due to several
reasons such as inability to recognize their symptoms as disease manifestations, embarrass-
ment, fear of being stigmatized by other people, and believing that what they experience is
transient [29, 30]. Furthermore, because adolescents hide their symptoms, it is dicult to deter-
mine the actual prevalence of the disorder, and when they seek professional help, they may be
misdiagnosed as depression or anxiety disorder due to not mentioning their symptoms [31].
In the past few decades, knowledge of OCD has increased, but studies were mostly done in
adult population and less studied in children. Although the rst study about the prevalence
of OCD in children was reported in 1970, there are few population-based studies presented
about the prevalence of OCD in children and adolescents recently [32]. The prevalence of
OCD in children and adolescents has been reported between 0.5 and 3% [33, 34]. In a recent
study, in 16 European countries, median prevalence of OCD was found 0.7% [35].
It is predicted that OCD is the fourth frequent psychiatric disorder after phobies, substance
use disorder, and depression. Studies in dierent countries and cultures show that OCD prev-
alence is independent from cultures [27]. Previous epidemiological and clinical studies show
that OCD is more frequent among males prior to adolescence and during childhood, the dif-
ference between the sexes diminishes to a similar rate as the age advances, and the prevalence
rate does not dier between sexes during adolescence and adulthood, and the rates are equal
in both sexes at this time [3646]. Although it was reported in the literature as early as 2 years
of age, OCD usually begins at late childhood and early adolescence in youth. Age at onset of
the OCD is averagely 10 years old, but age of diagnosis is around 13 years old [47]. Childhood-
onset OCD’s onset age is approximately 8–11 years old in boys and 11–13 in girls [48].
OCD has adverse eects on family, school, and social lives of children and adolescents [49,
50]. The age of onset has signicance in terms of the disease progression. Several studies
have detected that OCD often starts at late adolescence and early adulthood period [51, 52].
Cognitive Behavioral Therapy and Clinical Applications30
Cognitive-Behavioral Therapy of Obsessive-Compulsive Disorder in Children and Adolescents
like the Children’s Florida Obsessive Compulsive Inventory (C-FOCI), Leyton Obsessional
Inventory-Child Version, the Anxiety Disorders Interview Schedule for DSM-IV: Child and
Parent Version (ADIS-C/P) which could be used for OCD assessment in pediatric popula-
tion [6769].
6. Comorbidities
Among children with OCD, 85% of patients have at least one, and 21–75% have at least two
or more additional psychiatric diseases [7073]. The most commonly reported accompanying
diagnoses include anxiety disorder and depression [71, 72, 74]. Several studies involving chil-
dren and adolescents have reported that aention decit hyperactivity disorder, Touree’s
disorder, oppositional deant disorder, and generalized anxiety disorder are frequent comor-
bidities [7578]. In addition to these accompanying disorders, eating disorders, especially
anorexia nervosa, can be frequently observed concurrently with OCD in females [79]. Other
studies have found association between early onset OCD and somatoform disorders, tic dis-
order, impulse control disorder, and high resistance to treatment [8083].
7. Dierential diagnosis
There are many diagnoses that can be confused with OCD. For example, some anxiety disor-
ders must be considered like generalized anxiety disorder, specic phobia, and social anxiety
disorder. In generalized anxiety disorder, recurrent thoughts are usually about real-life con-
cerns as nances and family, but in OCD these thoughts are irrational. Anxiety of patients
with specic phobia is more limited with specic objects or situations, and they do not have
rituals or compulsions. In social anxiety disorder, fear is limited with social situations. Major
depression can be confused with OCD, but obsessions in major depression are usually appro-
priate with patients’ mood, not intrusive or distressing and not related with compulsive
behaviors. Some disorders that are under the category of OCD and related disorders like body
dysmorphic disorder, trichotillomania, and hoarding disorder can interfere with OCD. In
body dysmorphic disorder, obsessions and compulsions are only with physical appearance;
in trichotillomania there are no obsessions, and compulsive behaviors are only hair pulling.
Hoarding disorder patients have diculty in discarding or parting with possessions. In con-
sequence objects extremely accumulate, but in OCD obsessions are not typically related with
dispose of objects. Although obsessions and compulsions in anorexia nervosa are limited to
body image or weight, this disorder can be confused with OCD. Tic disorders also can be
misdiagnosed as OCD. Tics are not related with neutralizing obsessions, and tics are less com-
plex than compulsions. Not only OCD but also psychotic disorder patients can have irrational
thoughts or delusional beliefs. But OCD patients do not have other psychotic symptoms and
recognize that the intrusive thoughts are a product of their own mind. Obsessive-compulsive
personality disorder does not have specic obsessions or compulsions but have a resistant
perfectionist or controller personality structure. OCD can be confused with some medical con-
ditions because of the results of compulsions like eczema, rashes, and constipation [8, 9, 84].
Cognitive Behavioral Therapy and Clinical Applications32
8. Treatment
8.1. Cognitive behavioral therapy
Cognitive behavioral therapy (CBT) is recommended for the rst-line treatment in mild to
moderate OCD, but in moderate to severe OCD cases, it is recommended to support CBT with
medication [85].
CBT is a kind of psychotherapy which is developed on the basis of learning theories in psy-
chology and the principles of cognitive psychology. The purpose of this therapy is to change
emotions and incompatible behaviors by using psychotherapeutic methods based on these
principles [86]. Behavioral therapies began to be used in the treatment of emotional and
behavioral problems of young people in the 1950s. These behavioral approaches are based on
the theories of Thorndike, Watson, and Bandura, and classical and operant conditioning have
been used to treat behavioral disorders seen in infants and children. Cognitive therapies were
developed by Aaron Beck in the 1970s and started to be used in the treatment of child and
adolescent cases in the 1980s [87].
According to CBT, the mental condition of a person is the result of the mutual interaction of
the environment, relationships, the biological structure, emotions, cognition, and behaviors.
Psychotherapeutic methods can only be applied to cognition and behaviors of a person [86].
According to learning theory, compulsions reduce distress that triggered by obsession so that
negative reinforcement occurs over time (Figure 1) [88].
Figure 1. The obsessive-compulsive cycle used by Piacentini et al. [89] to describe OCD’s mechanism.
Cognitive-Behavioral Therapy of Obsessive-Compulsive Disorder in Children and Adolescents
In the CBT, children and adolescents learn to confront with their fears step by step. By learn-
ing how to behave against what the OCD tells them, they would understand that their fears
do not reect reality [90]. According to cognitive theory, cognitive processes determine the
feelings and behaviors of people. Cognitive processes provide one’s interpretation of the
external world, surrounding events, own life, and relations with other people. When the basic
assumptions and beliefs involved in the cognitive structure that determines the person’s view
of the world and its interpretations are distorted or functionally improper, a person begins to
experience problems [91]. Hence, problems that disturb the person are not due to the events
and experiences themselves but due to perception and evaluation of the events and experi-
ences [92]. Instead of these problematic forms of interpretation, cognitive therapy tries to
reveal more compatible and appropriate perception and evaluation structures for a situation
[93]. Additionally, cognitive therapy emphasizes that improper cognitive structures are an
important factor in emerging and maintaining mental disorders. The basic cognitive features
of OCD are an overestimation of thoughts and feelings, exaggerated sense of responsibility,
perfectionism about controls of thoughts and behaviors, and catastrophic interpretation of
possible outcomes of thoughts and impulses, and these features lead to misinterpretations
[21]. Cognitive therapy rstly tries to establish connections among emotion, behavior, and
thought [94]. According to the cognitive theory, cognition is examined in two sets: automatic
thoughts and schemes (Figure 2) [86].
Cognitive therapy deals with automatic thoughts. These thoughts are spontaneous and located
in the stream of mind. Also, they are cognitions that are mostly specic to environment and
situation that accompanied to moments of emotional distress. Contrary to emotions automatic
thoughts are rarely noticed. These thoughts could be verbal or imaginary. There are unsaid
Figure 2. Cognition structure [86].
Cognitive Behavioral Therapy and Clinical Applications34
intermediate beliefs, rules, and assumptions regulating one’s behavior underlying automatic
thoughts. These are permanent rules and anticipations about the behavior of himself/herself
and others, their life, and things that happened to them. Nonfunctional intermediate beliefs
lead the therapist to core beliefs that are the deepest cognitive structures. Core beliefs consist
of people’s early life experiences and their identication with the people around them. These
beliefs are reinforced by similar experiences and learnings by time [95]. According to Piaget,
the child enters the concrete operational stage around the age of 7–8. Most of the children at
the concrete operational stage have the logical processes to take advantage of the cognitive
debate. There may be diculties in cognitive therapy in children who have not reached the
concrete operational stage [95]. Children and teenagers often apply to therapy by caregiver’s
decision. So the rst thing to do by the therapists is to introduce themselves and to explain to
the child who they are, what they do, and how they can help [93].
The most eective behavioral techniques are a combination of exposure and response preven-
tion. Exposure to anxiety-producing stimulus is advised to a person, and decrease of anxi-
ety is expected after repeated practices. During exposure, the person must prevent rituals
and avoidance behaviors. At this stage, response prevention is used. Practices can be in real
or imaginary ways. A list should be made of the anxiety-inducing stimuli before practice.
Practice starts with easy tasks in the list, and the diculty of the tasks is increased step by
step [27, 96].
CBT session consists of symptom control, review, and geing feedback of homework done;
determines the agenda items; congures session content; and determines the new homework,
[97]. CBT usually continue 10–14 weeks, with weekly sessions taking 45–90 min [98]. Among
the basic principles of the CBT, the rst step is psychoeducation. In psychoeducation session,
the incidence and prevalence of OCD, age-dependent normal obsessive-compulsive behav-
iors, OCD’s symptoms and disorder’s nature in child and adolescent age group, OCD’s mech-
anism, and the impact of factors like developmental level and temperament are given. Also in
this session, knowledge of underlying reasons of OCD and basis of cognitive and behavioral
therapy, especially exposure and response prevention, and social learning theory, when the
medical treatment is needed, are given.
The second step is the diagnostic assessment. There must be a detailed assessment of child’s/
adolescent’s problem and history of coping methods and medical, developmental, family,
and school features. Social and cultural characteristics must be considered. Dierent sources
of information such as the clinical interview, parents, questionnaires, and information from
school must be integrated. Specic OCD symptoms and comorbidities should be asked. A for-
mulation should be made including protective, precipitating, predisposing, and maintaining
factors linked to child/adolescent’s situation. The decision should be given about whether an
additional medical treatment is necessary. A family assessment involving the capacity to sup-
port the child/adolescent of the family should be undertaken. Which family members have
become involved in rituals, avoidance behaviors, and obsessions and family functioning must
be questioned.
In the third step, emotions, behaviors, and cognitions should be assessed. Anxiety should
be explained and normalized in ordinary fear-inducing situations. Furthermore, thoughts,
Cognitive-Behavioral Therapy of Obsessive-Compulsive Disorder in Children and Adolescents
feelings, and behaviors should be assessed. Detailed list of obsessive ideas and rituals should
be done by standardized instruments. Insight level should be questioned. A list of triggers to
obsessional fears and compulsive behaviors/rituals and avoided situations should be gener-
ated. Cognitive and behavioral rituals used to reduce discomfort should be identied. By
using scales appropriate for the age such as “fear thermometer” or “SUDS ratings” anxiety
levels should be rated, and child/adolescent should rate how dicult to resist OCD symp-
toms. For exposure and response prevention, targets should be identied.
The next step is intervention stage. At this step, OCD and intervention rationale should
be explained. OCD could be explained by age-appropriate metaphors. With positive rein-
forcement like praise, awards, and “certicates of achievement,” engagement to therapy
should be increased. OCD symptoms are tried to be externalized by giving a nickname
to OCD, using “boss back OCD” strategy, being child/adolescent’s ally in ghting OCD
and guring out strategies for ghting OCD. Constructive self-talk might be helpful for
coping, and cognitive reconstruction would be useful for unhelpful assumptions under-
lying the obsessions. In the exposure trials, a child/an adolescent creates a hierarchic list
of anxiety situations. Mutually agreed targets are chosen from the list, and those targets
are worked together. A direct exposure method is implemented on the agreed targets,
and enough exposure time is allowed for habituation. In this process, anxiety levels are
rated. Graded exposure including imaginal exposure, exposure to cartoons or images of
the feared trigger, is used in the session [99]. The exposure trial is continued until distress
ratings decrease by 50% [100]. By agreeing on realizable daily homework tasks, chances of
success are maximized.
For ritual prevention, a plan will be made as delaying, shortening, doing dierently or
performing the ritual slowly. Also, self-monitoring and recording rituals are a part of the
exposure process. During response prevention, child’s/adolescent’s anxiety is measured by
the fear thermometer. Then relapse prevention is used. The distinction between “lapse”
and “relapse” is explained to child/adolescent and parents. For any future OCD symp-
toms, a rehearsal is made for remembering and using CBT techniques. Family members are
included in the intervention as “coaches” for supporting children during exercises, and it is
important to work with the school [99]. When CBT is implemented, escape, avoidance, and
security search behaviors must be considered because these behaviors are the factors lead-
ing to anxiety [101].
Child/adolescent is trained for some anxiety management strategies like breathing and relax-
ation techniques [102]. CBT could be implemented in groups. Studies show that group CBT
programs are more comfortable for patient children because of seeing other children with the
same problem [90]. The developmental characteristics as a level of autonomy and dependence
of the child should also be considered when CBT is applied [101]. The level of language devel-
opment during therapy can cause problems. They may not express their feelings verbally.
For this reason, rst of all, emotional words and concepts should be studied with comics,
pictures, heroes, and narratives [93]. And cognitive behavioral play therapy can be applied
while working with very young children [101].
Cognitive Behavioral Therapy and Clinical Applications36
8.2. Medical treatment
In OCD’s pharmacological treatment, uoxetine, sertraline, and uvoxamine as selective
serotonin reuptake inhibitor (SSRI) and clomipramine as nonselective serotonin reuptake
inhibitor have the approval of US Food and Drug Administration for child and adolescents.
Which serotonergic drug is the rst choice is unknown. But clomipramine’s eect was found
superior than SSRIs [103]. Clomipramine is considered as the gold standard medication in
pharmacological treatment of OCD; however, 46–74% of adolescent OCD patients have been
reported to benet from this drug [104]. Studies indicate that selective serotonin reuptake
inhibitors (SSRIs) are superior to placebo for treatment of childhood OCD [103].
Some supportive strategies can be applied in case SSRI treatment is not adequate. These
supportive methods include options like addition of CBT, risperidone, clonazepam, clomip-
ramine, aripiprazole, or memantine to the treatment [105, 106]. Medication augmentation is
recommended for cases which have moderate impairment persists in at least one function-
ing area despite adequate monotherapy. Treatment resistance can be described as failing ≥2
adequate SSRI monotherapy treatment, 1 SSRI and a clomipramine trial, and failure of ade-
quately delivered CBT [85].
In augmentation strategy especially clomipramine and the atypical antipsychotics are com-
monly used [107, 108]. And also some other drugs like stimulants, gabapentin, sumatriptan,
pindolol, inositol, opiates, St. John’s wort, N-acetyl cysteine, memantine, and riluzole, with-
out evidence-based results, have also been tried [109].
Adding clomipramine to an SSRI (often uvoxamine at low doses like 25–75 mg/day) could
be a useful augmentation strategy. But practitioner must be careful about adding clomip-
ramine to uvoxamine or to other CYP-450 2D6 inhibitors like uoxetine or paroxetine to
prevent potentially toxic serum clomipramine levels which would cause cardiological side
eects and must follow up with electrocardiography. In augmentation therapy, mostly atypi-
cal antipsychotics are chosen. This strategy can improve oppositional behaviors which are
caused by increased anxiety level [85]. Riluzole is a “glutamatergic modulator” which eects
on glutamate release and increases the level of α-amino-3- hydroxy-5-methyl-4-isoxazolepro-
pionic acid tracking and amino acid transporters that stimulates neuroglia [110]. Riluzole
has FDA indication only in amyotrophic lateral sclerosis, but there are no indications for
childhood conditions. Recently, riluzole was studied in a few open-label trials for general-
ized anxiety disorder, major depressive disorder, bipolar depression, and OCD in adults, and
these results showed riluzole’s benecial eects, and it was well tolerated [111]. In an open-
label trial of riluzole of childhood OCD, four of six patients’ OCD symptoms had improved
signicantly. In this study riluzole was well tolerated, and there were no any side eects seen
in children [112].
In a study that includes 17 children and adolescents between aged 8 and 18 years with a pri-
mary diagnosis of OCD, eectiveness of D-cycloserine (DCS)-augmented CBT for children
and adolescents was investigated. Results of this study showed DCS-augmented exposure,
and response prevention produced signicant improvements in OCD severity relative to a
Cognitive-Behavioral Therapy of Obsessive-Compulsive Disorder in Children and Adolescents
placebo control in severe and dicult-to-treat pediatric OCD [113]. Lamotrigine is an anti-
epileptic drug and also a mood stabilizer that decreases extreme glutamate release [114, 115].
Thus Lamotrigine could be a good augmentation agent in refractory OCD cases. Except those
studies, there is a case report that aripiprazole was used with clomipramine, which showed
remarkable improvement [116].
9. Conclusion
OCD is an important psychiatric disorder in childhood and adolescence. At this age OCD is
common, but the diagnosis is often missed. For this reason OCD usually shows chronic prog-
ress and serious loss of function. OCD could be confused with other diseases, or comorbidi-
ties could be seen. These conditions make it dicult to treat the disease. Although the disease
has not completely recovered by the treatment, symptoms can be improved, or functionality
may improve somewhat.
OCD could not be as well-dened as adults. Therefore more clinical studies are needed. These
studies lead to a beer understanding for etiology, treatment, and course of OCD. With the
new treatment approaches, OCD could be treated at early age period, and chronicity could
be preventable. Thus the incidence of OCD in adulthood may decrease, and it may increase
patients’ quality of life.
Author details
Irem Damla Cimen
Address all correspondence to:
Darica Farabi Public Hospital, Child and Adolescent Psychiatry Clinic, Kocaeli, Turkey
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Cognitive-Behavioral Therapy of Obsessive-Compulsive Disorder in Children and Adolescents
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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.
The psychological treatment of obsessive–compulsive disorder (OCD) with exposure and response prevention (ERP) methods is one of the great success stories within the field of mental health. Within the span of about 20 years, the prognosis for individuals with OCD has changed from poor to very good as a result of the development of ERP. This success not withstanding, the procedures are far from perfect because a substantial minority of patients still either refuse treatment, drop out prematurely, or fail to benefit. I begin this article with a review of the development of ERP from early animal research on avoidance learning conducted during the 1950s. Next, I discuss the mechanisms of ERP. The bulk of the article reviews the treatment-outcome literature on ERP for OCD and includes comparisons with cognitive therapy—the “new kid on the block” with respect to psychological treatments for OCD.
Obsessive-compulsive disorder (OCD) is ranked by the World Health Organization (WHO) among the 10 most debilitating disorders. The treatments which have been found effective are cognitive behavior therapy (CBT) and serotonin reuptake inhibitors (SRI). This meta-analysis includes all RCTs of CBT (25) and SRI (9) for OCD in youth using the Children’s Yale-Brown Obsessive Compulsive Scale (C-YBOCS). CBT yielded significantly lower attrition (12.7%) than SRI (23.5%) and placebo (24.7%). The effect sizes for comparisons of CBT with waiting-list (1.53), placebo (0.93), and SRI with placebo (0.51) were significant, whereas CBT vs. SRI (0.22) and Combo (CBT + SRI) vs. CBT (0.14) were not. Regarding response rate CBT (70%) and Combo (66%) were significantly higher than SRI (49%), which was higher than placebo (29%) and WLC (13%). As for remission CBT (53%) and Combo (49%) were significantly higher than SRI (24%), placebo (15%), and WLC (10%), which did not differ from each other. Combo was not more effective than CBT alone irrespective of initial severity of the samples. The randomized controlled trials (RCTs) have a number of methodological problems and recommendations for improving research methodology are discussed as well as clinical implications of the findings.
OBJECTIVE: To describe clinical features, clinical course, comorbidity and subtypes of obsessive-compulsive disorder (OCD) and incidence of familial pathology in a sample of children and adolescents whose diagnosis was obsessive-compulsive disorder. METHODS: Forty patients whose age was below 18 years suffering from OCD were prospectively evaluated from June 1995 to August 1998 by means of K-SADS interview version E - IV and Y-BOCS symptom rating scale in the Children and Adolescent Psychiatric Facility (SEPIA). Data upon familial pathology were searched in the anamnesis. Data on clinical course were obtained during follow up in SEPIA and also retrospectively since the beginning of the illness as stablished from the clinical anamnesis. RESULTS: 77.5 per cent of patients were male and average age of starting symptoms was 10.04 years. The subtype with mixed obsession and compulsion predominated and multiple and changeable symptoms were frequent. Co-morbidity was very common (77.5%) specially with depression; tics were uncommon in this sample (10%). There are 22.5% of relatives with OCD or SOC (sub-clinical obsessive-compulsive disorder). Natural history was of chronic, waxing and waning illness. CONCLUSIONS: SEPIA is a referral center so our sample had a large amount of severe cases. Therefore a bias may be responsible for the discrepancy between our findings and that of the literature about children OCD.