Behavioral Psychotherapy for Children and Adolescents withObsessive-Compulsive Disorder: An Open Trial of a New

Protocol-Driven Treatment Package

JOHN S. MARCH, M.D., M.P.H., KAREN MULLE, B.S.N., M.T.S., AND BRYON HERBEL, M.D.

ABSTRACT

Objective: The authors present an open trial of cognitive-behavioral psychotherapy for children and adolescents with

obsessive-compulsive disorder. Method: The authors developed a treatment manual explicitly designed to facilitate (1)

patient and parental compliance, (2) exportability, and (3) empirical evaluation. Successive versions of the manual were

used to treat 15 consecutive child and adolescent patients with obsessive-compulsive disorder, most of whom were

also treated with medications. Results: Statistical analyses showed a significant benefit for treatment immediately

posttreatment and at follow-up. Nine patients experienced at least a 50% reduction in symptoms on the Yale-Brown

Obsessive-Compulsive Scale at posttreatment; 6 were asymptomatic on the National Institute of Mental Health Global

Obsessive-Compulsive Scale. No patients relapsed at follow-up intervals as long as 18 months. Booster behavioral

treatment allowed medication discontinuation in 6 patients. No patient refused treatment; 2 discontinued prematurely.

Conclusions: Cognitive-behavioral psychotherapy, alone or in combination with pharmacotherapy, appears to be a

safe, acceptable, and effective treatment for obsessive-compulsive disorder in children and adolescents. J. Am. Acad.

ChildAdo/esc. Psychiatry, 1994,33, 3:333-341. Key Words: obsessive-compulsive disorder, behavior therapy, cognitive

therapy, follow-up studies, children and adolescents.

Obsessive-compulsive disorder (OCD) affects childrenand adolescents as well as adults (Rasmussen and Eisen,1990), and one third to one half of adults with OCDreport the onset of OCD symptoms during childhoodor adolescence (Rasmussen and Eisen, 1990). In anepidemiological study of New Jersey adolescents, Fla­ment et al. (1988) reported a weighted point prevalence

Accepted October 20, 1993.From the Program in Childand Adolescent Anxiety Disorders, Division of

ChildPsychiatry, Department ofPsychiatry, Duke University Medical Center,and the Department of Psychology, Social and Health Sciences, at DukeUniversity.

Thisworkwassupported in part byan NIMH Scientist DevelopmentAwardfor Clinicians (I K20 MH00981-G1) to Dr. March.

The manual, a part of which is excerpted in the Appendix, is a researchtool With additional replication studies addressing the twin issues ofefficacyand exportability, the authors plan to revise the manualfor publication as aself-help/treatment manual. For clinicians who wish to participate in thereplication study, "HowI Ran OCD Off My Land'v;, is available (at the costof reproduction) from Dr. March.

Address correspondence to Dr. March, Department of Psychiatry, DUMCBox 3527, Durham, NC 27710. email: jsmarch@acpub.duke.edu.

0890-8567/94/3303-0333$03.00/0©1994 by the American Academyof Child and Adolescent Psychiatry.

of approximately 1%. In their study, only 4 of the 18children diagnosed as having OCD were receivingmental health services; none were receiving appropriatetreatment (Flament et al., 1988). This is unfortunateas effective treatments for OCD, including both phar­macotherapy and behavioral psychotherapy, are avail­able (Rapoport et al., 1992).

Behavioral psychotherapy in the form of exposureand response prevention (E/RP) is generally held tobe an effective treatment for OCD in young persons(Wolff and Wolff, 1991). However, clinicians routinelycomplain that "children will not comply" with behav­ioral treatment; parents routinely complain that"clini­cians are poorly trained" in the application ofbehavioralpsychotherapy to OCD. Furthermore, empirical docu­mentation regarding the effectiveness of behavior ther­apy in child and adolescent patients greatly lags behindthat for pharmacotherapy (Rapoport et al., 1992), andwhat documentation is available isweak at best (March,in press). To address these deficiencies, we developeda protocol-driven treatment manual ("How I RanOCD Off My Land"©) explicitly designed to facilitate

j. AM. ACAD. CHILD ADOLESC. PSYCHIATRY, 33:3, MARCH/APRIL 1994 333

MARCH ET AL.

(1) patient and parental compliance, (2) exportability,and (3) empirical evaluation. Part of the manual isexcerpted in the Appendix. We report here an opentrial of this protocol in 15 consecutive child andadolescent patients with OeD, most of whom werealso treated with medications.

METHOD

Subjects

Subjects are patients referred to the Duke University Programin Childhood and Adolescent Anxiety Disorders (PCAAD). ThePCAAD is a clinical research program specializing in the neuropsy­chology, psychopharmacology, and cognitive-behavioral treatmentof child and adolescent anxiety disorders. Patients enter PCAADclinical and research protocols via community referrals and an­nouncements in local media. The patients reported here representall child and adolescent patients entering treatment for OCD fromJanuary 1991 to September 1992 (with the exception of patientsseen solely for consultation or who lived too far away to participatein the behavioral treatment program) who scored greater than10 on the Yale-Brown Obsessive-Compulsive Scale (YBOCS) atstudy entry.

BehaviorTherapists

Behavioral psychotherapy was administered by a child psychiatrista.S.M.) or a clinical research nurse (K.M.) experienced in the careof children and adolescents with a wide variety of anxiety disorders.All patients were discussed in weekly clinical research meetingswith respect to the design and clinical implementation of thebehavioral treatment protocol; however, treatment integrity wasnot monitored via review of audio or videotapes.

neuropsychological tests. Patients were evaluated using the symptomchecklist from the YBOCS and were assigned a baseline score onthe YBOCS and the National Institute of Mental Health (NIMH)Global Obsessive-Compulsive Scale. Each patient then received aDSM-III-R diagnosis of OCD plus comorbid conditions. Duringtreatment, patients were rated for improvement on the YBOCS,NIMH Global scale, and the Clinical Global Impression (CGI)Scale. The YBOCS rates obsession and compulsions separatelyon time occupied, distress, impairment, resistance, and control(Goodman et al., 1989) and is currently considered the scale ofchoice for rating OCD symptoms in children and adolescents (Wolffand Wolff, 1991). The NIMH Global Obsessive-Compulsive Scaleis a measure of illness severity rated from 1 (normal) through 12(extremely impaired) (Leonard et al., 1989). The CGI is a measureof global impairment rated from 1 (nor at all ill) to 6 (severelyill); the CGI is inversely related to improvement. Because ofdisparities in clinical assessments, particularly during early imple­mentations of the protocol, not all patients received assessment onall scales.

Protocol Development

Patients presented in this report were treated with incrementallyrefined versions of this protocol. All versions included E/RP,anxiety management training (AMT) , and some form of familyintervention, most often psychoeducational in nature. In each case,treatment took place within a neurobehavioral framework in whichOCD was explicitly named as the problem. Refinements in themanual primarily involved implementing narrative interventions,such as informal symptom diaries, and formalizing the parentinterventions and monitoring procedures. Protocol developmenttook place largely within the framework of social learning theory.However, in the interest of exportability, the manual is written insuch a way as to be intelligible to lay readers and to therapistsnot specifically trained in cognitive-behavioral techniques.

Treatment Protocol

Note: OCD = obsessive-compulsive disorder.

Table 1 summarizes the current version of our protocol fortreating OCD in children and adolescents with behavioral psycho­therapy. Treatment takes place in four steps distributed over 16weekly sessions. Each session includes a statement of goals, a reviewof the preceding week, new information and selection of E/RPtargets as indicated, "nuts and bolts" practice, homework forthe coming week, and monitoring procedures. Information sheetsoutlining the homework for that week are given at the end ofeach session. Steps 1 to 3 cover the first 3 weeks of treatment and

Concurrent Treatment

All but one patient received concurrent treatment with a seroto­nin reuptake inhibitor for at least a portion of the study interval.Three were treated with more than one medication, either becauseof comorbidity or to augment the serotonin reuptake inhibitor.Seven of the 15 patients reported here were participating in astudy of sertraline in pediatric OCD funded by Pfizer Pharmaceuti­cals, Inc. The remainder received individualized clinical treatment.Patients in the sertraline in pediatric OCD study were excludedfrom other treatments during the 12-week double-blind phase ofthe study; all began behavioral psychotherapy upon entering ayear-long open-label extension in which all patients received sertra­line. For these patients, initial (pretreatment) scores are those atentry into the open-label extension. Three patients referred forbehavioral and medication management of OCD continued toreceive concomitant family or individual psychotherapy with othertreatment providers.

Measures

Each patient received an extensive evaluation that included aclinical interview of the child and his or her parents with a childpsychiatrist a.S.M.) covering Axis I through V of DSM-III-R,multiple rating scales, review of school and previous mental healthtreatment records, and a series ofcomputerized and pen-and-pencil

Session

Week 1Week 2Week 3Weeks 4-15

Weeks 1, 6, and 12Week 16Week 22

TABLE 1Treatment Plan

Goals

Establish OCD as an illnessMap OCDTeach transition zoneAnxiety management trainingExposure and response preventionParent sessionsGraduation ceremonyBooster session

334 ]. AM. ACAD. CHILD ADOLESC. PSYCHIATRY, 33:3, MARCH/APRIL 1994

form the basis for step 4. Step 4 applies AMT and E/RP to OCDover the next 13 sessions.

Step 1 (week 1) is a predominately psychoeducational sessionthat places OCD securely within a medical model. In addition toan extensive discussion of OCD as a medical illness, step 1 presentsthe risks and benefits of behavioral treatment for OCD and reviewsspecific details of the treatment protocol. The intent is to yokeOCD, a specific set of behavioral treatments , and a desired outcomein the form ofsymptom reduction within a neurobehavioral frame­work. By asking the child co give OCD a nasty nickname, andby always using this name to refer to OCD, the therapist endeavorsto "externalize" OCD, that is, to definitively make OCD theproblem (White and Epston , 1990). In this way, the child andhis or her family begin to ally with the therapist against OCD to"boss back" the obsessions and compulsions. Step 1 also introducesSt0ty metaphors by placing OCD in a narrative context. As treat­ment progresses, the patient begins to generate a new story inwhich the child "authors" OCD out of his or her life. The useof story methodology facilitates the therapy process (White andEpston, 1990) and provides a convenient means of monitoringtreatment through the use of informal diaries.

Steps 2 and 3 (weeks 2 and 3) map the child's experience withOCD, including specific obsessions and compulsions, triggers,avoidance behaviors, and consequences, ranked in order ofseverity.In behavioral terms, these steps generate a stimulus hierarchy,albeit within a narrative context. We use a cartographic metaphor,diagrammed in Figure 1, to understand where the child is freefrom OCD, where OCD and the child each "win" some of thetime, and where the child feels helpless against OCD. The centralregion, where the child already has some success in resisting OCD,is labeled the " transition zone." Teaching the child to recognizeand use che transition zone, which usually falls on the lower endof the stimulus hierarchy, provides a reasonably reliable guide co

Before Treatment

After Treatment

TransitionZone

Fig . 1 Mapping obsessive-compulsive disorder (OeD).

OPEN TRIAL OF CBT IN OCD

identifying targets for graded exposure. To gauge the patient'stolerance of anxiety, level of understanding, and willingness orabiliry to comply with treatment, steps 2 and 3 include introductoryAMT and E/RP tasks. Trial E/RP tasks also demonstrate whetheror not the transition zone has been accurately located, therebyavoiding disruptive "surprises" due to miss-calculated exposure orresponse prevention targets.

Step 4 (weeks4-16) initiates formal cognitive-behavioral therapy(CBT) in che form of AMT and E/RP. Anxiety managementtra ining, including relaxation, conscruccive self-calk ("bossingOCD"), breaching techniques, and positive coping strategies, pro­vides the child with a " tool kit" co use during E/RP. E/RP includesimaginal and in vivo practice assisted by the therapist, as well asweeklyhomework assignments. Using the nasty nickname for OCDchosen by the patient at step 1, OCD is explicitly framed as theenemy, and all parties remain intransigent against OCD. Thisattitude requires that the child use his or her allies (therapist,parents, and friends) and new strategies (AMT and E/RP) to resistOCD, thereby preventing the therapy from becoming an excuseto avoid exposure. On the other hand, because only the child canactually complete the exposure tasks, having the child chooseE/RP targets from the transition zone maximizes compliance andthus che likelihood of successful E/RP. The transition zone isupdated each session as the child becomes more competent andsuccessful at resisting OCD.

Parents are included in step 1, and in sessions 6 and 12, whichare specifically devoted to incorporating targets for parental responseprevention or extinction. Usually the child selects targets for hisor her parents from the transition zone. Rarely, parents are encour­aged to select targets for response prevention or extinction, evenwhen the child protests. Parents also receivea "self-help" instructionbooklet, including written "ti ps" on how to manage themselveswith respect to their child's OCD that are keyed to che weeklyhomework assignments. Some parents need considerable encourage­ment to stop giving advice or insisting on inappropriate exposuretasks. Weekly homework assignments are described for parents,and parents are invited to comment on the progress of treatmentat the beginning of each session. To facilitate positive reinforcementand to extinguish punishment for OCD-related behaviors, effortsare made to make friends and significant adults (such as teachersor grandparents) aware of the child's progress.

Monitoring includes weekly to biweekly clinical assessment,informal symptom diaries, fear thermometer ratings to assess within­exposure anxiety to specific targets, the YBOCS, the NIMH Globalscale, and Clin ical Scales of Global Improvement. Treatment endswith a graduation ceremony, followed by a booscer session at22 weeks.

Statistics

Results were analyzed using repeated-measures analysis of vari­ance, using the Greenhouse-Geiser correction , with treatment asa within-subjects factor and time as a between-subjects factor.Planned contrasts were conducted using paired t tests at an a levelof .05 (Maxwell and Delaney, 1992). Patients with missing datawere assigned the group mean score or their highest score, whicheverwas greater, on the variable in question. Eight patients had missingdata, mostly on the pretreatment or posttreatment YBOCS; nopatient had more than one missing data point per scale. Resultswere identical for analyses conducted without replacement ofmissing data (unpublished data).

J. AM . ACAD. CHILD ADOLESC. PSYCHIATRY, 33:3. MARCH/APRIL 1994 335

MARCH ET AL.

RESULTS35

FlUPOST

TREATMENT (n" 15)

o L------=::~.-=:=.::::::::====----=::::~PRE

Fig.2 Yale-Brown Obsessive-Compulsive Scale (YBOCS) scoresfor indi­vidual subjects.

5

::.~ll1 x===-~==-x~~. .1Ilg 15

~10

measures. Repeated-measures analysis of variance re­vealed clear benefit for treatment on the YBOCS (F =

36.0 [2,28], P < .001), NIMH Global (F = 40.3[2,28], P < .001), and CGI (F = 88.6 [2,28], P <

.001). Planned contrasts using paired t tests showedthat pretreatment scores differed significantly fromposttreatment and follow-up scores, which did notdiffer from each other, on all measures. For example,pretreatment was significantly different from posttreat­ment (mean difference = 10.9, SO = 6.9, T = 6.1,P < .001) and follow-up (mean difference = 13.0,SD =7.29, T =6.9, P< .001) on the YBOCS, whereasposttreatment and follow-up did not differ (meandifference = 2.09, SO = 4.52, T = 1.79, P < .095),suggesting that the benefits of treatment persist afterthe withdrawal of treatment. Results for the NIMHGlobal and CGI were essentially equivalent (datanot shown).

Three of 15 patients were nonresponders as definedby less than a 30% improvement on either the YBOCSor NIMH Global scales. One was a 14-year-old girlwith severe OCD referred for treatment after a 5­month hospitalization failed to decrease OCD symp­toms. Complicating factors included severeopposition­al-defiant disorder (worsened by hospitalization) andmarked family dysfunction. After limited initial im­provement, her parents withdrew her from treatment,citing cost and time as reasons. Another was an 18­year-old Caucasian female with obsessional slowness

Patients' ages ranged from 8 to 18 years (mean 14.3)at the beginning of treatment. Ten were female; fivewere male. Two were African-American; the remainderwere Caucasian. All but one received some form ofmedication; two received adjunctive family therapy,and two receivedsupportive psychotherapy. Seven wereconcurrently enrolled in the sertraline in pediatric OCDstudy. Not counting booster sessions, the mean numberof session devoted to behavioral psychotherapy was10.44 (range 3 to 21). The mean length of treatmentwas 8.0 months (range 3 to 21); the mean length offollow-up was 7.3 months (range 1 to 21 months).

All patients had a primary diagnosis of OCD asdetermined by clinical interview and the YBOCS obses­sive-compulsive symptom checklist. Contaminationfears (11 patients), fear of harm (8 patients), andsymmetry urges (5 patients) were the most commonobsessions. Washing (8 patients) and checking (9 pa­tients) were the most common compulsions. Twelvehad problems with avoidance behaviors. Pretreatmentratings were available on the Revised Children's Mani­festAnxiety Scale (RCMAS) and Children's DepressionInventory (COl) for 14 patients. The group mean Tscore on the RCMAS was 54.5, indicating averagelevels of anxiety. The group mean COl score was 14,indicating mild depressive symptoms. When present,comorbidity generally favored the other anxiety disor­ders, particularly overanxious disorder and social pho­bia, but depression and attention-deficit disorderwithout hyperactivity were not uncommon.

Figure 2 graphs results for individual patients onthe YBOCS; Figure 3 presents the mean YBOCSpretreatment, posttreatment, and follow-up scores.Simple inspection reveals that the majority of patienrsmade substantial improvement and that improvementpersisted at follow-up. Ten patients experienced agreater than 50% reduction in YBOCS score at follow­up. As judged by an NIMH Global score of 2 or less,six patients were asymptomatic by the posttreatmentvisit; nine were asymptomatic at follow-up. Withbooster behavior therapy, six of the nine were ableto discontinue medications, with either no return orminimal return of symptoms.

Table 2 presents the mean pretreatment, posttreat­ment, and follow-up scores for the three outcome

336 ]. AM. ACAD. CHILD ADOLESC. PSYCHIATRY, 33:3, MARCH/APRIL 1994

OPEN TRIAL OF CBT IN OCD

TABLE 2Pretreatment, Posttreatment, and Follow-up Scores

Measure (n = 15)

YBOCSNIMH GlobalCGI

Pre

21.78.54.85

Post

10.84.11.52

Follow-up

8.72.51.62

Significance

F =36.0 (2,28); p < .001F =40.3 (2,28); P < .001F = 88.6 (2,28); p < .001

Note: YBOCS = Yale-Brown Obsessive-Compulsive Scale; NIMH Global = National Institute of Mental Health GlobalObsessive-Compulsive Scale; CGI = Clinical Global Impress ion Scale.

as well as hoarding and grooming rituals. Althoughshe remains in treatment, her slowness symptoms didnot respond well to modeling, shaping, and speedingprocedures. The last patient who did poorly was a15-year-old Caucasian male with long-standing con­tamination fears. Although this patient also remainsin treatment, denial and minimization coupled withpoor tolerance for anxiety have slowed treatment. Onlytwo improved patients discontinued treatment prema­turely, one citing cost and family illness, the other"enough" improvement.

DISCUSSION

The results of this study are consistent with earlierwork suggesting that behavioral psychotherapy in theform of E/RP is the psychotherapeutic treatment ofchoice for OCD in children and adolescents (March ,in press). This study breaks new ground by applyingreliable and valid measures of treatment outcome toa larger number of patients; assessingpatients pretreat­ment and posttreatment, and at follow-up; and speci­fYing treatment in a manualized format. However,

2521.73

20WII:8 15f/lf/lo 100

~5

. 0

PRE POST FlU

Fig. 3 Yale-Brown Obsessive-Compulsive Scale (YBOCS) scores at pre­treatment, posttreatment, and follow-up.

a number of important methodological deficienciesseriously limit interpretability. Because the study wascomposed of clinical patients, they were not alwaystreated identically, and no control condition was possi­ble. Moreover, intensity of treatment as measured bythe number of sessions differed between patients, andnot all patients received all measures. Although proce­dures to define OCD symptoms, functional impair­ment, and comorbidities were implemented, patientswere not assessedwith the use of structured interviews.All but one patient received concurrent treatment withmedications, so that the effects of behavioral psycho­therapy and medication cannot be independently evalu­ated. Nonetheless, it is unlikely that the positive resultsseen in our patients were due to medication alone.The average magnitude of improvement seen in ourpatients is larger than that usually seen with medications(37% in the multicenter child clomipramine trial;DeVeaugh-Geiss et al., 1992), perhaps suggesting anindependent or positive interaction effect for behavioralpsychotherapy. Inasmuch as relapse commonly followsmedication discontinuation (Leonard et al., 1989), thefinding that improvement persisted after the withdrawalofmedication provides limited support for the hypothe­sis that booster behavior therapy prevents relapse whenmedications are discontinued. Because we administeredtreatment as a package, it is also impossible to disentan­gle the relative contributions of E/RP, AMT, andfamily interventions. Clinically, exposure appeared tobe the active ingredient of treatment; all other interven­tions then serve to permit adequate exposure. Finally,as illustrated by the poor response of our patient withobsessional slowness, treatment for OCD varies bysubtype , and innovation in this area is clearly needed .

In addition to addressing issues involving empiricaldocumentation, we also wanted to promote improvedcompliance on the part of both patients and parents.Given the Widespreadpessimism about getting children

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MARCH ET AL.

and adolescents to cooperate with CBT, it is strikingthat we had no child refuse to start treatment, andonly two who discontinued prematurely. Moreover, inthe two patients who ended treatment prematurely, itwas family factors and not unwillingness to continuetreatment on the child's part that prompted discontinu­ation. Several things appear to account for the trendtoward increased compliance. First, we presented CBTas the treatment of choice for OCD, either alone orin combination with medication. Second, we made aclear conceptual and linguistic distinction betweenOCD and the child, allowing all parties to ally againstOCD (White, 1984). Third, OCD is itself a powerfulnegative reinforcer, and the promise of competentempirically supported treatment is attractive, especiallyfor families that have been victimized by years ofunsuccessful play or family therapy. Fourth, we makeit clear from the very beginning that the child is incharge of the choice of exposure targets and that wewould provide a "tool kit" to help fight back againstOCD. Since no one wants to go into battle withouta strategy or allies, providing both in the form of AMTand E/RP decreases anticipatory anxiety and promotessuccessful E/RP. Fifth, we provided a series of parentinterventions designed to extinguish parental behaviorsthat reinforce OCD and to increase parental behaviorsthat facilitate the treatment process. This invariablyhelps parents, who generally feel upset and helpless,to feel more competent, hopeful, and thus willing tocooperate with treatment.

Mental health practitioners experienced in the behav­ioral treatment of OCD in young persons are in shortsupply. While the spate of recent lay publicationsconcerning the behavioral treatment of OCD is encour­aging (Baer, 1991; Foa and Wilson, 1991), the treat­ment literature for children and adolescents lacks a"how-to-do-it" manual. Traditionally, manualized be­havioral programs for OCD have focused solely onthe techniques of CBT, omitting the "tricks of thetrade" that all skillful therapists use to enhance compli­ance. Foa has argued that these interventions are acrucial part of the treatment package and ideally shouldbe specified in the interest of ensuring reproducibilityof treatments (Edna Foa, personal communication).Through focusing on methods for increasing compli­ance, we hoped to expand the pool of potential researchpatients, thereby providing a better test of treatment

effectiveness, and eventually to facilitate improved clini­cal practice in this area. Nonetheless, it is not possibleon the basis of our data to know whether our resultswill generalize to child and adolescent patients treatedin other settings.

In summary, despite limitations in methodologicalpurity imposed by clinical verities, this report improveson previous investigations of behavioral treatment forOCD in children and adolescents by providing objec­tive assessmentsof treatment outcome across time usinga protocol-driven treatment package. Although we ob­tained encouraging results, further research is clearlynecessary. Comparisons of behavioral psychotherapyto other treatments using no-treatment or wait-listcontrols, componential analyses, and the applicationof exportable protocol-driven treatments to differentpatient populations are all necessary to disentangle theeffects of divergent treatments and components oftreatments. The availability of a manualized time­limited treatment protocol should drive this processforward to the benefit of children and adolescentswith OCD.

APPENDIX

"How I Ran OeD Off My Land!"©

A Guide to Cognitive-Behavioral Psychotherapy

for Children and Adolescents with

Obsessive-Compulsive Disorder (Excerpted)

John S. March, M.D., M.P.H., and Karen Millle, B.S.N, M. rs.On the following pages, we ptesent a guide to the cognitive­

behavioral treatment ofobsessive-compulsivedisorder (OCD). Eachsession includes a statement of goals, procedures to meet thosegoals, and a means of evaluating the outcome. The astute readerwill notice that topics from the next session are always introducedat the end of the preceding session. For example, trial exposuretasks begin almost immediately, but formal exposure and responseprevention (E/RP)does not starr until the "transition zone" mecha­nism for negotiating graded exposure has been carefully and clearlyco-located and the child has his or her "tool kit" in place. Similarly,we anticipate involving parents at week 6 by rehearsing parentalE/RP with the child at week 5. In our experience, schedulinginterventions in this fashion dramatically reduces anticipatoryanxiety.

In describing the intervention procedures, we move frequentlyberween the third person ("the therapist should ... ") and the firstperson ("we often ask ...") in order to present instructions bothdirectly and by example. Unless otherwise specified, the term"children" refers to both children and adolescents. Hundreds ofchild patients and more than 1,000 hours of therapist experiencewith child and adolescent OCD have gone into this manual. Alongthe way we have made plenty of mistakes and taken lots of

338 J. AM. ACAD. CHILD ADOLESC. PSYCHIATRY, 33:3. MARCH/APRIL 1994

therapeutic detours, most of which you can avoid by followingthe manual. Children and families react differently to OCD, andOCD varies tremendously in its manifestations, so feel free toimprovise when circumstances dictate. Remember though thatOCD is the enemy; failure to focus on OCD (for example, bydiscussing peer or family problems instead of the session goals)makes the therapist an ally of OCD through complicity withantiexposure instructions. In our experience, this is a commonproblem for inexperienced therapists or therapists used to othertraditions, especially play therapy or family therapy. Be sure tostay within a skills-based cognitive-behavioral framework, and youwill more often than not keep your child patient cheerfully engagedin treatment until one day he or she (gratefully, no doubt) nolonger needs your services.

SESSION 1: A MODEL FOR UNDERSTANDING OeD:

INFORMATION GIVING AND GETIING

Goals:

1. Establish rapport2. Provide a neurobehavioral framework3. Explain treatment process4. Introduce story metaphors

1. Nuts and Bolts of Treatment

1.1 Establish Rapport. To enlist the child's cooperation in therapy,session 1 begins with small talk designed to establish rapport. Inaddition, we often ask younger children to choose a game to playat the end of the session. To relieve anxiety, initial questions arefocused on the child's background and narrative history. In thisway, the therapist notes what interests and strengths the childbrings to treatment. Since the child and family are in a battle withOCD, we state at the outset that the goal of treatment is toprovide the child with allies and a strategy for "bossing backOCD." Stated differently, the tone and content of the conversationmust explicitly and implicitly document that the therapist is onthe side of the child and family against OCD. It is often helpfulto identify what went well or poorly in previous treatments. (Inour experience, blaming the child or parent, an exclusive focus ondrug treatment, or failure to consider comorbid conditions, suchas depression or an occult learning disability, characterize mosttreatment failures.) Once rapport is established, the interviewfocuses on building a common neurobehavioral framework forunderstanding OCD.

1.2 Provide a Neurobehavioral Framework. By reviewing thecurrent scientific understanding of OCD, the therapist placesOCD in a neurobehavioral framework: "neuro" as in neurologicaldisorder; "behavioral" as in manifested in thoughts, feelings, andbehaviors. While we take pains to point out that OCD can beeliminated through actions taken by the child, we also emphasizethat OCD is not a "bad habit" that must be corrected. Stateddifferently, we help the child understand that OCD is a neurologicalproblem that cannot, in any way, be viewed as the his or her"fault" or as something the child could stop "if he or she justtried harder." Instead we explicitly present OCD as a "shortcircuit," "hiccups," and/or a "volume control" problem in thebrain-whatever metaphor the child finds appealing. Using thechild's OCD symptoms as a guide to the discussion, the therapistdefines a "worry computer" that inappropriately sends fear cueswhen no threat is present or turns up the volume on fear cuesthat do not deserve such attention.

OPEN TRIAL OF CBT IN OCD

In this context, the therapist then carefully defines obsessionsas unwanted thoughts, urges, or images that are accompanied bynegative feelings. Compulsions are actions designed to make thesethoughts go away and to relieve accompanying negative affects.The therapist illustrates these definitions using examples takenfrom the child's OCD, using other obsessive-compulsivesymptomsas necessary. Returning to the child's strengths, the therapist thennotes that this definition of OCD as "brain hiccups," namely asan illness distinct from the child as person, leaves the rest of thebrain (and child) functioning normally. Analogies to diabetes orarthritis often help to clarify this picture. Finally, using informationfrom the child's prior psychiatric or psychological evaluation, thetherapist provides information and answers questions regardingthe phenomenology, epidemiology, neurobiology, and appropriatetreatment of OCD. For children receiving concurrent pharmaco­therapy, the therapist should emphasize the potential synergy ofpharmacotherapy and cognitive-behavioral psychotherapy.

By viewing OCD as a specific brain problem, the child can letgo of the notion that he or she is the problem, thereby taking afirst step toward explicitly defining OCD as the problem andtoward giving OCD a name. These related tasks comprise theagenda for session 2, but should be introduced here as part ofobtaining a narrative history and building the neurobehavioralframework. Making OCD the problem is the process oflinguisticallyseparating OCD as a medical illness from the child (who is thuslabeled as an otherwise normal youngster) so that OCD becomesan object in the child's story that can be addressed in treatment.This allows the child, family members, and the therapist to allyagainst OCD rather than battle with each other over "who is atfault." Naming OCD involves choosing an epithet for OCD thatassists in making OCD the problem by setting up a "good guys"versus "bad guys" dichotomy between the child and OCD. Youngerchildren often choose names like "stupid" or "terrible trouble."Somewhat older children may choose a comic book character ora less than favorite adult. Adolescents usually call OCD by itsmedical name. Once OCD is clearly identified and named as theproblem, the treatment process of "bossing back" OCD begins.

1.3 Explain Treatment Process. "Bossing back" or "saying no"to OCD is the essence of the treatment process. "Bossing backOCD" requires two things: allies and a battle strategy, both ofwhich are virtually always missing when parents and children entertherapy. For the child to be successful in his or her strugglewith OCD, we provide allies (therapist, parents, and friends) andstrategies (the techniques of cognitive-behavioral psychotherapy).Exposure and response prevention is the core of "bossing" OCD;the therapist serves as "coach" to facilitate the process. In thisway, the therapist controls the structure of the treatment; theinitiative is left to the child, thereby avoiding the problem of thetherapist telling the child what to do and so missing the markwith respect to E/RP.

It is critical for the therapist to be sure that the child understandsthe related concepts of E/RP in the context of the statement,"Who's boss, you or OCD?" The exposure principle states thatadequate exposure to a feared stimulus will ultimately reduceanxiety. The response prevention principle states that adequateexposure depends 'on blocking rituals and/or minimizing avoidancebehaviors. Exposure therefore requires the child to confront triggersfor OCD, for example, holding a "contaminated" door knob.Response prevention takes place when the child refuses to performthe usual anxiety-relieving compulsion, in this case washing handsor using a tissue to grasp the knob. When explaining E/RP, it isalways helpful to use examples from the child's OCD to clarify

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MARCH ET AL.

the treatment process. However, you must make it clear that thechild will be able to "boss OCD" in the future without anyexpectation that the child will do so today.

Exposure and response prevention are always threatening forthe child, and the implementation or E/RP requires two primaryassurances: (1) the child will receive a "tool kit," in the form ofcoping strategies to use while experiencing anxiety or other dys­phoric affects during E/RP; and (2) treatment will proceed at thechild's chosen pace, that is, the "allies" will not suddenly becomeenemies by asking the child to do the impossible. When a childis exposed to a feared cue without performing the usual compulsiveresponse, he or she will invariably experience increased anxietyand, therefore, must be prepared to expect, measure, and toleratethat anxiety. The "tool kit," introduced in session 3, provides thispreparation. The therapist sets the pace by coaching the child tochoose tasks that he or she is ready to face-usually those thatthe child has already confronted with some success. By hookingOCD to a different affect, humor also helps alleviate the embar­rassment and demoralization children feel as a result of OCD. Sincechildren are frequently secretive about their symptoms, laughing atOCD (not at the child) can help children discuss OCD in a lessthreatening context, while building trust in the therapist.

Although the treatment may proceed slowly, there must alwaysbe some movement, however small, toward the goal of generatinga story in which OCD plays a less prominent part. Otherwise thetherapy itself can come to serve as an avoidance behavior. Thusthe therapist must emphasize his or her intransigence against OCDon the side of the child and that this shared attitude will notpermit the absence of progress.

In this context, the therapist then provides a session-by-sessionoutline of the course of treatment for the child and his or her parents.Introducing stories about other children who have successfullycompleted treatment is often helpful in making the treatmentprotocol real to the child.

1.4 Introduce Story Metaphors. The therapist now introduces theidea that the child has a choice about including or excluding OCDfrom his or her life story. Past chapters have been taken up withOCD; future chapters need not be. Story metaphors are found byselecting out of the totality of the child's experience those aspects(1) that can be readily assembled into an autobiographical ornarrative format and (2) that can be used to drive OCD out ofthe child's life space. Conceptualized in this fashion, childrenreadily incorporate story metaphors into OCD treatment. Storymetaphors stimulate the child's hope that he or she can author amore congenial story, namely a story without OCD at its center.As described in session 2, story metaphors are a crucial tool inmapping OCD onto the child's life experience-past, present, andfuture. In cognitive-behavioral terminology, this map is termed astimulus hierarchy.

During session 1, the child is asked to write (or dictate) a briefpersonal story, noting how OCD influences it negatively, but alsobeing mindful that OCD will be "written out" through thetreatment process. Anticipating session 2, the therapist suggeststhat the child choose a disparaging name for OCD. Youngerchildren in particular may wish to write a story about anotherperson or a pet who is a stand-in figure. Careful questioning bythe therapist encourages the child to add as much detail as possible.Some children will know right away; others will have to thinkabout it through session 2 or even 3. Since this exercise is primarilyaimed at developing a framework for treatment, not history taking,this is acceptable, but the therapist should note that the goal oftreatment is for the child to author his or her story in a way that

leavesOCD out of the picture. Once OCD is named, the therapistalways refers to OCD by this name as a character (and a rathertroublesome oriel) in the child's story. This both facilitates theprocess of making OCD the problem and reinforces the storymetaphor. The written story is used throughout the treatmentprocess as (1) a motivational tool, (2) a symptom diary for evaluativepurposes, and (3) a communicative tool for informing others aboutthe child's progress.

2. Homework

2.1 General Principles. Just as tennis or ballet lessons requirepractice, a child with OCD must practice "bossing back" OCDin the office and in homework assignments. The therapist mustcarefully explain these homework assignments to the child, empha­sizing the importance of bossing OCD each day, aswell as providingreassurance that homework will be decided upon mutually. Thetherapist informs the child that homework is time limited andspecific and, therefore, will be under the child's control. Stateddifferently, the child must come to understand that he or she willchoose only those E/RP tasks that he or she feels quite ready toperform. As explained in sessions 2 and 3, the story metaphor andassociated "map" of OCD are the primary sources for home­work tasks.

2.2 Homework Assignment. This week's homework assignmentis prescriptive. The therapist asks the child to choose a name forOCD and to continue writing (or dictating to a parent) his orher story, using the chosen name for OCD as a character in thestory. This naming and story assignment not only serves as a placefor the child to tell about specific obsessions and compulsions, butalso actively reinforces the concept of making OCD the problem.

3. Evaluations

3.1 Rating Scales. Scalescompleted as part of the initial psychiatricand psychological evaluation include several copyrighted scales:the Conners Parent and Conners Teacher Rating Scales, Multi­Dimensional Anxiety Scale for Children, Revised Children's Mani­fest Anxiety Scale, and Children's Depression Inventory. Noncopy­righted baseline rating scales also are obtained during this firstvisit. These rating scales include the Leyton Obsessional Inventory,Yale-Brown Obsessive-Compulsive Scale, National Institute ofMental Health Global Obsessive-Compulsive Scale, and ClinicalGlobal Impression Scale. The story written by the child will alsoserve as an evaluative tool throughout treatment. Finally, the FearThermometer (introduced in session 2) will be used to assess thechild's progress with specific obsessions and compulsions as wellas anxiety levels during exposure tasks.

REFERENCESBaer L (1991), Getting Control. Boston: Little, Brown, and CompanyDeVeaugh-Geiss J, Moroz G, Biederman J et aI. (1992), Clomipramine

hydrochloride in childhood and adolescent obsessive-compulsive disor­der: a multicenter trial.] Am Acad ChildAdolesc Psychiatry 31:45-49

Flamenr MF, Whitaker A, Rapoport JL et aI. (1988), Obsessive compulsivedisorder in adolescence: an epidemiological study. ] Am Acad ChildAdolesc Psychiatry 27:764-771 .

Foa E, Wilson R (1991), Stop Obsessing. New York: Bantam BooksGoodman WK, Price LH, Rasmussen SA et al. (1989), The Yale-Brown

Obsessive-Compulsive Scale. I. Development, use, and reliability. ArchGen Psychiatry 46: I 006-1 0 II

340 ]. AM. ACAD. CHILD ADOLESC. PSYCHIATRY, 33:3, MARCH/APRIL 1994

Leonard HL, Swedo SE, Rapoport jl, et aI. (1989), Treatment of obsessive­compulsive disorder with clomipramine and desipramine in childrenand adolescents: a double-blind crossover comparison. ArchGenPsychia­try 46: 1088-1 092

March J (in press), Cognitive-behavioral psychotherapy for children andadolescents with obsessive-compulsive disorder: a reviewand recommen­dations for treatment. JAm Acad ChildAdolesc Psychiatry

Maxwell S, Delaney H (1992), Designing Experiments and Analyzing Data:A Model Comparison Perspective. Belmont, CA: Wadsworth

Rapoport Il., Swedo SE, Leonard HL (1992), Childhood obsessivecompul­sive disorder. J Clin Psychiatry 53:11-16

OPEN TRIAL OF CBT IN OCD

Rasmussen SA, Eisen JL (1992), Epidemiology of obsessive compulsivedisorder. J Clin Psychiatry 53:4-10

White M (1984), Marital therapy: practical approaches to longstandingproblems. Australian Journal of Family Therapy 5:27-44

White M, Epston D (1990), Narrative Means to Therapeutic Ends. NewYork: WW Norton

Wolff RP, Wolff 15 (1991), Assessment and treatment of obsessive­compulsive disorder in children. Behav ModifI5:372-393

]. AM. ACAD. CHILD ADOLESC. PSYCHIATRY, 33:3, MARCH/APRIL 1994 341