Benefits of cognitive behavioural therapy for

children and youth with obsessive compulsive

disorder: re-examination of the evidence

Richard O’Kearney

The aim of the present paper was to critically examine evidence about the benefits of
cognitive-behavioural therapy (CBT) for pediatric obsessive-compulsive disorder (OCD)
from controlled and single group studies, including its benefits relative to medication are
critically reviewed. Selected studies were categorized by study type and by risk of bias
classification. Standardized mean differences (Hedges’ g or Cohen d) and, where
appropriate, weighted mean difference (WMD) were calculated. All five comparison and
14 one-group studies showed a significant benefit for CBT within a wide range (ES /.78 to
4.38). Low risk of bias studies produced the lower adjusted effect sizes. The best available
estimate of CBT efficacy relative to no treatment is about 1 standardized mean difference,
equivalent to a treatment effect of 8 points on the Children’s Yale-Brown Obsessive-
Compulsive Scale. This represents a reduction in the risk of continuing to have OCD post-
treatment of about 37% (95% CI 14% to 54%). Evidence from 3 studies indicates that the
efficacy of CBT and medication do not differ significantly. CBT combined with medication is
significantly more efficacious than non-active controls or medication alone but not relative
to CBT alone. CBT should be regarded as a first line equivalent to anti-OCD medication
with the potential to lead to better outcomes when combined with medication than
medication alone can provide. Additional studies are needed to further clarify CBT’s
benefits and to investigate how it can be made more available as a treatment option for
children and youth who suffer from OCD.
Key words: children and youth, cognitive
behavioural therapy, meta-analysis,
obsessive
compulsive disorder, treatment evaluation.

Australian and New Zealand Journal of Psychiatry 2007; 41:199 212

Cognitive
behavioural therapy (CBT) is recom- exposure with response prevention (ERP), CBT
mended as the psychotherapeutic treatment of treatments include various other components such
choice for children and adolescents with obsessive
as psycho-education, cognitive training, anxiety
compulsive disorder (OCD) [1,2]. For pre-pubertal management training and parental or family invol-
children it is recommended as the first-line treat- vement. At the time, the reasons for the expert
ment, and for adolescents CBT combined with a consensus recommendation in favour of CBT for
selective serotonin re-uptake inhibitor (SSRI) is the children and adolescents with OCD were the de-
recommended first-line approach. In addition to monstrated efficacy of CBT with ERP for OCD in
adults [3], together with the belief that OCD
in childhood is ‘virtually identical to the adult
Richard O’Kearney, Senior Lecturer
form’ [4, p. 94]. ERP in particular also has a
School of Psychology, The Australian National University, Canberra,
ACT 0200, Australia. Email: [email protected] logically consistent and compelling rationale that
Received 12 November 2006; accepted 15 November 2006. presents a clear relationship between the obsessive

# 2007 The Royal Australian and New Zealand College of Psychiatrists

200 CBT FOR PEDIATRIC OCD

and compulsive symptoms, their maintenance and to support their OCD child in undertaking self-
the CBT treatment. directed ERP.
There are a number of issues, however, which These potential difficulties make it doubly impor-
indicate that the downward extension of CBT to tant to examine carefully the evidence base for
pediatric forms of OCD may face unique problems. the effectiveness of CBT for pediatric OCD. There
Firstly, a number of recent studies question the are indications that the empirical evidence to support
presumed developmental continuity between pedia- the use of CBT in children with OCD and adolescents
tric OCD and adult OCD. Geller and colleagues have with OCD is not of the highest quality [2], may
described a bimodal age of onset for OCD, with be simply lacking [10] or is being misinterpreted.
one peak at about 10 years of age and another during Abramowitz et al. [11] recently presented a meta-
puberty or early adulthood [5,6]. While equally analysis of the effectiveness of treatments for pedia-
prevalent and similar in its clinical characteristics to tric OCD reviewing 18 studies using either CBT or
the later-onset OCD, the childhood-onset disorder medication. While they concluded that CBT with
has a number of distinctive features that have ERP was effective in reducing pediatric OCD symp-
implications for clinical management, including pos- toms, they recognized that their conclusions were
sible responsiveness to psychotherapeutic interven- based predominantly on uncontrolled trails. In addi-
tions. In particular, it is male-predominant and more tion, their meta-analysis did not consider risk of bias
strongly co-morbid with disruptive behavioural pro- in the reviewed studies and used only pre
post
blems, and developmental disorders, including autis- differences to estimate effect sizes even for the
tic disorder, depression and other anxiety disorders controlled trails. A recent wide-ranging review of
[7]. OCD in children also co-occurs with tic disorders, the status of CBT theory and the treatment for
and has been noted as a part of a pediatric pediatric OCD [12] presented similar evidence con-
autoimmune neuropsychiatric disorder associated cluding that CBT is an effective treatment without
with streptococcal infections [8]. These co-morbidities considering the impact of study design, study com-
may impact on the rationale for CBT in so far as they parability and study quality on treatment effect sizes.
indicate differing mechanisms for symptom onset and There are strong indications that the use of one-
maintenance. For example, the observation that group prior to post comparisons artificially inflates
OCD children with co-morbid tics have less well- effect sizes because of how meta-analysis deals with
developed cognitions triggering their compulsions correlated scores and because of the confounding of
suggests a lesser role for cognitive appraisals in the maturation effects with treatment effects. Lipsay and
maintenance of the OCD than proposed by current Wilson [13] and Wilson and Lipsay [14] analysed the
CBT models [6]. Alternatively, co-morbidities asso- results of numerous meta-analyses of psychological,
ciated with impulsivity may reduce the capacity of behavioural and educational treatments and found
child and adolescent OCD patients to tolerate the that pre
post estimates consistently overestimate the
discomfort involved in the exposure and response treatment effects relative to comparison designs. For
prevention component of CBT. some types of intervention the bias was large. They
A second issue of extending CBT to pediatric forms calculated that pre
post designs produced effects
of OCD concerns the more self-reflective cognitive sizes on average 60% larger than those from compar-
techniques utilized with adults to enhance tolerance ison designs [13]. Although Abramowitz et al. [11]
and adherence to ERP. Some of these techniques may weighted individual studies’ effect sizes to take into
be of limited value with younger children because consideration differences in precision due to sample
they presume a level of meta-cognitive skill; for size and design, their overall strategy of only con-
example, an ability to reflect on thoughts and sidering pre
post effects even for comparison designs
emotions, not common until adolescence. In addition, assumed that pre
post effects were unbiased esti-
CBT for OCD in children and adolescents generally mates of the effect of the treatment for pediatric
requires support and therapeutic assistance from the OCD. Consequentially, the pooled mean effect sizes
family. Recent findings [9] show that parents of OCD for CBT and medication presented in that review
children aged 8 to 14 years were less rewarding of the [11] may have been substantially inflated. For exam-
child’s independence and less likely to promote ple, the mean pre
post effect sizes for medication in
positive problem-solving than parents of children that review of 1.13 (95% CI /0.82
1.25) was 2.5
with other types of anxiety disorders, externalizing times higher than the overall effect size of 0.46 (95%
problems or those with no problems. Barrett et al. [9] CI /0.37
0.55) reported in a recent meta-analysis of
suggested significant limitations to parents’ capacity randomized controlled trails of psychopharmacology
 R. O’KEARNEY 201

for pediatric OCD [15]. While O’Kearney et al. [16] [20] because of the impact of between study differ-
recently reviewed randomized controlled trials of ences. When combined with inflated treatment effects
CBT for pediatric OCD and found two studies that for CBT because of the use of pre
post estimation,
examined CBT efficacy against a non-active control, such comparisons risk providing a conclusion incon-
because of substantial differences between these sistent with the evidence. In their review, O’Kearney
studies and their exclusion of pre
post designs it et al. [16] located only two studies comparing CBT
remains unclear if pre
post estimates for CBT are and medication for pediatric OCD, both of which
also inflated. In addition, none of the attempts at reported equivalent results for the two treatments. In
summarizing the evidence for CBT for pediatric OCD view of the controversy over the potential for self-
so far have considered study quality in regard to harm with SSRIs, despite evidence of their benefits for
potential risk of bias nor discussed study heteroge- children and adolescents with OCD, it is extremely
neity in considering pooled effect size estimates. important that researchers and practitioners provide
Inferences about treatment effectiveness from sin- non-partisan readings of the evidence.
gle group designs are also more vulnerable to error It is also important for clinicians to have reliable
because of the impact of testing or re-test effects and realistic estimates of the relative benefits of
[17,18]. These effects refer to the consistent observa- CBT in order to set reasonable benchmarks for
tions of significant decreases in negative states in treatment progress for their patients. Regardless of
groups that have not received treatment. In particu- the recent advances in treatment, OCD remains a
lar, Arrindell [17] reported effect sizes of 0.33 and difficult disorder to treat with the adult research
0.38 for a group of 95 adult OCD patients for indicating that OCD symptoms rarely remit and few
decreases in self-report measures of OCD symptom patients remain symptom-free. In addition, the on-
severity over time without intervention. These effect going process of improving treatment options and
sizes represent increased improvement rates due to a developing new treatments requires accurate esti-
testing effect of between 16 and 18%. While data is mates of the benefits of existing ones in order for
available from several studies to estimate this effect researchers and clinicians to advocate for treatments
for OCD measures in children and youth, none of the that may produce benefits beyond these levels.
reviews or meta-analyses of CBT for pediatric OCD The present study is a critical appraisal of the
have included a correction for this effect in estimates evidence about the benefits of CBT for pediatric
of effect sizes from one-group studies. OCD. It presents the first comprehensive considera-
Consideration concerning study design, risk of bias tion of the quality, comparability and statistical rigor
and study comparability are particularly important of the evidence from two types of studies: controlled
from a clinical perspective when examining the relative trials and single-group pre to post designs. It provides
benefits of CBT against other available and effective a critical summary of the findings and their implica-
treatments. Evidence for the efficacy of pharmacolo- tions for clinical practice, research and policy-
gical treatment of OCD in children and adolescents, making. Overall, the study asks how beneficial
particularly for the SSRIs fluoxetine and sertraline, CBT is for children and adolescents with OCD and
appears conclusive from good quality controlled trials what its relative benefits are compared to medication.
[3,10,15,19]. Nevertheless, many clinicians are under- It substantially extends recent reviews [12,16] by
standably reluctant to prescribe psychotropic medica- contrasting estimates of the benefits of CBT from
tion to children and adolescents. Consequently, controlled and one-group designs taking into account
clinicians often recommend CBT, when available, as study quality. The paper also aims to demonstrate the
the first-line treatment. While there are many other importance for clinicians, policy-makers and clinical
factors besides relative efficacy that influence a researchers of considering the type and quality of
clinician’s treatment recommendation for an indivi- evidence in their recommendations and advocacy of
dual patient, it is important that evidence about particular treatments for individuals and services.
relative efficacy not be misinterpreted by advocates
of either medication or CBT. For example, in her
summary of the relative benefits of CBT and medica- Method
tion Turner [13] implies that CBT is superior because
it ‘produces consistently larger effect sizes and greater Inclusion criteria
rates of clinically significant improvement in compar-
ison to psychopharmacology’ (p. 18). Comparing Studies were selected if they were judged to be randomized
effect sizes between studies is inherently problematic controlled trials, quasi-randomized trials or one-group ‘open’ trials.
202 CBT FOR PEDIATRIC OCD

Case studies were excluded but case series where estimates of group TRIAL:it #3 RANDOMIZED-CONTROLLED-TRIALS #4
pre
post treatment effects were provided were included. RANDOM-ALLOCATION#5 DOUBLE-BLIND-METHOD #6
Eligible studies included participants who were 18 years of age or SINGLE-BLIND-METHOD #7 #1 or #2 or #3 or #4 or #5 or
younger at the time of treatment or who were considered ‘children #6 #8 HUMANS/lim#9 7 and 8 Clinical Trial (phase 2) #10
and adolescent’ as defined by the study. Participants had a CLINICAL-TRIAL:it #11 CLINICAL-TRIALS/exp #12 (clin*
diagnosis of OCD, established by clinical assessment or standar- *25 trial*):ta,ab. #13 ((singl* or doubl* or trebl* or tripl*) *25
dized diagnostic interview. Studies were included if they have used (blind* or mask*)):ta,ab. #14 PLACEBOS #15 placebo*:ta,ab. #16
any of the main CBT techniques (exposure with response preven- random*:ta,ab. #17 RESEARCH-DESIGN #18 #10 or #11 or
tion, psycho-education, cognitive training, anxiety management #12 or #13 or #14 or #15 or #16 or #17 or #18 #19 #18 and #8
training and parental or family involvement), either alone or in #20 #19 not #9 Comparative/Evaluation Studies (phase 3) #21
combination. Trials were included regardless of ‘treatment’ status COMPARATIVE-STUDY #22 EVALUATION-STUDIES/
of comparison, and the non-CBT control included active drug, exp #23 FOLLOW-UP-STUDIES #24 PROSPECTIVE-STUDIES
placebo or wait list. Studies of medication efficacy that used CBT #25 (control* or prospective* or volunteer*):ta,ab. #26 #21 or #22
as a comparison group were included as well as studies that or #23 or #24 or #25 #27 #26 and #8 #28 #27 not (#9
combined CBT and medications. or #20)Combine all 3 phases#29 #9 or #20 or #28, (b) Health
Condition #30 Obsessive
compulsive-Disorder/exp Combine
Measures (a) & (b)).
The Cochrane Collaboration Depression Anxiety and Neurosis
Controlled Trials Registry was also searched, using search terms
Primary outcomes
Diagnosis/Obsessive
compulsive, and Age Group/Children or
Adolescent.
For the comparison designs, the primary continuous outcome
In addition, the reference lists of all selected studies were
examined was between-group differences in endpoint (post-
inspected for more published reports and citations of unpublished
treatment) measures on OCD symptoms’ severity. For the
research. Other relevant papers and major textbooks, which cover
one-group design, the primary outcome examined was prior to
anxiety disorders, were checked. Any journals or conference
post-treatment differences in OCD severity. Continuous outcome
proceedings specifically relating to behavioural treatment of OCD
measures included the frequency, duration and degree of distress
were searched.
of obsessions and compulsions measured by clinician-rated or self-
Where required, the contact author of the included studies was
monitoring standard measures (e.g. Children’s Yale-Brown Ob-
contacted for clarification or additional information or data.
sessive Compulsive Scale [CY-BOCS]). Binary primary outcomes
examined were post-treatment improved/not-improved status or
diagnosis remitted/non-remitted as defined by the studies. Where Data analysis
individual’s CY-BOCS scores were available and binary outcomes
were not reported, we classified endpoint scores of
/10 as non- Effect sizes are reported as standardized mean differences (SMD;
remitted. Hedge’s g) for the comparison studies. Where the same measure-
ment scale (e.g. CY-BOCS) was used across studies for a
Search strategy for identification of studies comparison and the studies have low to moderate heterogeneity,
the weighted mean difference (WMD) was used to pool mean post-
treatment outcomes with the weight given to each study determined
Electronic searches were conducted on Medline and PsychINFO
by the precision of its estimate of effect. For the one-group designs,
using the following search strategy: (a) RCT (phase 1), 1 RANDO-
effect sizes (Cohen d) were estimated adjusting for sample size using
MIZED CONTROLLED TRIAL.pt, 2 CONTROLLED CLINI-
the criteria described by Morris and DeSohn [21].
CAL TRIAL.pt. 3 RANDOMIZED CONTROLLED TRIALS.sh.
For dichotomous outcomes (improved/not-improved), relative
4 RANDOM ALLOCATION.sh., 5 DOUBLE BLIND METH-
risks together with the 95% confidence intervals were calculated at
OD.sh., 6 SINGLE BLIND METHOD.sh., 7 or/1 6, 8 ANI-
post-treatment for the comparison studies and absolute risk at
MALS.sh. not HUMAN.sh., 9 7 not 8, Clinical Trial (phase 2), 10
post-treatment for the one-group designs.
CLINICAL TRIAL.pt.,11 exp CLINICAL TRIALS/, 12 (clin$
adj25 trial$).ti,ab.,13 ((singl$ or doubl$ or trebl$ or tripl$) adj25
(blind$ or mask$)).ti,ab.,14 PLACEBOS.sh. 15 placebo$.ti,ab.,16 Results
random$.ti,ab., 17 RESEARCH DESIGN.sh.,18 or/10 17, 19 18 not
8, 20 19 not 9, Comparative/Evaluation Studies (phase 3), 21 After reviewing the titles, abstracts and full texts, when
COMPARATIVE STUDY.sh. 22 exp EVALUATION STUDIES/ necessary, of the 153 relevant titles initially identified by our
23 FOLLOW UP STUDIES.sh.,24 PROSPECTIVE STU- search, 30 studies providing data on CBT for OCD in children and
DIES.sh.25 (control$ or prospective$ or volunteer$).ti,ab.,26 or/ adolescents were located. Nine studies were excluded; four
2125 27 26 not 8, 28 27 not (9 or 20), Combine all 3 phases, 29 9 or [22
25] were case studies, two [26,27] had samples of only three
20 or 28,(b) Health Condition, 30 exp Obsessive Compul- participants, three [28
30] failed to report data separately for the
sive Disorder/Combine (a) & (b)), and EMBASE (using the participants who were less than 18, while one [31] looked at
following search strategy: (a) RCT (phase 1),#1 RANDOMIZED- outcomes for a group of adolescents with various anxiety disorders
CONTROLLED-TRIAL:it #2 CONTROLLED-CLINICAL- and did not report separate outcomes for OCD. One of the
 R. O’KEARNEY 203

comparison studies [32] was a report on the design and methods of The one-group studies described between seven and 18 sessions
another study [36], leaving five [33
37] comparison studies and 14 of 1, 1.15, 1.5 or 2 hours. Most sessions were provided weekly
[38
51] one-group designs with data suitable for extraction. except for: Knox et al. [40], which had three sessions per week;
Wever and Rey [42], which had 10 daily and two weekly sessions;
and Franklin et al. [44], which had two CBT conditions, an
Participants intensive condition with 18 daily sessions and a group condition
with 16 weekly sessions. Bolton et al. [38] did not stipulate the
Table 1 presents the characteristics of the patient samples for number of sessions but gave the number of months of inpatient and
each of the included studies grouped by study type. The compar- outpatient treatment for each participant. Treatment in the one-
ison studies had a total of 262 children and adolescents ranging in group studies was mostly administered as individual sessions except
age from 7 years to 18 years 2 months. Gender distribution was for five studies that ran group treatment [43
45,49,50]. Both
about even for all studies. The ethnicity of the participants was individual and group treatment focused on exposure and response
Dutch [33], Australian [35], American [34,36] and Brazilian [37]. prevention with varying levels of psycho-education, parent train-
Participants were diagnosed with OCD by clinical interview ing, and pharmacology included. Nine one-group studies
[33,34,37] or using a well-established diagnostic semi-structured [39,41,43
47,49,50] based their treatment on the protocol devel-
interview for anxiety disorders (Anxiety Disorders Interview oped by March [2] or were similar to methods of March et al. [39].
Schedule [ADIS]; Barrett et al. [35] used the parent as respondent Four other studies used different manualized treatments
[ADIS-P]; the POTS Team [36] used the child as respondent [ADIS- [40,42,48,51]. Bolton et al. [38] described their treatment as
C]). Of those assessed for eligibility, 28% [33] and 27% [36] were primarily behavioural (response prevention) and also included
excluded, while the numbers excluded in Neziroglu et al. [34], family therapy, medication, psychotherapy, and ‘milieu’ therapy.
Barrett et al. [35] and Asbahr et al. [37] were not reported. The amount of parent involvement varied between studies from an
The one-group studies also had a total of 300 children and optional parent session [49], to weekly 30-minute parenting skills
adolescents ranging in age from 5 years to 18 years. The percentage sessions [46], to weekly 60-minute parent session and 30-minute
of males in each group ranged from 29 to 75. The ethnicity of combined child and parent session [50]. The number of participants
the majority of participants was American with the exception of concurrently on medication in the one-group studies ranged from
one British study [38], two Australian studies [42,46], and one 21% [51] to 100% [42]. Fidelity to the treatment protocol was
Norwegian study [51]. Participants were diagnosed with OCD protected by regular supervision of therapists in the individual
mainly with the use of an unstructured clinical interview, except for treatment studies, except for Bolton et al. [38], March et al. [39],
two studies that used the ADIS-C [48,46], and three studies that Wever and Rey [42], and Martin and Thienemann [50], which did
used the Schedule for Affective Disorders and Schizophrenia for not report their fidelity checks.
School-Age Children [47,49,51]. Of those participants assessed for
eligibility, 22% [44], 59% [49], and 2% [42] were excluded, while the Non-CBT comparison group
numbers excluded in the remaining studies were not reported.

Four of the comparison studies used a medication comparison

Cognitive behavior therapy protocols group (clomipramine [33], fluvoxamine [34], sertraline [36,37]), one
[36] had a pill placebo control and one [35] had a waitlist control. In
the POTS Team [36] CBT was combined with medication in one
The comparison studies delivered CBT interventions of between
group. Asbahr et al. [37] compared group CBT with medication.
12 to 20, 1 or 1.5-hour weekly sessions with total hours of
The medication administration was standardized and well-
treatment of 30 hours for Neziroglu et al. [34], 21 for Barrett
described. All control groups were assessed at post-treatment
et al. [35], 18 for Asbahr et al. [37], 14 for the POTS Team [36] and
except for Barrett et al. [35], where it was assessed after 4 to 6
12 hours for de Haan et al. [33]. In Neziroglu et al. [34], therapy
weeks wait because of ethical concerns.
focused exclusively on exposure with response prevention. For the
other studies [33,35
37], therapy was multi-modal, manualized and
had equivalent components including psycho-education, cognitive Risk of bias
therapy and ERP. These studies were based on a similar protocol
[2,52] and included parent involvement (all sessions for Barrett The methodological criteria required to lower risk of bias were
et al. [35], at least three sessions for POTS [36] with additional based on the various aspects of study design, implementation,
sessions determined by the symptom picture and developmental analysis and reporting that are specified for controlled trails [53],
stage of the child, two sessions in Asbahr et al. [37] and and also on consideration of the additional threats to internal
not specified for de Haan et al. [33],). Barrett et al. [35] also validity for one-group designs. Because different aspects of study
included sibling involvement and compared CBT delivered in an design are important to risk of bias for the two types of studies,
individual or group format to a waitlist condition. Except for only the relevant design and implementation aspects was used in
Neziroglu et al. [34] and Asbahr et al. [37], which did not report on assessing quality. Two raters independently judged each study on
fidelity checks, fidelity to the treatment protocol was protected by the criteria described below, allocating points from 0 to 2 according
regular supervision of therapists in all studies. Barrett et al. [35] to the degree there was evidence that the study met the criteria. The
reported strong concordance between actual sessions and the total score was used to classify the studies as low, low to moderate,
manual using videotapes of sessions. moderate to high, or high risk of bias. Any disagreements between
 204
Table 1. Descriptive characteristics of patients in the CBT studies and of the CBT delivered by study type

Total n Age range Duration

(% male) (mean; SD) Exclusion (%) Initial severitya No CBT sessionsb (hours) Frequency
Comparison studies
De Haan et al. [33] 23 (50) 9
18 (13.30; 2.90) 28.13 21.5 (5.9) 12 Not stated Weekly
Neziroglu et al. [34] 10 (60) 10
17 (14.50; 2.40) None 28.0 (6.2) 20 1.5 Weekly
Barrett et al. [35] 77 (51) 7
17 (11.78; 2.61) Not stated
Individual (10.75; 2.54) 23.64 (4.3) 14 1.5 Weekly
Group (12.90; 2.30) 21.38 (5.6) 14 Group 1.5 Weekly
POTS Team [36] 112 (50) 7
17 (11.7; 2.7) 27.27 26.0 (4.7) 14 1 Weekly
Asbahr et al. [37] 40 (65) 9
17 (13.7; 2.32) Not stated 26.3 (4.9) 12 Group 1.5 Weekly

CBT FOR PEDIATRIC OCD

Single-group studies
Bolton et al. [38] 15 (53) 12
18 (14.07; 1.75) 2 refused treatment 2.5 (0.63) rating Not stated 58 weeks Out/inpatient
unit
March et al. [39] 15 (33) 8
18 (14.3) Not stated 21.7 (10.44) 3
21 Not stated Weekly
Knox et al. [40] 4 (75) 8
13 (10.75) Not stated 5.75 ADIS-C/P 12 1.5 3 times a week
Scahill et al. [41] 10 (71) 9
16 (13.0; 2.02) 3 refused treatment 22.3 (6.02) 14 Not stated Weekly
Wever and Rey [42] 82 (70) 7
19 (13.7; 2.7) 2 excluded, 25.2 (5.5) 12 Not stated 2 weekly;
8 refused treatment 10 daily
Fischer et al. [43] 15 (60) 12
17 (14.5) Not stated 21.8 (8.38) 7 Group 1.5 Weekly
Franklin et al. [44] 14 (71) 10
17 (14.1; 2.2) 22.22 23 18 intensive/16 1.5/1 Daily/weekly
Thienemann et al. [45] 18 (67) 13
17 (15.2) Not stated 24.8 (5.4) 14 Group 2 Weekly
Waters et al. [46] 10 (60) 10
14 3 dropouts 22.14 (3.0) 14 1.5 Weekly
Benazon et al. [47] 16 (50) 8
17 Not stated 22.56 (6.45) 12 1 Weekly
Piacentini et al. [48] 44 (40) 5
17 (11.8; 3.5) 2 dropouts 21.3 (6.4) 12.5 (4.7) 1 Weekly
Himle et al. [49] 19 (58) 12
17 (14.63; 1.71) 58.93 22.0 (8.17) 7 Group 1.5 Weekly
Martin and Thienemann [50] 14 (29) 8
14 (11.3) Not stated 22.5 (5.29) 14 Group 1.5 Weekly
Valderhaug et al. [51] 24 (50) 8
17 (13.3, 2.3) 4 dropouts 23.1 (3.1) 12 1.15 Weekly for
10 then
fortnightly

a
CY-BOCS unless otherwise stated; bIndividual treatment unless otherwise stated.
 R. O’KEARNEY 205

the raters in assignment of a study to a risk category were resolved specify method of allocation concealment, whether assessors were
through discussion. blinded, and did not use intention-to-treat analyses. Barrett et al.
[35] was judged as moderate risk of bias arising from the method of
Risk of bias: comparison studies randomization, between-group differences in timing of endpoint
assessments, non-blinded post assessment and lack of intention-to-
Selection bias: The POTS Team [36] reported on the method treat analyses. Asbahr et al. [37] was also considered moderate risk
of randomization and on allocation concealment that were of bias because of lack of specification of method of randomization
adequately done. De Haan [33] clarified the method of randomiza- and incomplete reporting of recruitment, flow-though study and
tion and reported on allocation concealment, which appear post-test data.
adequate. Neziroglu et al. [34], Barrett et al. [35] and Asbahr
et al. [37] did not report on the method of randomization or on Risk of bias: one-group studies
allocation concealment. In Barrett et al. [35], the process of block
randomization described suggested quasi-randomization. De Haan Selection bias: Stability of symptoms at pre-treatment is
et al. [33], the POTS Team [36] and Asbahr et al. [37] checked for important for meeting the threat to internal validity of one-group
baseline comparability on all outcomes, demographics and co- studies due to maturation effects or symptom variability. Children
morbidity. Barrett et al. [35] checked for comparability on age and and adolescents who are on improving trajectories before com-
co-morbidity but not on outcomes and made appropriate adjust- mencement of treatment are likely to bias the strength of prior to
ment in the analysis for the between-group age difference. post-treatment change. None of the studies use multiple pre-
Neziroglu et al. [34] did not check for baseline comparability. treatment assessments to establish a stable baseline. Participants
It was not possible to blind participants and therapists in the recruited from treatment settings are more likely to have a stable
CBT conditions. For the pills-only conditions in the POTS Team
symptom pattern than those recruited from community settings or
[36] (sertraline, placebo), both participants and psychiatrists were
via media announcements. Bolton et al. [38], Wever and Rey [42],
blinded to condition. There was no blinding in the CBT-combined-
and Valderhaug et al. [51] recruited participants from community
with-sertraline condition in the POTS Team [36]. De Haan et al.
outpatient and inpatient mental health settings and approached
[33] and Neziroglu et al. [34] do not report on blinding for their
consecutively referred children and adolescents to take part. Martin
medication condition. De Haan et al. [33], Barrett et al. [35] and
and Theinemann [50] and Thienemann et al. [45] recruited from a
the POTS Team [36] described processes to enhance the fidelity of
specialist clinic and reported long durations of illness for all
the delivered intervention with the manual by using supervision by
participants. March et al. [39] and Waters et al. [46] included
experienced clinicians. Barrett et al. [35] formally assessed protocol
recruitment via advertisement as well as referrals to their clinics,
adherence by the therapists and found it to be good. Neziroglu
while the other studies do not report details of referral and
et al. [34] and Asbahr et al. [37] do not describe any fidelity or
recruitment procedures.
quality assurance processes.

Detection bias: Blinding of outcome detection was not Detection bias: Only Himle et al. [49] clearly identifies
outcome assessors as blinded, although blinding may be inferred
possible for participant self-report measures. For the CY-BOCS
and other clinical-rated instruments, assessors were clearly blinded in Thienemann et al. [45], Waters et al. [46] and Martin
in the POTS Team [36] and Asbahr et al. [37]. De Haan et al. [33] and Theinemann [50]. The other studies either do not use blind
and Neziroglu et al. [34] do not report on the status of assessors. assessors for measurement of outcomes [41,42,51] or do not report
Barrett et al. [35] described the assessors at the initial assessment as of the status of assessors [38
40,43,47,48].
blind to study hypotheses but it is not clear if assessors at post-
treatment for CY-BOCS were also blinded. Barrett et al. [35] Attrition bias: All the studies report dropout and/or refusal
compared endpoint status on all measures assessed 4 to 6 weeks rates if relevant. Wever and Rey [42] report that eight children
after initial assessment for the waitlist condition and after 12 weeks refused treatment but do not provide reasons. There were generally
for CBT conditions. very small numbers of dropouts from the studies. Only Bolton
et al. [38], March et al. [39], and Scahill et al. [41] accounted for
Attrition bias: The POTS Team [36] described flow of dropouts and included them in their analysis. None of the studies
participants and reasons for attrition from all conditions and corrected effect sizes for testing effects.
performed intention to treat analyses using last observation carried
forward. Summary: In addition to the lack of a control group, the
Barrett et al. [35], de Haan et al. [33] and Asbahr et al. [37] main sources of differential bias in one-group studies come from
reported loss to follow-up for the CY-BOCS of two, one and two the selection process and non-blinding of outcomes assessors.
case(s), respectively, but did not use intention-to-treat analyses. While none of the studies could be clearly considered low risk of
There was no attrition at post-treatment in Neziroglu et al. [34]. bias, Bolton et al. [38], Thienemann et al. [45], Himle at al. [49] and
Martin and Theinemann [50] had overall a low to moderate risk of
Summary: The POTS Team [36] study overall had a low risk bias. Knox et al. [40], Scahill et al. [41] and Waters et al. [46] were
of bias, while de Haan et al. [33] and Neziroglu et al. [34] were judged to have moderate to high risk of bias because of an
considered as low to moderate risk of bias because they failed to additional threat to validity due of very small sample size. The
206 CBT FOR PEDIATRIC OCD

other studies had a moderate risk of bias arising from recruitment Barrett et al. [35] used the ADIS-P diagnosis and found
issues and non-blinding of assessors. the relative risk of participants continuing to have OCD at
post-treatment was 0.13 (95% CI/0.4
0.36) the risk in the
Outcomes waitlist group for the individual-CBT group and 0.24 (95% CI/
0.13
0.46) the risk in the waitlist group for the group-CBT
group. Risk of not-improved status at post-treatment in the one-
OCD severity
group studies ranged from highs of 0.87 [45], 0.79 [49] and 0.73
[39] to lows of 0.29 [46], 0.21 [48] and 0.13 [38]. It needs to be
All of the comparison studies reported data on the clinician-
noted that the criteria for not improving varied considerably
rated CY-BOCS that has strong reliability and validity [54] and is
between studies.
considered the gold standard of outcome assessment for OCD. It
Figure 1 depicts each study’s effect size estimates for OCD
assesses the frequency and intensity of obsessions and compul-
severity with their 95% confidence intervals grouped by type of
sions, as well as the amount of interference and degree of distress
study. With the exception of Bolton et al. [38], all of the studies
they produce. Neziroglu et al. [34], Barrett et al. [35] and Asbahr
have been carried out since 1994. The figure demonstrates that the
et al. [37] also reported data about OCD severity using the
range of estimates for improvement in symptom severity with CBT
clinician-rated single-item National Institute of Mental Health
overall is very wide (0.82 to 4.38), with no indication of a narrowing
Global Obsessive Compulsive Scale (NIMH-GOCS) and also on
of this variability over time. The two relevant randomized
the Clinical Global Impressions Severity and Improvement Scales
controlled trials produced considerably different estimates,
(CGIS; CGII). All the one-group studies also used the CY-BOCS
although the effect size of the study with the lowest risk of bias
except for Bolton et al. [38], which used a three-point clinician-
[36] (ES/0.96) was the third lowest of all the studies. Ten of the
rated OCD severity and Knox et al. [40], which used the ADIS-C
single-group studies produced point estimates of the CBT effect
eight-point clinician rating of severity. Martin and Thienemann
outside of the upper 95% confidence interval for the POTS Team
[50] and Valderhaug et al. [51] also used the Child Obsessive
study.
Compulsive Impact Scale (COIS) [55] that assesses functional
impairment at school and home and in social relationships due to
the OCD, using child and parent reports. All studies provide data Does quality matter?
that allowed comparisons of rates of dichotomized outcomes
(non-remission from OCD) at post-treatment or provide some Effect sizes for the single-group studies were adjusted by
index of improved/not-improved status, with the exception of subtracting the testing effect. This effect for the CY-BOCS was
Fischer et al. [43]. estimated as the average standardized change (dc /(Xpost

Xpre)/SDpre) in non-treated groups in three studies [35,36,54].
How effective is CBT for pediatric OCD? Barrett et al. [35] reported a standardized mean increase in CY-
BOCS total scores for the waitlist group of 0.19, the POTS Team
[36] reported a standardized mean decease for the placebo-control
Table 2 presents the effects sizes for severity of OCD symptoms
group of 1.12, and Storch et al. [54] reported a standardized mean
and the relative or absolute risk of remaining disordered at post-
decrease for their standardization sample in estimating test
retest
treatment grouped by type of study and nature of comparison.
reliability of 0.56. The average standardized change from these
Three comparisons (two studies [35,36]) tested the efficacy of CBT
three studies equals /0.49. This is similar to the average effect
against a non-active control group, and 14 one-group studies looked
size for the drug-placebo groups in controlled trails of SSRIs for
at pre
post change with CBT. All of the studies reported
pediatric OCD of /0.48 [11]. Figure 2 depicts the adjusted effect
statistically significant effect sizes showing superiority or efficacy
sizes studies grouped in terms of categories of risk of bias. The
of CBT.
figure clearly shows that lower-risk-of-bias studies produce lower
In regard to the controlled trials, because of marked statistical
effect sizes. Only one study (20%) in the low- and low-to-
heterogeneity (I2 /89.3%) between Barrett et al. [35] and the
moderate-risk-of-bias categories report adjusted effect sizes above
POTS Team [36] pooling of estimates was not undertaken. The
1, while 11 (92%) in the moderate- and moderate-to-high-risk-of-
POTS Team [36] with low risk of bias showed an effect size of
bias category report effects about 1, and seven (58%) report
0.96 (95% CI/0.40
1.51) in favour of the CBT group. Barrett
effects above 2.
et al. [33] reported substantially larger effects sizes of 2.73 (95%
CI/1.91
3.55) in favour of individual CBT and of 2.54 (95%
CI/1.74
3.28) in favour of group CBT. Outcomes from the one- CBT versus medication
group studies ranged from a mean effect change in CY-BOCS
scores favoring the CBT group of 0.78 (95% CI/0.04
1.52) [43] Three comparisons [33,36,37] tested the relative efficacy of CBT
and 0.82 (95% CI/0.16
1.48) [49] to mean effect sizes of 2.58 alone against medication (clomipramine, sertraline). The pooled
(95% CI/1.58
3.58) [44], 2.73 (95% CI/2.22
3.24) [42] and 3.49 weighted mean difference from two of these studies [33,36]
(95% CI/2.59
4.30) [51]. showed equivalence of the two treatments (WMD/ /3.87, 95%
The POTS Team [36] used a cut off of
/10 on the CY-BOCS CI/ /8.15
0.41). Neither study found a significant difference in
to classify participants as still having OCD. The relative risk post-treatment CY-BOCS between the treatments (CBT versus
of participants continuing to have OCD at post treatment was clomipramine WMD/ /8.50, 95% CI/17.44
0.44 [33]; CBT
0.63 that of the risk in the placebo group (95% CI/0.46
0.86). versus sertraline WMD/ /2.50, 95% CI/ /7.37
2.37 [36]).
 R. O’KEARNEY 207

Table 2. Effect sizes (95% CI) favouring CBT group for severity of OCD symptoms and for risk of not
improved status by study type

Comparison studies/contrast n of CBT group Effect size (severity of OCD) Risk of not improved status
De Haan et al. (1998) [33]
CBT vs clomimpramine 12 0.79 ( /0.09 to 1.66) 0.69 (0.30 to 1.61)
Neziroglu et al. (2000) [34]
CBT with medication vs 5 0.95 (0.02 to 1.89) 1
fluvoxamine alone
0.08 ( /0.80 to 0.06) NIMH-GOCS
1.31 (0.32 to 2.29) CGIS
0.92 ( /0.01 to 1.85) CGII
Barrett et al. (2004) [35]
Individual CBT vs waitlist 24 2.73 (1.91 to 3.55) 0.13 (0.04 to 0.36)
2.51 (1.74 to 3.28) NIMH-GOCS
Group CBT vs waitlist 29 2.54 (1.74 to 3.28) 0.24 (0.13 to 0.46)
2.69 (1.89 to 3.49) NIMH-GOCS
POTS Team (2004) [36]
CBT vs placebo 28 0.96 (0.40 to 1.51) 0.63 (0.46 to 0.86)
CBT vs Sertraline 28 0.27 ( /0.26 to 0.79) 0.77 (0.54 to 1.01)
CBT with medication vs placebo 28 1.41 (0.82 to 2.00) 0.48 (0.32 to 0.72)
CBT with medication vs Sertraline 28 0.59 (0.05 to 1.13) 0.59 (0.39 to 0.92)
CBT with medication vs CBT alone 28 0.30 ( /0.22 to 0.83) 0.56 (0.19 to 1.62)

Bolton et al. (1983) [38]

Single-group studies (pre post)
15 1.59 (0.77 to 2.41) (rating) 0.13 (compulsions B/1 h day 1)
March et al. (1994) [39] 15 1.80 (0.95 to 2.65) 0.73
Knox et al. (1996) [40] 4 3.39 (2.43 to 4.35)(ADIS-C/P) 0.25
Scahill et al. (1996) [41] 7 2.26 (0.92 to 3.60) 0.29
Wever and Rey (1997) [42] 57 2.73 (2.22 to 3.24) 0.32 (CY-BOCS B/15)
Fischer et al. (1998) [43] 15 0.78 (0.04 to 1.52) Not available
Franklin et al. (1998) [44] 14 2.58 (1.58 to 3.58) 0.14 (
/50% in CY-BOCS)
Thienemann et al. (2001) [45] 18 1.15 (0.44 to 1.86) 0.87
Waters et al. (2001) [46] 7 4.38 (2.44 to 6.31) 0.29
Benazon et al. (2002) [47] 16 1.67 (0.87 to 2.47) 0.56 (NIMH global score B/2)
Piacentini et al. (2002) [48] 42 2.29 (1.74 to 2.84) 0.21 (Clinician-rated CGI B/2)
Himle et al. (2003) [49] 19 0.82 (0.16 to 1.48) 0.79
Martin and Thienemann (2005) [50] 14 1.05 (0.26 to 1.84) 0.57 (B/25% in CY-BOCS)
Valderhaug et al. (in press) [51] 24 3.49 (2.59 to 4.30) 0.50

Asbahr et al. [37] does not provide endpoint scores on total CY- They do report marked discontinuation effects in the sertraline
BOCS and there are inconsistencies between outcomes presented group by 4 weeks post treatment.
in tables and those depicted in figures in the study write-up. While
they conclude that the two treatments (group CBT; sertraline) are CBT combined with medication versus other groups
equally beneficial, the standardized mean difference could not
be computed. Asbahr et al. [37] have not, to date, responded to The POTS Team [36] post-treatment data showed a superior
request for clarification of their data. effect of CBT combined with medication relative to placebo
To allow comparability for binary outcomes, we classified de (SMD/ /10.30, 95% CI/ /14.06
/6.54). Neziroglu et al.
Haan et al. [33] participants into those continuing to have OCD at [34] and the POTS Team [36] compared CBT combined with
post-treatment using the POTS Team criteria (CY-BOCS
/10) medication relative to medication alone. Outcomes on the CY-
[36]. The pooled data indicated that CBT and medication had an BOCS at the two post-treatment points (43 and 52 weeks) were
equivalent proportion of participants continuing to have OCD at averaged in the Neziroglu et al. study [34]. The pooled weighted
post-treatment (RR/0.75, 95% 0.54 to 1.05). In de Haan et al. mean difference in favour of the combined treatment was /4.55
[33], participants in the CBT group (5/12) and in the medication (95% CI/ /7.40
/1.70), with both studies reporting a signifi-
group (6/10) were equally likely to continue to have OCD at post- cant superior effect for CBT combined with medication relative
treatment (RR/0.69, 95% CI/0.30
1.61). In the POTS Team to medication alone. The POTS Team [36] also compared
[36], participants in the CBT group (17/28) and medication (22/28) CBT combined with sertraline with CBT alone. Examination of
were also equally likely to continue to have OCD at post-treatment unadjusted CY-BOCS scores post treatment showed that the two
(RR/0.77, 95% CI/0.54
1.10). Asbahr et al. [37] do not provide treatments were not significantly different (SMD/ /2.80, 95%
numbers for those with not-improved status at post-treatment. CI/ /7.55
1.95).
208 CBT FOR PEDIATRIC OCD

7
6

Effect size (95% CI)

5
4
3
2
1
0

s
al 6

a 8

Pi azo t al 01

de ene t al 02
3
no a 3
W ahi t al 94

ie kl t a 997

Be ers l 8

tin al 1
a 2

TS t al 04

04
h e 96

am 04
al 05

es
K et 198

er et 99

m et 9 9

at t a 99

0
0

au an 0

pr
Sc x e l 19

e 20
ac n e 20

V Th le e l 20
rh m 20
et n 20
Fi d 19

20

PO ) e 20
Te 20
20
1

ne in l 1

W nn e l 1
Th Fran er e y 1

in
ch l

(G al
ar t a

sc R

en t
an im t

tt et
M ne

i e
ev ll

rre ett
n
lto

g
a

Ba arr
Bo

i
H
n

B
d
al
tin
ar
M
Study (date)

Figure 1. Effect sizes (95% CI) for OCD severity for each study by type of study.

Neziroglu et al. [34] participants were classified into those Other primary outcomes
continuing to have OCD at post-treatment using the POTS
Team criteria (CY-BOCS
/10) [36]. As all participants in
Barrett et al. [35] compared the group and individual CBT to
both groups scored above 10, the relative risk could not be
their waitlist condition on the NIMH-GOCS measure. Both CBT
estimated. In the POTS Team [36], participants in the CBT
groups were superior to the waitlist group with a mean difference of
combined with medication group (13/28) were significantly less
5.50 (95% CI/ /6.74
/4.28) in favour of individual CBT and of
likely to continue to have OCD at post-treatment compared to the
5.69 (95% CI/ /6.87
/4.51) in favour of group CBT. Bolton
medication alone group (22/28) (RR/0.59, 95% CI/0.38
0.92)
et al. [38] reported an effect size for prior to post change for
and the placebo group (27/28) (RR/0.48, 95% CI/0.32
0.72).
the CBT group on a clinician OCD severity rating of 1.59 (95%
The relative risk of participants continuing to have OCD in the
CBT combined with medication group (13/28) was not significantly CI/0.77
2.71), while Knox et al. [40], using the ADIS-C/P
different from that of the CBT alone group (17/28) (RR/0.76, severity rating, found an effect size for prior to post change of
95% CI/0.47
1.26). 3.39 (95% CI/2.43
4.35).

5
Adjusted effect size

0
*

83

05

sc Rey 4

an et a 97
Be in e 998

8
i e 002

t a 02

4*

4*

et 996

ta 6

1
al
04

00

00

-9

99

00
19

20

19

Ba t I e 20

00

00

19
et
ar
20

l2

l2

l1

l1

l2
l2

2
M
al

al

al
a
ta

ta

ta
am

an

al

au

Sc Kno
et

et

ac n et
e

se
em

rh
et
Te

d
n

le

ill
tin

de
he
an

er
to

an

zo

G
n
im

kl

ha
TS

ie

at
al
l

en

t
m

na

tt
Bo

er

rre
H

Th

W
V
rre
Fi
PO

ne

ev

Fr

Ba
ie

Pi
d

W
an
Th

tin
ar
M

Low Low to Mod Moderate Mod to High

Risk of bias category

Figure 2. Effect sizes adjusted for testing effect for each study by risk category (*RCT).
 R. O’KEARNEY 209

In terms of life-functioning, both studies [50,51] that used the illustrated by the differences in precision of the best
COIS reported higher effect sizes for parent’s report of improve- estimate of CBT (Hedge’s g /0.96; 95% CI /0.40

ment (SMD/ /0.90 [50]; SMD/ /0.96 [51]) than for the child’s
1.51 [36]) when compared to the effect size estimates
self-report of functioning (SMD/ /0.22 [50]; SMD/ /0.64 [51]).
for OCD-specific medications (Hedge’s g /0.46; 95%
These effect sizes for improvement in function were less notable
than the effect size for symptom severity in the respective studies.
CI /0.37
0.55 [9]). One implication of the current
study for clinical research is that a well-conducted
replication of POTS [36] would be important for
Discussion enhancing confidence about the magnitude of the
benefits of CBT for pediatric OCD.
This systematic re-examination of the evidence The evidence reviewed here places CBT as an
clarifies the benefits of CBT for pediatric OCD. It equally effective first-line treatment with SSRIs in
found that in terms of post-treatment levels of the treatment of OCD in children and youth. The two
symptom severity and interference due to symptoms treatments could not be distinguished in terms of
using the gold standard outcome (CY-BOCS) that reductions in symptom severity and interference, or in
CBT is an empirically supported treatment. There post-treatment remission rates in three head-to-head
remains, however, considerable variability in esti- studies. Rather, the evidence from the current review
mates of the strength of CBT’s efficacy. It is difficult provides some support for CBT combined with
in view of the elevated risk of bias in many of the medication as the ‘treatment of choice’. This advice
studies and the association between low risk of bias is clear in regard to a non-active treatment with a
and lower effect size estimates to confidently attribute strong relative effect for CBT combined with medica-
the larger effect sizes to intervention differences. This tion (Hedge’s g /1.14, 95% CI /0.82
2.00) but also
review suggests that the best current estimate of CBT relative to medication alone (pooled effect size of
efficacy relative to no treatment is about 1 standar- 0.68, 95% CI /0.21
1.15). But the utility of the
dized mean difference equivalent to a treatment effect combined treatment as treatment of choice relative to
of about 8 points on the CY-BOCS. The highest beginning with CBT alone is less compelling (Hedge’s
confidence is in the results of the POTS Team study g/0.30, 95% CI / /0.22
0.83). While favoring the
(SMD /7.5; 95% CI /3.45
11.55 [36]). This effect combined treatment over CBT alone, the confidence
represents a reduction in the risk of continuing to interval around this estimate from one randomized
have OCD of about 37% (95% CI /14
54%). controlled trial does not exclude the possibility of a
Treatment of about three pediatric OCD patients superiority of CBT alone. Clearly, decisions to begin
with CBT (95% CI /2
7) would be needed to treatment for pediatric OCD with CBT alone or with
facilitate remission of OCD in one extra child or CBT and medication rather than medication alone
adolescent. are warranted on the basis of the reviewed evidence.
It is interesting to compare these conclusions Of course, a number of other important issues such as
with the pooled pre
post effect size of 1.98 (95% patient preference, likelihood of adverse effects of
CI /1.40
2.56) for eight uncontrolled and two con- medication, the availability of skilled CBT practi-
trolled studies of CBT reviewed by Abramowitz et al. tioners, cost to patients and the patient’s treatment
[12]. The present review demonstrates that effect size history, need to be included in decision-making in
estimates for CBT’s efficacy for pediatric OCD are individual cases. The small number of quality studies
significantly moderated by study design and by the also dampers the confidence with which decisions
risk of bias in the studies. In addition, testing effects made on the basis of the current evidence can be
in pre
post designs play a substantial role in elevat- made.
ing effect sizes estimates. Taken together, these In addition to the caveats to conclusions due to the
considerations question the usefulness of the results quantity and quality of studies, there are a number of
of uncontrolled trials in meta-analytic thinking about other limitations to the current evidence that need to
the benefits of a treatment. While they have an be considered. Most studies used the CY-BOCS as
important function in initial assessments of the the main outcome indictor. While it is regarded as the
potential of new treatments, their overrepresentation ‘gold standard’ measure for child and adolescent
in the efficacy evaluations of CBT for pediatric OCD OCD and has good reliability and validity [54], there
(14 of 16; 88%) highlights the fact that the paucity of are some recent indications that the CY-BOCS total
high-quality studies places ongoing questions on the score may underestimate symptom severity in many
accuracy and precision of conclusions about the pediatric patients [56,57]. In addition, there are no
degree of benefit associated with CBT. This is further normative data on the CY-BOCS for typical children
210 CBT FOR PEDIATRIC OCD

and youth so it is not possible to assess the clinical patients. As well, trials of alternative modes of
importance of treatment-related reductions in terms delivery of CBT for pediatric OCD, such as group
of the likelihood of end-state functioning being more and self-directed approaches, are warranted in order
typical than disordered. The cut-offs used to categor- to increase access to empirically-validated treatments.
ize responders or remitters in the studies reviewed are Overall, the current review reaffirms CBT as a
rules of thumb or based on adult data. There is some promising treatment for OCD in children and youth.
suggestion [58] that it may be more normative for On the basis of the reviewed evidence, CBT should be
younger children to spend more time on behavioural regarded as an equivalent first-line treatment to anti-
and cognitive rituals making it difficult to define OCD medication with the potential to lead to better
obsessions and compulsions as disordered or proble- outcomes when combined with medication than
matic by using measures that rely on frequency and medication alone can provide. Nevertheless, there
duration. In addition to better normative data across are significant problems with the quantity and quality
the developmental span for the CY-BOCS, it would of CBT trials that obscure the degree and nature of
be useful in supplement assessment of the clinical the benefits associated with CBT. Further open trails
importance of treatment effects with sound measures are unlikely to clarify these benefits. Rather, the
of the impact of the OCD on the child’s or youth’s direction for clarification should be towards well-
life-functioning. The Child Obsessive Compulsive conducted controlled trials similar to the POTS Team
Impact Scale [55] is a promising measure in this [36] study using a range of outcomes including
regard and has been shown to be sensitive to measures of life-functioning. In the interim, clinical
treatment effects in medication trails. It is also researchers and policy-makers need to attend to ways
beginning to be applied in CBT outcome evaluations in which CBT might be made widely available as a
[50,51]. The results of these two studies suggest that treatment option for children and youth who suffer
the degree of symptomatic improvement may not be from OCD.
reflected in functional improvement particularly from
the child or adolescent’s point of view. While there
are best bets for the estimates of the effects of CBT on Acknowledgements
pediatric OCD it is still not clear what the clinical and
functional importance of these effects are. Joanne Speyer and Kaarin Anstey undertook the
Besides the implications for practice coming out of risk-of-bias ratings for the one-group and controlled
this review, there are a number of general conclusions studies, respectively.
about the direction of research into the benefits of
CBT for pediatric OCD that can be made from its
observations. One is the need to improve the quality References
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controlled trials carried out with low risk of bias is Summary of the practice parameters for the assessment and
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