Psychological treatment that teaches children to face their fears is the most effective treatment for pediatric obsessive-compulsive disorder (OCD), according to a new Mayo Clinic analysis of previously published research.
The treatment, a form of cognitive-behavioral therapy (CBT) called exposure and response prevention, produces almost twice as much benefit compared with medications used for childhood OCD, says Jonathan Abramowitz, PhD, Mayo Clinic psychologist and lead researcher on the study. The study is published in the spring issue of Behavior Therapy, and is the first meta-analysis (a quantitative approach to combining the results of previous studies) to focus on children with OCD.
OCD is an anxiety disorder that affects about 1 percent of children and adolescents, and 2 to 3 percent of adults.
Just like adults with OCD, children with OCD are plagued with persistent, distressing and illogical fears. These obsessions, such as fear of dirt or germs, compel the child to perform repetitive behaviors, such as excessive hand washing. The obsession and compulsive behavior can interfere with school, friends and family life.
Abramowitz and his colleagues reviewed 18 studies on OCD treatment published from 1983 to 2004. The studies examined the effectiveness of CBT or medication therapy.
Both CBT and antidepressant medications such as fluoxetine (Prozac) and clomipramine (Anafranil) are considered standard treatment for OCD. And many children with OCD are able to benefit from either form of treatment, or their combination.
Abramowitz and his colleagues compared the results from 10 studies of CBT and 11 studies of medication treatment to determine whether either treatment has an advantage.
“Because very few studies have directly compared the effects of medication versus CBT for treating children, our results give parents and health care providers more insight as they choose treatment,” says Abramowitz.
Exposure and response prevention
In exposure and response prevention, children learn strategies to manage obsessional fears and compulsive urges by gradually facing their fears. For example, a child who is afraid of getting sick if she touches her shoe would practice touching her shoe without washing her hands. A youngster with a fear that the number 13 will cause bad luck might go to the 13th floor of a building to get exposure to this number. Exposure and response prevention teaches children how to reduce their fears and rituals by thinking and acting in more healthy ways. The children learn that their fears and rituals are unnecessary.
And treatment is short term. At the Mayo Clinic OCD program, treatment typically lasts from one to four months.
“Most importantly, the improvements that children make appear to last after therapy ends,” says Stephen Whiteside, PhD, Mayo Clinic child psychologist and coauthor of the study. “That’s because children learn skills in therapy that no one can ever take away from them.”
Not all families have access to this type of treatment. Whiteside notes that effective therapy requires a mental health care provider who has specific training or experience in exposure and response prevention therapy.
Medication therapy also reduces symptoms of obsessive-compulsive disorder, though doctors aren’t sure why. OCD symptoms usually return when children stop taking medication.
“Medication therapy is based on the idea that OCD has something to do with serotonin, which is a neurotransmitter,” says Abramowitz. “But experts remain unsure of exactly how medications work.” Also puzzling, the researchers noted a placebo effect. The analyses suggested that some children benefited from receiving a placebo instead of the real drug.
“The study supports clinical impressions that both antidepressant medication and exposure and response prevention therapy can reduce symptoms for children with OCD,” says Abramowitz. “But neither approach cures the disorder.”
Abramowitz says that more studies are needed to evaluate if the exposure and response prevention therapy could be used together, or in sequence with medication, to reduce symptoms more effectively.