Behavioural and cognitive-behavioural therapy for obsessive-compulsive disorder (OCD) in children and adolescents

The onset of obsessive-compulsive disorder often occurs in childhood and adolescence. Paediatric OCD 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 include assisting the child to better tolerate the anxiety-provoking situations and thoughts without the use of compulsive behaviour to manage their anxiety, psycho-educationabout anxiety and OCD; cognitive therapy in which the child is helped to learn to identify and challenge unhelpful ways of thinking; and parental support.

This review identified eight randomised controlled trials involving 343 participants, evaluating the benefits of behavioural and cognitive-behavioural therapy. The results 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 three studies that directly compared BT/CBT with medication, there was no current evidence to suggest that either BT/CBT or medication was superior to the other. When combined with medication, BT/CBT produces better outcomes than medication alone. Although based on a small number of studies, these findings provide support for the value of BT/CBT in the treatment of children and adolescents with OCD.

Authors' conclusions: 

Although only based on a small number of studies which vary in quality, behavioural or cognitive-behaviour therapy alone appears to be an effective treatment for OCD in children and adolescents. It is as effective as medication alone and may lead to better outcomes when combined with medication compared to medication alone. Additional higher quality trials are needed to confirm these findings.

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Background: 

This is an update of a Cochrane Review first published in The Cochrane Library in Issue 4, 2006.

Obsessive-compulsive disorder (OCD) in children and adolescents is characterised by persistent intrusive thoughts, inappropriate impulses or images which cause marked anxiety, and/or by persistent repetitive behaviours such as hand washing, checking and ordering. Along with antidepressant medication, behavioural or cognitive-behavioural therapy (BT/CBT) is recommended as the treatment of choice for paediatric obsessive-compulsive disorder (OCD).

Objectives: 

This review examines the overall efficacy of BT/CBT for paediatric OCD, its relative efficacy against medication and whether there are benefits in using BT/CBT combined with medication.

Search strategy: 

We searched CCDANCTR-Studies,CCDANCTR-References (16/3/2009), MEDLINE, EMBASE, PsycINFO, national trials registers, reference lists of all selected studies and handsearched journals related to cognitive behavioural treatment of OCD.

Selection criteria: 

Included studies were randomised or quasi-randomised controlled trials trials with participants 18 years of age or younger with a diagnosis of OCD, established by clinical assessment or standardised diagnostic interview. Reviewed studies included standard behavioural or cognitive-behavioural techniques, either alone or in combination, compared with wait-list, attention placebo, pill placebo or medication.

Data collection and analysis: 

The quality of selected studies was assessed independently by two review authors. Using Review Manager software, weighted mean differences were calculated for the total severity of OCD symptoms at post treatment and relative risks for having OCD at post treatment.

Main results: 

Eight studies with 343 participants were included. The review found evidence for lower post-treatment OCD severity and reduced risk of continuing with OCD for the BT/CBT group compared to pill placebo or wait-list comparisons. There was no evidence found that the efficacy of BT/CBT alone and medication alone differ in terms of post treatment symptom severity or in the risk of having OCD. There was some evidence of a benefit for combined BT/CBT and medication compared to medication alone but not relative to BT/CBT alone. The low rates of drop out suggested BT/CBT is an acceptable treatment to child and adolescent patients and their families.

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