Cochrane review: Behavioural and cognitive behavioural therapy for obsessive compulsive disorder in children and adolescents

Abstract

AbstractBackgroundWhile behavioural or cognitive‐behavioural therapy (BT/CBT) is recommended as the psychotherapeutic treatment of choice for children and adolescents with obsessive‐compulsive disorder (OCD), the application of BT/CBT to paediatric OCD may not be straightforward.ObjectivesThis review examines the overall efficacy of BT/CBT for paediatric OCD, its relative efficacy against psychopharmacology and whether there are benefits in using BT/CBT combined with medication.Search strategyWe searched CCDANCTR‐Studies and CCDANCTR‐References (searched on 5/8/2005), MEDLINE, EMBASE, PsycINFO, the reference lists of all selected studies and handsearched journals specifically related to behavioural treatment of OCD.Selection criteriaIncluded studies were randomised controlled trials or quasi‐randomised trials with participants who were 18 years of age or younger and had a diagnosis of OCD, established by clinical assessment or standardised diagnostic interview. Reviewed studies included the standard behavioural or cognitive‐behavioural techniques, either alone or in combination, compared with wait‐list or pill placebo.Data collection and analysisThe quality of selected studies was assessed by two independent reviewers. The primary outcomes comprised of endpoint scores on the gold standard clinical outcome measure of OCD symptoms, distress and interference (CY‐BOCS) and endpoint OCD status.Main resultsFour studies with 222 participants were considered eligible for inclusion and for data extraction. Two studies showed significantly better post‐treatment functioning and reduced risk of continuing with OCD at post‐treatment for the BT/CBT group compared to placebo or wait‐list comparisons. We suggested that the POTS 2004 result, equal to a difference of about eight points on the CY‐BOCS, represented the best available estimate for the efficacy of BT/CBT relative to no treatment. (WMD ‐7.50; 95% CI ‐11.55, ‐3.45). Pooled evidence from two trials indicated that the efficacy of BT/CBT and medication did not differ significantly (WMD ‐3.87; 95% CI ‐8.15, 0.41). There was evidence of the benefit of combined BT/CBT and medication compared to medication alone (WMD ‐4.55; 95% CI ‐7.40, ‐1.70), but not relative to BT/CBT alone (WMD ‐2.80; 95% CI ‐7.55, 1.95). The rates of drop out suggested BT/CBT is an acceptable treatment to child and adolescent patients and their families.Authors' conclusionsAlthough only based on a small number of studies, behavioural or cognitive‐behaviour therapy appears to be a promising treatment for OCD in children and adolescents. It can lead to better outcomes when combined with medication compared to medication alone. Additional trials are needed to confirm these findings. In the interim, consideration should be given to the ways in which BT/CBT might be made more widely available as a treatment for OCD in children and adolescents.Plain language summaryPlain language summaryBehavioural and cognitive‐behavioural therapy for obsessive‐compulsive disorder (OCD) in children and adolescentsThe onset of obsessive‐compulsive disorder often occurs in childhood and adolescence. It can be an extremely debilitating disorder, resulting in high levels of distress, impairment and disruption of psychosocial development. It also has a considerable impact on other family members. While there is evidence that medication can reduce symptoms, behavioural and cognitive‐behavioural therapy (BT/CBT) are often proposed as acceptable alternative treatments. These therapies have various components, but commonly include assisting the child to better tolerate the anxiety provoking situations and thoughts, without the use of compulsive behaviour to manage their anxiety. Other components include psycho‐education about anxiety and OCD, cognitive training involving learning to identify and challenge unhelpful ways of thinking, and parental involvement.This review identified four RCTs, involving 222 participants, evaluating the benefits of behavioural and cognitive‐behavioural therapy. The results from two individual studies show that, compared to a wait‐list or pill placebo, BT/CBT is an effective treatment for reducing OCD symptoms and lowering the risk of having OCD after treatment. Based on two studies that directly compared BT/CBT with anti‐OCD medication, there was no evidence to suggest that either BT/CBT or anti‐OCD medication was superior to the other. When combined with medication, BT/CBT produces better outcomes than medication alone, but combining medication and BT/CBT does not result in better outcomes than BT/CBT alone.Although based on a small number of studies, these findings provide some support for the potential value of BT/CBT in the treatment of children and adolescents with OCD. Sufferers and their families may wish to enquire about the appropriateness of BT/CBT, and to request information about the availability of appropriately skilled clinicians.