This was another great presentation today by Dr. Martin Franklin entitled: “Treating OCD in Children and Adolescents: A Cognitive-Behavioral Approach.” This was a return visit to the Foundations Community Partnership behavioral health lecture series by popular demand. Due to Covid-19, today’s workshop was presented in Webinar format. Thanks to Dr. Franklin’s expertise and relaxed presentation style, and the efforts of the FCP, the workshop was flawless.
The goals for today’s workshop included:
At the end of the workshop participants will be able to:
- Describe how OCD is diagnosed in children and adolescents.
- Discuss the current empirical evidence on the treatment of pediatric OCD.
- Summarize the rationale for using CBT for the treatment of OCD in pediatric patients.
Dr. Franklin started with a brief description of the prevalence and manifestation of OCD in children and adolescents, He said that the prevalence rate is 1% to 2% and may cause moderate to severe functional impairment. Compared to adults, Dr. Franklin pointed out that children may be less likely or able to describe feared consequences and are more likely to engage in reassurance seeking with adults. Important to understanding OCD, Dr. Franklin described the Obsessive-Compulsive Cycle. He said that Obsessions (intrusive thoughts or images) will trigger Anxiety (distress, fear, discomfort, or shame) which lead to Compulsions (repetitive thoughts or actions) which provide Relief (temporary reduced distress). Unfortunately, this cycle is dysfunctional to daily life and requires assessment and treatment.
Assessment of OCD with children typically begins with a history of severity of the symptoms.
This looks at symptoms that include:
- How much they occupy the patient’s time.
- How much they interfere with functioning.
- How much subjective distress.
- How much they are resisted.
- How much they can be controlled.
It is also important to evaluate the family’s support of the child and/or tendency to enable OCD symptoms by reinforcing the anxiety. It is also important to learn the child’s strengths, likes and dislikes. These will be used later as part of treatment.
Dr. Franklin discussed the Children’s Yale-Brown Obsessive-Compulsive Scale (CT-BOCS) as an assessment instrument to determine the severity of OCD in children. He said that his instrument is frequently used in research studies evaluating the effectiveness of treatments for this disorder. The scale ranges from 0 to 40, with 0 showing no symptoms and 40 showing very severe symptoms. Scores in the mid 20’s are typical for patients entering treatment, while scores around 10 are typical of many children. A score of 16 is considered entry level for research.
According to the research, co-morbidity may occur with children suffering from OCD. Assessment should include child and family demographics and other relevant disorders. Depression or another anxiety disorder are not uncommon. As part of the assessment, the clinician must determine which disorder to treat first.
Dr. Franklin spent some time talking about the importance of helping families understand theoretical rationale and outcome data for treatment of children and adolescents with OCD. This includes factors likely to contribute to good and poor outcomes. Also, specific examples of how OCD can be applied. Dr. Franklin described the use of Cognitive-Behavior Therapy in the treatment of children and adolescents with OCD. He provided a list of research studies showing the efficacy of this approach with and without medication. The list included:
- deHaan et al. (1998): CBT vs. clomipramine
- Barrett et al. (2004, 2005): Individual and Family CBT vs. WL
- Pediatric OCD Treatment Study I, II & Jr. (2004, 2011, 2014)
- Storch et al. (2007): Intensive vs, Weekly CBT
- Bolton & Perrin (2008): “Pure” BT vs. WL
- Bolton et al. (2011): Brief & Full cognitively oriented TX vs, WL
- Freeman et al. (2008) & Piacentini et al. (2011) CBT vs Rel
Dr. Franklin’s discussion of these studies suggested that medication alone does show decrease in OCD symptoms while the treatment continues, but the symptoms may return when the treatment stops. Most studies showed that the combination of CBT and medication were most effective. Research shows that typical treatment can be 12 to 15 weekly sessions. CBT treatment can be effective with a wide variety of mental health professionals in community settings with training, not just in laboratory conditions. As a result of the research, CBT is considered an evidenced based approach to the treatment of OCD in children and adolescents.
During the second part of today’s workshop Dr. Franklin walked us through the progression of typical treatment and highlighted this with a description of sessions along the way. He discussed parenting strategies that don’t work such as advice, or reassurance, and those that do such as allowing the child to learn to tolerate symptoms, encouraging progress and reviewing future challenges.
As usual, I learned a bunch of things from Dr. Franklin this morning. His focus on the Obsessive-Compulsive Cycle (Obsession-Distress-Compulsion-Relief) is important. He reiterated that his treatment would increase obsessive thoughts and distress, while limiting or eliminating compulsive behavior. Tolerating and habituating to the obsessive thoughts and eliminating the compulsion is essential in treatment. He described many creative techniques to increase exposure to the obsessions that need to be challenged without the relief provided by the compulsive behavior. Dr. Franklin pointed out that these techniques also work with children and others who do not have high ability for insight. He said that the clinician must work hard to find creative but concrete opportunities for exposure to obsessions, because the child may not recognize that the obsessions and compulsions are unreasonable.
Dr. Franklin mentioned that research often explains very complex things in complex ways. He was trying to make it simple in his presentation. As the former college linebacker and current coach, father, Philly sports fan, and everyday guy that he appears, Dr. Franklin did just that. As he stated, his daughter, at age six did better. She described his treatment methods in a couple of sentences.
“Blah, blah blah, do the thing you’re afraid of.
Blah, blah, blah, the more you do it, the easier it gets.”
Today’s presentation was both enjoyable and informative. The 3 hours went by quickly. His workshop included the necessary elements including: Phenomenology and description of the disorder, assessment instruments and strategies, research to support the theory and treatment, and an overview of treatment techniques. Dr, Franklin told humorous but very relevant stories, provided case examples, and included research studies. He quickly came back to his point for each item. Overall, I thought that his presentation was well balanced, and all elements were covered. He really knows this stuff!
Any other thoughts?