Master of Counselling
Counselling Children and Young People
Critical Review of an Intervention
Student name: Glaucia Barbosa
Introduction
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)
PACFA Reg. Provisional 25212
MCouns, MQCA(Clinical)
ABN: 19 476 932 954
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Appendix
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
21
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).
22
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).