Obsessive Compulsive Disorder (5 page)

The role of medication

Studies suggest that serotonin reuptake inhibitors are effective in treating young people with OCD (e.g. Flament
et al.
, 1985; Leonard
et al.
, 1989; March and Mulle, 1998). Geller
et al.
(2003) completed a meta-analysis of pharmacotherapy trials in young people with OCD and found clomipramine to be more effective than four newer selective serotonin reuptake inhibitors (SSRIs). However, the side effects from clomipramine mean that it is no longer widely used. There was no significant difference between the newer SSRIs and overall medication appeared to be reasonably effective for around 60 per cent of young people. However, there are concerns that antidepres-sant medication may increase suicidality and consequently the advice in the UK is to carefully monitor potential adverse outcomes. A significant problem with medication is the relapse rate and consequently the National Institute for Health and Clinical Excellence (NICE) guidelines (2005) for the UK

suggest long-term use.

The paediatric OCD treatment study (POTS) randomised controlled trial (March
et al.
, 2004) compared medication, CBT and a combination of medication and CBT. They found that the young people treated with CBT alone or in combination with medication showed the greatest improvement, although medication alone was better than a placebo. However, it has not yet been established who benefits from which treatment.

There is an evidence base for the use of medication with young people.

However, CBT alone or in combination with medication appears to be more effective and less likely to lead to relapse.

Choice of treatment

The consensus guidelines produced by the American Psychiatric Association (March
et al.
, 1997) suggested that CBT was the first choice treatment for children and young people. More recently, NICE described a stepped care model beginning with self-help materials for mild cases through to CBT, medication and finally combined treatments (NICE, 2005). However, self-help materials for young people with OCD are not readily available and have 18

Williams and Waite

not been evaluated. Consequently, it is not clear how effective they are.

There is a danger that by beginning with interventions that do not have an adequate evidence base we are delaying the young person receiving effective treatment and this may lead to additional problems, such as symptoms increasing in frequency and severity, as well as leading the young person, family and professionals to believe that the problem is difficult to treat.

When deciding what treatment should be used in treating OCD, the general consensus is for a stepped care approach with CBT as a first line treatment.

2

The use of CBT with children

and adolescents

Cathy Creswell and Polly Waite

Introduction

CBT is based on the general notion that a psychological disorder is caused or maintained by ‘dysfunctional’ patterns of thoughts and behaviours (e.g. Beck
et al.
, 1979). That is, the disorder is conceptualised as resulting at least in part from the individual’s cognitive distortions (such as false attribu-tions or expectations about the self, others or the world) that then undermine positive coping or problem-solving behaviour. CBT has its roots in behaviour therapy, which applies learning theory to psychological problems; for example, using ‘exposure’ to overcome avoidance of anxiety-provoking stimuli, and ‘response prevention’ to minimise compulsive behaviours. To date many CBT treatments with younger populations have been predominantly behavioural in content. Recently, however, there have been exciting developments in the understanding of cognitive aspects of psychological problems in childhood. In addition, recent models have begun to incorporate the maintaining role of environmental influences. For example, in Rapee’s (2001) model of the development of generalised anxiety disorder (GAD), parental reaction and factors associated with socialisation are hypothesised to promote the expression of anxious vulnerability in young people. As cognitive and behavioural models of childhood disorder become further refined, so will treatments, leading to greater specificity of treatments to particular disorders and a clearer understanding of how best to include families in treatment.

CBT is based on the idea that psychological problems are maintained by unhelpful patterns of thinking and behaviour.

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Creswell and Waite

Developmental issues in CBT

In order to benefit from CBT for OCD, young people need to be able: (a) to distinguish between thoughts, feelings and behaviours; (b) to reflect on their own cognitive processes; (c) to understand the relationship between cause and effect. It appears that the majority of children can demonstrate these skills by seven or eight years of age (Salmon and Bryant, 2002). For example, Quakley
et al.
(2004) presented children with a thought–feeling– behaviour sorting task and whilst four-year-old children performed at a level that did not differ from chance, by seven years of age most children performed at the ceiling level. Interestingly, at younger ages using a glove puppet to present the task improved performance, highlighting the need for careful consideration not only of
what
we do in therapy, but also
how
we do it to maximise children’s engagement and understanding. In terms of reflect-ing on thoughts, or ‘thinking about thinking’, a number of studies have demonstrated that pre-school children can attribute different thoughts to different people. By five years of age they can use mental state terms to explain behaviours, and by eight years to explain feelings (see Grave and Blissett, 2005). In terms of causal reasoning, again pre-school children are able to accurately use internal states to inform reasoning, and furthermore are able to consider ‘counterfactuals’; in other words, what if something different happens next time they are in this situation? Again though, studies have highlighted the importance of how these questions are asked in younger children (Robinson and Beck, 2000).

Does the basic cognitive model apply to children?

Research over the last decade has shown that characteristic cognitions are associated with particular mood disorders, including anxiety (Barrett
et al.
, 1996b), depression (Abela
et al.
, 2002) and conduct disorder (Crick and Dodge, 1994) in young people, largely mirroring those cognitive patterns found in adult populations. For example, in comparison to adolescents (11–18 years) with other anxiety disorders and non-anxious participants, adolescents with OCD have been found to have inflated responsibility beliefs, increased thought–action fusion (the idea that having a thought of something bad happening increases the likelihood of the event occurring) and concern over mistakes (Libby
et al.
, 2004). An integral relationship between cognitive style and OCD is also supported by a case series of six adolescents where measures of inflated responsibility decreased as OCD

symptoms decreased (Williams
et al.
, 2002). Among younger children, these characteristic cognitive styles may not be fully developed. For example, in a younger sample, children (aged 7 to 13 years) with OCD also reported inflated responsibility and increased thought–action fusion in comparison to other anxious and non-anxious children, as well as the highest ratings of
The use of CBT with children and adolescents
21

harm severity (that is, how bad it would be if the feared consequence happened). However, these were not statistically significant differences. The only domain that significantly differentiated the OCD group clearly from the other groups was that of cognitive control, in that the OCD group indicated that they were less able to stop themselves worrying about a thought than the others (Barrett and Healy, 2003).

There is also some evidence that levels of magical thinking – that is, the attribution of causal effects on real events by a thought or action that is physically unconnected to the event – are associated with obsessive compulsive symptoms in young people between the ages of five and 17 (Bolton
et al.
, 2002; Muris
et al.
, 2001). However, further research is required to establish whether this relationship exists in young people who fulfil criteria for a diagnosis of OCD and if it is specific to OCD.

Together, these studies provide initial evidence for a cognitive account of OCD in young people. However, the reliance of studies to date on samples representing broad age ranges means we do not know whether these cognitive styles are present in both young and older children. Our reliance on data from cross-sectional studies also limits the conclusions that can be drawn about the direction of the association between cognitions, behaviour and affect in OCD. For example, it is unlikely that intrusive thoughts will present a problem or drive compulsive behaviour until a young person has developed the ability to reflect on thoughts and their meaning. Indeed, it is widely recognised that intrusive thoughts are experienced by the majority of people (e.g. Rachman and de Silva, 1978). So does OCD in youth represent a failure to learn to disregard these normal intrusive phenomena? If so, why do some children fail to go through this otherwise normative process of development?

CBT models for adult populations are focused largely on the maintenance cycles, based on the premise that maladaptive thinking styles have developed during childhood which are no longer adaptive in the adult’s life (e.g. Beck
et al.
, 1979). When working with younger populations it is important to establish whether these beliefs continue to serve an adaptive function in the child’s life. For example, it is essential to consider the wider environmental influences that will be affecting the young person’s thoughts, behaviour and mood. However, the specific influences on the development of cognitions and behaviour associated with OCD in childhood are not well understood. Salkovskis
et al.
(1999) argue that the origins of obsessional problems are likely to be the result of complex interactions specific to the individual, but that there are likely to be a number of different pathways to the development of beliefs around inflated responsibility (see Chapter 1).

Prospective, experimental and treatment studies are all urgently needed to provide a better understanding of the specific environmental influences on OCD in young people and the relative importance of these, cognitions and behaviours in order for us to know the crucial elements to target within therapy.

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Creswell and Waite

• Similar cognitive styles have been identified in children and adults with OCD. However it is not yet clear whether the
nature
of the relationship between cognitions, affect and behaviour is the same throughout development.

• The specific influences on the development of cognitions and behaviour associated with OCD in childhood are not well understood and further research is necessary.

An overview of CBT with young people

A cornerstone of the practice of CBT is
collaboration
between the therapist and the client, whether that client is an adult or a young person (or a family).

The therapist is
working with the young person
. The therapist is not ‘the expert’ but all the different parties are bringing together their particular areas of expertise to overcome the problem. This approach is crucial when working with young people with difficulties including depression, anxiety and specifically OCD, where cognitions are commonly characterised by self-doubt. For this reason therapy needs to be delivered in a way that
promotes
the young person’s self-efficacy and perceived control
. This approach is also essential from a practical point of view. Due to the resource limitations that face services it is essential that therapy promotes the development of skills that can continue to be used over time, independently from the therapist and enable the young person to deal effectively with any future setbacks that may occur once therapy has come to an end.

There are a number of key features in delivering CBT that meet these theoretical and practical demands, which will be reviewed briefly below.

First, however, we should acknowledge that when working with young people, in contrast to adults, it is extremely unlikely that the young person will be the one who has sought help. In most cases it will be a parent or carer, or in some cases a teacher or other adult. For treatment to work, the young person needs to play their part and so it is important to consider their
motivation to change
right from the start. A common method in helping the young person is to identify the pros and cons of having OCD and the pros and cons of changing how things are. Young people may need prompting to consider longer term considerations. Even when long-term factors have been taken into account, particularly for pre-adolescents, they may not be weighed as heavily as immediate or short-term factors. For this reason it is necessary to make sure that the current environment promotes change and this may involve working with parents to ensure that they are reinforcing the young person to take risks and be brave in order to overcome their problem.

Equally, motivation to change and engagement in therapy should be regularly reviewed as the young person is unlikely to complain during the therapy sessions, but instead will simply refuse to come back. This can be addressed
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23

directly with the young person but also signs of withdrawal from the therapist or the therapy process should be picked up and discussed openly at the earliest opportunity. Allowing the young person to express both the things they like and dislike will allow the therapist and young person to consider ways of making the therapy more acceptable. For example, should the sessions be shorter? Should they take place somewhere else? Should someone else attend too?