Family-based CBT benefits young children with OCD

Although children as young as 5 can be diagnosed with obsessive-compulsive disorder (OCD), few research studies have looked at treatments specifically geared toward young children with this disorder. Now, a new study from the Bradley Hasbro Children's Research Center provides some of the first evidence-based data on a successful intervention for early childhood OCD.

According to the study's findings, published the Journal of the American Academy of Child and Adolescent Psychiatry, children with OCD between the ages of 5 and 8 may benefit from a form of psychotherapy, known as family-based cognitive behavioral therapy (CBT), that is uniquely tailored to the child's developmental needs and family context. The overall focus of family-based CBT is to provide both child and parents with a set of tools to help them understand, manage and reduce OCD symptoms.

"If left untreated, early childhood OCD can severely disrupt and impair a child's development and functioning and can extend into adulthood. Despite this risk, clinicians do not have a proven treatment model for these young children," says lead author Jennifer B. Freeman, PhD, of the Bradley Hasbro Children's Research Center and an assistant professor of psychiatry/human behavior (research) at The Warren Alpert Medical School of Brown University.

"Based on our findings, we believe that family-based cognitive behavioral therapy for early childhood OCD offers a promising intervention that may help to minimize the chronic nature of OCD and decrease the morbidity of this debilitating illness," she adds.

Researchers worked with 42 young children with OCD who were randomized to receive 12 sessions - completed over 14 weeks - of either family-based CBT or family-based relaxation treatment (RT), an approach that teaches the family and child relaxation techniques aimed at reducing some of the stress inherent with OCD. Just over half of the patients were randomly assigned to CBT and 48 percent were assigned to RT. Overall, 74 percent of patients completed all 14 weeks of treatment.

The CBT program was found to be significantly more effective than RT in decreasing OCD symptoms and, most importantly, helping a large number of children achieve clinical remission. Specifically, 69 percent of the children who completed all 14 weeks of CBT treatment achieved remission compared to 20 percent who fully completed the RT program. Even those children who started, but did not complete, the CBT program did well, with 50 percent achieving clinical remission.

"An important takeaway from this study is that children in this age range can actively participate in and benefit from CBT that is appropriately tailored to their cognitive developmental level," Freeman says. "And from a research perspective, these findings are particularly promising because they demonstrate that it's possible to recruit, treat and collect data about young children with OCD."

The family-based CBT method modeled in the study draws on successful approaches used with older children but also contains innovative elements that have been specifically tailored to children ages 5 to 8, with special attention paid to the child's cognitive and developmental level and awareness of a child's involvement in and dependence on a family system.

Freeman points out that there are a number of reasons why younger children experiencing OCD require this kind of tailored approach. "Developmentally, younger children generally have less sophisticated emotion awareness and expression skills than older children. Also, younger children rely on parents for guidance and direction more so than older children and parents may be more likely to inadvertently reinforce or even actively accommodate a young child's rituals," she says.

Based on the study's findings, Freeman and colleagues offer the following recommendations:

• Treatment of children experiencing early childhood-onset OCD will be most effective if parents are involved in all phases of treatment.



• Clinicians should consider the child's unique developmental characteristics and tailor psychoeducation, exposures and homework accordingly.



• Clinicians should take time to understand the family context and, in particular, the parents' response to their child's anxieties.



• Teach parents to tolerate their own anxiety about their child's level of distress.



• Use humor generously.

According to the American Academy of Child and Adolescent Psychiatry, as many as 1 in 200 children and adolescents struggle with OCD, an anxiety disorder characterized by recurrent, intense obsessions and/or compulsions that cause severe discomfort and interfere with daily functioning. Compulsions are repetitive behaviors such as hand washing, counting, checking, or cleaning and they are often performed with the hope of preventing obsessive thoughts or making them go away. Performing these so-called "rituals," however, provides only temporary relief, and not performing them can cause significant anxiety or distress and can interfere with a child's normal routine, academic functioning, social activities, or relationships.

The study was funded by a grant from the National Institute of Mental Health.

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Freeman JB, Garcia AM, Coyne L, et al. Early Childhood OCD: Preliminary Findings From a Family-Based Cognitive-Behavioral Approach. J Am Acad Child Adolesc Psychiatry. 2008 May;47(5):593-602.   [Abstract]