Sunday, 8 May 2016

Literature Review: Utilisation of CBT for children and adolescents with OCD in clinical settings

Master of Counselling

Counselling Children and Young People

  Critical Review of an Intervention

Student name: Glaucia Barbosa

The evaluation of treatment efficacy through scientific research and evidence-based practice is a requirement in the psychotherapy field (Chiu et al., 2013). It is necessary not only to prove cost and clinical effectiveness, but also to promote development and improvement of practices which are able to meet the client's needs and produce positive, as well as, long term clinical gains (Gilroy, 2006). While a number of therapeutic approaches, especially the Cognitive-Behavioural Model (CBT) of Obsessive-Compulsive Disorders (OCD) for adult clients, have been extensively explored (Rosenfelt,G.W., 2009), it is argued that relatively little attention has been given toward the effectiveness of the CBT model for OCD in children and adolescents (Turmer, 2006). This essay will provide a critical review of Cognitive-Behavioural intervention for children and young people with OCD symptoms, supported by an analysis of the evidence as reported by ten selected empirical studies of CBT employed in children and adolescents. Data for this review was gathered from the University of Queensland Library in PsychcINFO, Cochrane Database of Systematic Reviews, and library books. Recommendations for the utilization and implementation of the intervention in clinical setting will also be given.

Cognitive-Behavioural Therapy (CBT) is a widely used therapeutic approach with confirmed positive effects to treat a variety of psychological and psychiatric disorders including depression, phobias and anxiety disorders (Hall & Iqbal, 2010). CBT can be defined as a psychotherapeutic treatment in which the client is instructed in how to recognize negative thoughts and feelings and replace them for more adaptive thought patterns, in order to promote psychological well-being (Kazantzis, Reinecke & Freeman, 2010). The cognitive model states that specific life events are interpreted by automatic thoughts, based on beliefs that the person has about themselves, the world and the future called sachems, which may lead, when the thought patterns are negative, to dysfunctional emotions and behaviors (Chichester, 2012). The CBT sessions are time-limited, structured, goal-directed, problem-solving oriented, psycho-educational, and focus on the present. In conjunction with these, homework is used as an essential feature and aims to bring self-resources to the client (Prochaska & Norcross, 2010). The existing literature indicates that CBT has been the first recommended approach to be employed on children and adolescents with OCD symptoms (Zohar, 2012).

Obsessive Compulsive Disorder (OCD) is an anxiety disorder described by the presence of intrusive thoughts, obsessions and behaviors compulsively performed in order to reduce the anxiety caused by the intrusive thoughts (Hyman & Pedrick, 2010). Some forms of OCD treatment utilizing CBT interventions include inpatient, outpatient, individual, group and family-based approaches (Grave, 2013). The CBT Treatment Manual has been largely used to treat OCD and it is based on fourteen weekly sessions, over twelve weeks, including telephone contacts (Piacentini et al., 2007). Throughout this period, techniques applied include psycho-education, when parents receive information about OCD and how to assist the child with tasks, as well as homework, training and relapse prevention; In addition, cognitive training and mapping OCD, in which obsessions, compulsions, triggers and consequences are defined, as well as a starting point and degree of the exposure to be applied. Exposure/response prevention (E/RP), which consists of the child's gradual increased exposure to what they fear (Piacentini et al., 2007) and relapse prevention are also included (Dulcan, 2010).

Each session specifically involves the gathering of new data, a review of past tasks, the setting of
new goals, tasks, homework, monitoring the progress and possible therapist-assisted practice for
ERP (Weisz & Kazdin, 2010). Clients with more severe symptoms or co-morbidity also make use of medication (Rachman & Silva, 2009). Some of the most common rating scales used to identify the severity of the OCD symptoms in children and adolescents are the Children's Yale-Brown Obsessive Compulsive Scale (CY-BOCS) (Galanter & Jensen, 2009) and the National Institute of Mental Health- Global Obsessive-Compulsive Scales (NIMH-GOCS) (Martin et al., 2005).

Findings outlined by the controlled studies selected for this review demonstrated strong evidence that cognitive-behavior therapy (CBT) can be considered an efficacious treatment for children and adolescents with OCD (Williams et al., 2010), due to reports of statistical and substantial clinical decrease in their OCD symptoms (Whiteside et al., 2008). High improvement rates were not associated with size sample, age range (Valderhaug et al., 2007), gender, use of medication, type of inclusion/exclusion criteria, or even therapist experience (Piacentini et al., 2002). Additionally, results suggested that The Cognitive-Behavioral Treatment Manual for childhood can be successfully delivered via regular outpatient community clinics (Valderhaug et al., 2007). Moreover, long term follow-up studies showed that positive clinical outcomes can even be seen beyond 24 months after CBT treatment has stopped (Shaley et al., 2009). Some aspects considered as contributors to enhance positive outcomes are parental involvement in the treatment (Martin & Thienemann, 2005) and the use of exposure and response prevention (ERP) technique (Piacentini & Langley, 2004).

It is important however, to note that the promised results also reveal a number of limitations that need to be highlighted (Shalev et al., 2009). The first question to be raised is about the inconclusive results regarding the real effect of medication, such as the serotonin re-uptake inhibitors (SRIs) in the OCD symptoms reduction (Nakatani et al, 2009). For instance, reports of outcomes from 75children and adolescents treated with CBT for OCD in a clinic setting in the United Kingdom, informed that clients who previously received only CBT, or only medication, or those who never had medication or CBT treatment before, all showed the same degree of reduced symptoms after receiving treatment with CBT only, as well as with CBT associated with medication (Nakatani et all, 2009). This information suggests that medication treatment for OCD, at any time, does not influence improvement outcome (Nakatani et all, 2009). From the other nine selected studies, three of them did not use any medication control and still exhibited positive results (Martin & Thienemann, 2005).

In contrast, six of the articles analyzed, partially supported the use of medication. They concluded that CBT should be the first option of treatment for children and young people (Bjorgvinsson et all, 2008). However, pharmacological augmentation was recommended for those with more severe symptoms, co-morbidity, or did not respond to CBT intervention (Piacentini & Langley, 2004). This conclusion is supported by previous trials which showed that 90% of adults who had symptoms reduced during the treatment with medication for OCD, relapsed after seven weeks after the treatment had stopped (Williams et all, 2010). Additionally, results revealed that SRIs used in adults for a long term may decrease psychological treatment efficacy (Williams et all, 2010). Furthermore, some research claimed responses of only 20% of OCD symptom reduction in young people who used medication, with a substantial number of clients still exhibiting mild or moderate symptoms after the treatment (Piacentini & Langley, 2004).

Taking into account that most of these studies used a relatively small sample, had no control group ( Shalev et al., 2009), and some of them had no data or follow-up control concerning the length of OCD medication used before or after the CBT treatment (Nakatani et al, 2009), it appears difficult
to determine whether the use of medication is associated with the related statistical OCD symptom reduction, as well as with long term of therapy gains (Pato & Zohar, 2008). Above all, recent studies of CBT and psychopharmacology revealed that both approaches, CBT and pharmacotherapy, can produce similar neurological changes in the temporal and frontal regions, with CBT showing faster neural modifications and, consequently, a faster decrease in OCD symptoms (Noggle & Dean, 2013). Hence, studies which recommended medication for clients who did not respond to CBT intervention (Piacentini & Langley, 2004), could consider, first, a case-review or even a re-evaluation of CBT delivered (Nakatani et all., 2009). This would identify causes for the poor outcomes such as: possible inappropriate CBT delivered, lack of therapist empathy or training, absence of parental support in work with the child exposure task (Krebs et all., 2010), client unwillingness to be treated, home or school environment stressors (O'Kearney et al., 2006), and cross-cultural relevance of the results (Freeman at all., 2009).

Another significant aspect exposed by the articles was the influence of parental involvement (Martin & Thienemann, 2005). In view of all the studies analysed, a substantial decrease in OCD symptoms are associated with having at least one parent participating in the treatment (Williams et all., 2010). However, once all clients from the studies analyzed lived with supportive families from high socio-economic background and were motivated to change as they chose to participate, it is questionable whether the same results, or even better, could be obtained with a different family profile and some adaptations in the treatment (Whiteside et all., 2008). For example, CBT practices or techniques would have to be adapted for parents or guardians who cannot attend the sessions, for single parents, families with a low income, and families who had experienced a traumatic event such as earthquakes or floods (Cohen et all., 2012); For parents with low education, mental illness, or other additional psycho-social stressors, appropriate psycho-educational booklets should be prepared to assist them (Cohen et all., 2012). Likewise, in order to deliver CBT to children who are the second generation of a culturally and linguistically diverse background (CALD) (Gaxiola & Gullotta, 2009), and also have to deal with their parents' stress of acculturation and chronic grief, CBT techniques should be accommodated to the relevant culture, as different ethnic groups have they particular ways of interpreting and reacting to stressful life events (Simos et all., 2013). Furthermore, written material for information or psycho-education in families' first languages, should be provided (Simos et all., 2013).

It was also pointed out by the findings mentioned in this analysis that efficacy in CBT treatment for OCD is not related to age or gender (Valderhaug et al., 2007). Regarding age, it can be argued that, although positive outcomes were displayed in all age ranges in nine of the analysed studies, it is recognized that the cognitive developmental level differs from children to adolescents, or even among children and adolescents within the same age range, which can influence treatment performance and symptom reduction (Piacentini et all., 2004). For instance, children, unlike adolescents, may not identify their symptoms as being obsessive or irrational. In addition, very young children may refuse to perform exposure tasks or undertake CBT homework (Piacentini et all., 2004). On the other hand, one of the articles gave evidence that adolescents had a maturity level which enabled them to effectively complete multiple exposure and response prevention tasks administered in an intensive one week treatment form, thereby accomplishing solid gains (Whiteside et al., 2008).

Similarly, data revealed by one of the studies also validates the idea that age can influence outcomes (Piacentini et all., 2004). This report attested that due to the different level of insight in two age ranges, CBT applied in groups for children from 8 to 14 years of age achieved lower levels of improvement in their OCD symptoms compared to the same group treatment approach which was applied in groups for adolescents from 13 to 17 years of age (Martin et al., 2005). It is also interesting to note that this was the only study in this review where non-selected children, from 8 to 14 years, with different developmental levels, were treated for OCD together, for one and a half year period, in a CBT group therapy, and expressed unsatisfactory measured results (Martin et all., 2005). Therefore, it is important to highlight that in order to achieve successful outcomes, a good assessment is necessary to determine if the client is more indicated for individual or group format, but, most importantly, in order to apply techniques relevant to the age range (Piacentini et all., 2004) and the young person's developmental level (Chiu et all., 2013).

A particular point observed in the ten articles, is that it was not stressed in any article the fact that therapist's professional and personal characteristics could have affected the treatment results (Fall et al., 2010). For instance, it is essential that the therapist have a specific CBT training to work with OCD clients and supervision (Clark, 2007). Additionally, attending skills such as unconditional respect, empathy, good listening, appropriate eye contact and body language, will facilitate the development of a safe environment (Carr & Cohen, 2008), where clients are able to down regulate their emotions, collaborate in building a good working alliance as well as enabling the therapist to give a more precise diagnosis, and, in turn, good treatment outcomes (Corey, 2009). A therapist's personality may also directly affect a client's response, as the client will mirror the therapist's behavior (Siegel, 2012). It would be difficult for a client with OCD symptoms to improve, if for example, they mirrored a therapist with a very formal, organized and meticulous behavior (Siegel, 2012).

An equally significant element in predicting therapeutic success not mentioned in any article is the
therapist's financial motivation for work (Chandler et all., 2009). A study to identify reasons for low motivation for working among health care workers in Africa, confirmed that salary is indeed a strong motivation to work (Chandler et all., 2009). An interesting example is the fact that nine of the studies from this review received a sufficient amount of funding, therefore, clinicians did not have to deal with personal financial stressors while performing their work, and treatments reported good rates of improvements (Nakatani et al., 2009). In contrast, in the only study not funded, where clients were seen in a medical center by busy clinicians performing normal routine work with no extra remuneration, reduction of symptoms were lower than expected (Martin et all., 2005).

Regarding inclusion and exclusion criteria, most of the studies analyzed used no or minimum exclusion criteria and different types of disorders were accepted in the treatments, with outcome measures of OCD symptoms exposing significant progress (Farrel et al., 2010). This confirms the hypothesis that general improvement rates are not associated with the type of inclusion/exclusion criteria (Piacentini et al., 2002). Nevertheless, results could be more precise if type of co-morbidity, use of medication, severity of symptoms, duration of illness, family support, home environment, client development level, age range, and type of treatment format were more appropriate for each client and treatment setting, and were more carefully considered in the assessment before determining client inclusion/exclusion to treatment (Dale & Vincent, 2010).

The type of technique and how it is applied is another factor to predict treatment efficacy (Nathan & Gorman, 2007). Most of the the treatments were based on the CBT Treatment Manual and the techniques used in group or individually were Psycho-education, cognitive interventions, exposure and response prevention (ERP), relapse prevention, family involvement, medication and behavioral rewarding (O'Kearney et al., 2006). Behavioural rewarding is not widely used, and more indicated for young children than for adolescents (Turner, 2006). Jackes (2006) argue that one of the advantages in utilizing ERP is that this technique, in a short time, stops compulsive behaviors which are the client's defense mechanisms against hidden unconscious feelings, that subsequently open new brain neural pathways, thereby, changing life responses behaviors (Bowers, 2013). The same process, in other approaches such as psychoanalyses, would take longer, preventing the client to have quality of life for a greater time (Jackes, 2006). The recent literature review and measured results from the studies reviewed concluded that ERP alone can be used as an efficacious treatment for child/adolescent OCD, which can be the only reason why OCD symptoms were reduced in all the studies, despite all mediators and moderators variables (O'Kearney et al., 2006). However, more investigation should be undertaken regarding about the efficacy of ERP applied alone as well as the influence of the therapist's style when applying the techniques, as even a very efficacious technique can produce better outcomes if applied with the art of a skillful therapist, especially in children (Clark, 2007). It should always be remembered, that regardless of the type of technique used, the cognitive-behavioral approach still involves a sensitive encounter between two human beings (Weibel, 2005).

The objective of six of the studies selected was to provide evidence that CBT can be successfully delivered to children and young people with OCD in a regular outpatient community clinical setting (Williams et al., 2010). One article outlined positive results from CBT applied in a specialized inpatient hospital setting for adolescents who failed previous outpatient interventions (Bjorgvinsson et al., 2008). Two articles that also presented CBTdelivered in a typical clinical setting, aimed to demonstrate CBT efficacy in pediatric OCD (Piacentini et al., 2004) and one study investigated the long term gains from CBT was, again, applied in a clinical setting (Shalev et al., 2009). Regarding the method employed, parents and children participated in the individual or group interventions
(Whiteside et al., 2008). A number of measures (see appendix) were used in the client's assessment
to confirm the OCD diagnosis and level of severity. The clients were selected according to the inclusion and exclusion criteria, and evaluated after the treatment by the same measures (Whiteside et al., 2008). Hence, substantial statistical evidence was presented by the articles to indicate that CBT is feasible and effective in a practical setting (Nakatani et al., 2009).

Despite positive evidence, these results are still questionable due to the limitations presented. These included the small size of samples, the absence of a control group, the fact that some studies were controlled trials utilizing manual-based treatment protocol, clients being from supportive families with high socio-economic and educational background, as well as having high motivation as the clients chose to participate (Whiteside et al., 2008). These conditions do not reflect reality (Chiu et al., 2013). More research with larger samples, a control group, long term follow-up and clients from different socio-economic, educational and ethnic backgrounds, is required to confirm effectiveness and feasibility in clinical settings (Williams et al., 2010).

Regarding inpatient treatment in a specialized hospital, it can be seen that although results indicated improvement, the conditions were perfect, the sample was small, there was no control group and, most importantly, in this case, no follow-up data collected to ascertain if the inpatient model was advantageous and the gains were maintained after the client had been discharged (Bjorgvinsson et al., 2008). 

In conclusion, the findings outlined in the articles exhibited significant evidence suggesting that CBT can be successfully delivered to children and adolescents with OCD, individually or in a group (Martin et all., 2005), with regular sessions or applied in an intensive form (Whiteside et all., 2008).

Consistent improvements were shown in different settings such as schools (Yeo et all., 2011),
specialized inpatient hospitals (Bjorgvinsson et al., 2008), and regular outpatient community clinics (Valderhaug et al., 2007), producing substantial long term (Shalev et al., 2009) symptom reduction
(Williams et al., 2010). Individual CBT was considered the best first option treatment (Barret et al., 2013), in conjunction with family involvement and exposure response prevention (ERP) (O'Kearney et al., 2006). ERP used alone was proved to be efficacious, which can be the only reason why OCD symptoms were reduced in all the studies, despite all variables (O'Kearney et al., 2006). However, a number of limitations were acknowledged such as the utilisation of very supportive high socio-economic level families (Whiteside et all., 2008), small samples, no control group (Shalev et al., 2009) and no data or follow-up control (Nakatani et al, 2009). Results regarding influence of medication and age range are inconclusive (Nakatani et al, 2009). Furthermore, issues which could have influenced the outcomes, such as differences in CBT delivered (Williams et al., 2010), therapist professional and personal characteristics (Fall et all., 2010), absence of parental support in work with the child exposure task (Krebs et all., 2010), client home or school environment stressors (O'Kearney et al., 2006), and cross-cultural relevance of the results were not addressed (Freeman at all., 2009).

Recommendations for the utilization of CBT for children and adolescents with OCD in clinical settings is supported by the positive results and can be applied by any trained counsellor or clinician (Turner, 2006). However, in order to confirm effectiveness in clinical practice, more investigation is needed in real world settings, along with the inclusion of larger samples, a control group, long term follow-up of clients and families to investigate occurrence of relapse and the durability of gains (Piacentini et al., 2002). In addition, more studies to compare outcomes from the use of medication, effectiveness of ERP utilized alone and cognitive therapy alone, as well as to what extent family
based treatment is more effective than individual treatment (March et al., 2001). Appropriateness of
intensive treatment utilizing ERP for children needs to be also carefully assessed (Whiteside et al., 2008). A case-review or re-evaluation of CBT delivered (Nakatani et all., 2009) is needed to identify causes for lack of the response to treatment, as well as what alternative techniques could be used (Barret et al., 2008).

Moreover, the utilization of CBT for children and adolescents could be implemented by adapting practices and techniques for parents who cannot attend the sessions. For example, telephone or internet support; resources with appropriate drawings and language which reflect the reality of families with a low income; an analysis of measures that considers those who are experiencing grief and trauma (Cohen et all., 2012); and, preparation of psycho-educational booklets for parents with low education or mental illness (Cohen et all., 2012). Similarly, CBT practices and techniques should be accommodated to different ethnic groups such as families from CALD background (Gaxiola & Gullotta, 2009), with provision of all written material for information and psycho-education in the client's and families' first languages (Simos et all., 2013). A good assessment is also necessary to determine if the client is suited for individual or group formats, what techniques would be more appropriate according to the age range (Piacentini et all., 2004), and developmental level (Chiu et all., 2013), the type of co-morbidity, the use of medication, the severity of symptoms, the duration of illness, the home environment and what family support can be expected during and after the treatment (Dale & Vincent, 2010).

Mrs Glaucia Barbosa,
PACFA Reg. Provisional 25212 
MCouns, MQCA(Clinical)  

ABN: 19 476 932 954

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Children's Yale Brown Obsessive-Compulsive Scale (CY-BOCS)- Indicates severity of symptoms (Martin & Thienemann, 2005).
National Institute of Mental Health-Global Obsessive-Compulsive Scales (NIMH-GOCS)- Assesses general level of impairment (Martin & Thienemann, 2005).
Clinical Global Impression of Improvements ( NIMH-CGI-I)- Assesses overall improvements (Martin & Thienemann, 2005).
Child Obsessive-Compulsive Impact Scale-Child and Parent versions (COIS-C/P)- Assesses specific impairment at home, school and relationships (Martin & Thienemann, 2005).
Children's Depression Inventory (CDI)- Provides depression score, as well as negative self-esteem, interpersonal problems, negative mood, anhedonia, ineffectiveness (Martin & Thienemann, 2005).
Multidimensional Anxiety Scale for Children (MASC)- Measure of anxiety including separation anxiety, physical symptoms, harm avoidance, social anxiety (Martin & Thienemann, 2005).
Child Behaviour check-list (CBCL)- Report of parents about children's behaviour and emotional problems (Martin & Thienemann, 2005).
Anxiety Disorders Interview Schedule for DSM-IV: Child version (ADIS:C)- Diagnostic of child mood, externalising disorders and anxiety disorders (Whiteside et al.,2008).
The Spence Children's Anxiety Scale (SCAC)- Measure of Social phobia, physical injure fears, obsessive-compulsive, agoraphobia, generalised anxiety, separation anxiety, panic attacks (Whiteside et al.,2008).
Modified Scheehan Disability Scale ( mSDS)- Measure of quality of life as well as the impact
caused in some areas of life (Whiteside et al.,2008).
Wechsler Abbreviated Scale of Intelligence (WASI) (Whiteside et al.,2008).
Trait Anxiety Inventory (STAI)- Measure of anxiety state (Bjorgvinsson et al., 2008).
Reynolds Adolescent Depression Scale (RADS-2)- Assesses depression including somatic complaints, Negative Affect, dysphoric mood, negative self-evaluation, anhedonia (Bjorgvinsson et al., 2008).
Thoughts Action Fusion Scale-Revised (TAF-R)- Assesses OCD cognitive construction (Bjorgvinsson et al., 2008).
Obsessive Belief Questionnaire (OBQ 44)- Assesses OCD symptoms (Bjorgvinsson et al., 2008).
Intolerance of Uncertainty Scale ( IUS-12)- Assesses intolerance degree of negative events (Bjorgvinsson et al., 2008).
Obsessional Beliefs Questionnaire-Responsibility and Threat Estimation subscale (Bjorgvinsson et al., 2008).
Obsessional Beliefs Questionnaire-Perfectionism and Certainty subscale (Bjorgvinsson et al., 2008).
Obsessional Beliefs Questionnaire- Importance I Control of Thoughts subscale (Bjorgvinsson et al., 2008).
Obsessions and Compulsions Inventory (OCI)- (Williams et al., 2010).
Children's Responsibility Attributions Scale (CRAS)- Assesses level of responsibility cognitions (Williams et al., 2010).
Children's Responsibility Interpretation Questionnaire (CRIQ)- Assesses level of responsibility cognitions (Williams et al., 2010).
Children's Global Assessment Scale (CGAS)- Assesses impairment (Valderhaug et al., 2007).
Child OCD Impact Scale (COIS)-Assesses functioning impact of OCD (Valderhaug et al., 2007).
Clinical Global Impression Scale (CGI) -Assesses severity of OCD (Valderhaug et al., 2007).
Clinical Global improvement Scale (CGI-I)- Assesses severity of OCD (Valderhaug et al., 2007).
Kiddie Schedule for Affective Disorders and Schizophrenia for School age children-(K-SADS-PL)- Diagnostic interview (Valderhaug et al., 2007).
The Anxiety Disorder Interview Schedule for Children-Parent version (ADIS-P)-Diagnose Anxiety disorders (Farrell et al., 2010).

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