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DOI: 10.1177/1534650113507744 2014 13: 95 originally published
online 24 October 2013Clinical Case Studies
Dara E. Babinski, William E. Pelham, Jr. and James G.
WaxmonskyComplicated by Stigma: A Case Study
Cognitive-Behavioral Therapy for Pediatric Obsessive-Compulsive
Disorder
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Clinical Case Studies2014, Vol 13(1) 95 110 The Author(s)
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DOI: 10.1177/1534650113507744ccs.sagepub.com
Article
Cognitive-Behavioral Therapy for Pediatric Obsessive-Compulsive
Disorder Complicated by Stigma: A Case Study
Dara E. Babinski1, William E. Pelham, Jr.2, and James G.
Waxmonsky2
AbstractNearly 50% of children continue to experience
obsessive-compulsive disorder (OCD) symptoms and impairment at the
end of traditional Cognitive-Behavioral Therapy (CBT), and some
studies suggest that stigma may complicate the course of CBT for
OCD. This case study describes the use of CBT for a 9-year-old boy,
Isaac, who was diagnosed with OCD and was experiencing stigma
related to a visible physical handicap. Manualized CBT was
conducted, and substantial improvement in OCD symptoms and
functioning emerged. However, given the persistence of obsessions,
which we believed to be particularly difficult to resist given the
visibility of his handicap and associated stigma, additional
booster sessions were included, from which more improvements
emerged, and they were maintained over a year. Thus, this case
study illustrates the benefit of addressing OCD symptoms and
impairment as well as other complicating factors, such as stigma,
in the course of treatment.
KeywordsOCD, child, stigma, CBT
1 Theoretical and Research Basis for Treatment
Obsessive-compulsive disorder (OCD) affects approximately 1% to
2% of children and involves recurrent thoughts (i.e., obsessions)
and ritualistic behaviors (i.e., compulsions) that are difficult to
control and cause clinically significant impairment in daily life
functioning (Zohar, 1999). Currently, individual
Cognitive-Behavioral Therapy (CBT) alone is recommended as the
first-line treatment for mild to moderate cases, while CBT with
antidepressant medication is indicated for the most severe
presentations (Geller, March, & AACAP Committee on Quality
Issues, 2012). A recent meta-analysis of randomized controlled
treatment trials showed that the effect size of CBT is very large
(Watson & Rees, 2008), which is larger than that found for
pharmacological treatments. It is likely that non-pharmacological
treatments such as CBT are more acceptable than pharmacological
ones to parents, given the warning of increased risk of suicidal
behavior
1Penn State College of Medicine, Hershey, PA2Florida
International University, Miami, USA
Corresponding Author:Dara E. Babinski, Penn State College of
Medicine, Hershey, PA 17033, USA. Email: [email protected]
507744 CCS13110.1177/1534650113507744Clinical Case
StudiesBabinski et al.research-article2013
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96 Clinical Case Studies 13(1)
(Goodman, Murphy, & Storch, 2007). Furthermore, given the
increased risk of comorbidities related to OCD, particularly other
anxiety and mood disorders (Stewart et al., 2004), CBT may provide
strategies that patients can actively use to prevent these
maladaptive outcomes.
Despite the very large effects of CBT for pediatric OCD, there
are still children who experi-ence persistent symptoms and
impairment after treatment. The Pediatric OCD Treatment Study
(POTS) is the largest randomized controlled trial of children with
OCD, which compared the relative efficacy of CBT, sertraline, and
their combination over 12 weeks (March et al., 2004) and showed
that all three active treatments were more efficacious than
placebo; combined treatment was associated with the highest
remission rate, although it was not significantly higher than that
of CBT alone. However, 46.4% of children did not experience a
remission of symptoms. While this seemingly high rate of CBT
nonresponders may be due to complications in delivering treat-ment
with integrity and fidelity in a multisite design (Watson &
Rees, 2008), other single site studies have still indicated a
considerable proportion of children who continue to experience
symptomatology with CBT (e.g., Barrett, Healy-Farrell, & March,
2004). Poor treatment out-come has been related to long-term
consequences for children with pediatric OCD (Stewart et al.,
2004); thus, it is important to understand which children are less
likely to benefit from CBT so that adequate interventions can be
designed.
Predictors of response to CBT for pediatric and adult OCD have
rarely been explored, although, recently, some factors have been
found to be associated with less optimal treatment outcomes
(Ginsburg, Kingery, Drake, & Grados, 2008; Keeley, Storch,
Merlo, & Geffken, 2008). For example, there is some evidence
that children compared with adults experience less optimal CBT
outcomes. In addition, as described in a review by Keeley and
colleagues (2008), several studies of adult and child OCD treatment
have shown that individuals experiencing sexual/reli-gious symptoms
have poorer treatment outcomes compared with those experiencing
more acceptable obsessions and compulsions (e.g., contamination
fears). Presumably, there is an additional burden for individuals
experiencing sexual/religious symptoms, as they must cope with
their obsessions and compulsions in addition to the social stigma
and guilt attached to expe-riencing socially unacceptable thoughts
and behavior.
More broadly, research shows that individuals experiencing
social stigma are at risk for less optimal outcomes (Jorm &
Wright, 2008; Sirey et al., 2001). Children with physical
handicaps, for example, have consistently been shown to experience
stigma, as they are often avoided by others who may be
uncomfortable with the handicap, and such interactions have been
associated with inhibited social interaction for children with
physical challenges (Rubin & Wilkinson, 1995). Not
surprisingly, children with physical handicaps are at risk for
anxiety disorders (Berk, Cooper, Liu, & Marazita, 2001), and
children with anxiety disorders may face negative peer evaluations
(Storch et al., 2005). Thus, children experiencing social stigma,
physical impair-ments, and OCD may be at particular risk for
maladaptive outcomes in CBT.
2 Case Introduction
The present report describes a case study of Isaac, a Caucasian,
9-year-old boy presenting with OCD. At the time of referral, Isaac
attended third grade at a suburban public school in the
north-eastern United States, where he was in a regular-education
classroom. He lived with his biologi-cal parents and 7-year-old
sister. Isaac did not have a left hand as a result of a birth
defect. It was believed that Isaacs visible disability complicated
the assessment and treatment of his OCD given the associated social
stigma and judgment he faced everyday. We will elaborate on our
hypothesis that CBT was an appropriately matched treatment for
Isaac. In addition, we will describe the course and outcome of
manualized treatment, as well as additional treatment pro-vided to
specifically address the complicating factors in his case.
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Babinski et al. 97
3 Presenting Complaints
Isaacs parents believed that he may have been experiencing
excessive anxiety, but were not certain because Isaac appeared to
have limited insight into his problems. He had difficulty
expressing his feelings and reported physical, but not
psychological, distress. Prior to treat-ment, Isaac reported
several instances of feeling faint, shortness of breath, and
increased heart rate, but he and his parents were unable to
identify triggers to these events. In another incident, Isaac went
to the school nurses office because he reported feeling faint and
thought he may be sick. Although he did not describe anxiety, his
parents speculated that he may have been expe-riencing anxiety
because this complaint corresponded with state testing at school.
Isaac was examined by his physician, and the examination yielded no
signs of seizures or other physical problems.
Isaacs parents also described that he would spend hours in the
morning and evening repeating routines, such as touching certain
items in his bedroom (e.g., Spiderman poster, stuffed bear),
brushing his teeth in a particular manner, and dressing himself so
that his clothes would not touch his body. They described that he
left drawers and doors open at particular angles, would sleep in
the middle of his floor, and needed to follow a specific routine
each morning and evening. His parents reported that he had shown
many of these behaviors since his earliest years, but they had only
recently become problematic. They described that Isaac demanded
that they participate in his routines, which interfered with their
own tasks at home. His parents recently started his bed-time and
awakening earlier so that he would have time to complete his
rituals and still prepare for bed and school. However, they noticed
that these scheduling changes afforded Isaac even more time to
engage in his rituals. Isaacs parents also reported that he was
becoming increasingly upset with his inability to control his
behavior. He made statements that everything would be easier if he
were not alive, and he had tantrums and crying spells that they
believed were related to his frustration and confusion with his
need to engage in these behaviors.
4 History
Developmental History
Isaac was born without a left hand (ulnar dysplasia), which was
detected in the 8th to 9th week of gestation. At birth, Isaac was
also diagnosed with congenital muscular torticollis, in which he
experienced shortened muscles on his left side. He experienced
delays in walking and did not speak until age 3. He received
extensive early intervention for these physical impairments,
receiving occupational therapy to cope with his handicap, from
preschool until first grade. He also worked with a behavioral
optometrist for issues related to vision and body coordination.
When presenting for the current therapy, Isaacs parents were also
concerned that Isaac was underweight and was eating little, which
they speculated may be related to anxiety.
Academic/Peer History
Isaacs parents chose to retain him in preschool before
kindergarten. He was classified in pre-school as orthopedically
impaired and received physical and occupational therapies for his
ulnar dysplasia and speech therapy for mild articulation
difficulties. In second grade, he was declassi-fied, and at the
time of intake, he had a 504 plan, which provided occupational
therapy.
Despite these delays, Isaacs parents reported that he had a
number of close friends. He lived in a neighborhood near many of
his classmates, and his parents often planned play dates and
encouraged peer interaction through participation in sports and
church groups. Notably, Isaac excelled in baseball and played in
two baseball leagues at the time of treatment.
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98 Clinical Case Studies 13(1)
Treatment History
Isaac had never received CBT or antidepressant medication for
any of his presenting problems. Since 2005, he had occasionally met
with a PhD-level psychologist for educational consultation. Isaacs
parents sought out self-help materials such as the book Outsmart
Your Worry: A Toolkit for Kids, which had several suggestions to
cope with anxiety, such as counting backward and reciting a game
plan of strategies to use, but these were not implemented
consistently or likely to be very helpful. Without formal
intervention, Isaac appeared to have incorporated these self-help
strategies into a compulsion, as he would recite his game plan five
times at several times throughout his day to increase the
likelihood of success at school. If he did not repeat these
phrases, he reported that he would become upset.
5 Assessment
Parent Report of Symptoms
According to Isaacs parents report on the NIMH Diagnostic
Interview Schedule for Children Version IV (NIMH DISC-IV; Shaffer,
Fisher, Lucas, Dulcan, & Schwab-Stone, 2000), he met diagnostic
criteria for OCD. They described that he engaged in excessive
rituals, such as touch-ing his Spiderman poster before bed, placing
his stuffed animal in a certain direction before bed, and dressing
himself repeatedly. His most distressing ritual was repeating
reassurance-seeking statements such as Ill be okay in the morning
or I can handle whatever will come my way in school tomorrow, which
most times were part of his game plan. While his par-ents
encouraged these statements, and repeated them with him to promote
his confidence for the school day, they were unsure of how to stop
him from repeating these statements exces-sively. Although his
parents were unable to describe specific obsessions he was having,
they stated that if Isaac did not engage in these behaviors, he
would become upset and throw tan-trums, and that these behaviors
lasted an hour or more each day. They described subthreshold
symptoms of social phobia, including feeling self-conscious at
school and being afraid to raise his hand in class, but they
reported that Isaac did not avoid social situations. They also
indi-cated that Isaac had told them about some passive suicidal
ideation related to feeling that these behaviors would never go
away.
Self-Report of Symptoms
On the Kiddie-Schedule for Affective Disorders Present and
Lifetime Version (Kiddie-SADS-PL; Kaufman et al., 1997), Isaac
endorsed the same compulsions his parents described, as well as
touching corners in a room, washing his hands, and opening the
bathroom door at a certain angle. He reported that at school he
often rewrote assignments, and placed his eraser in a particular
posi-tion on his desk. Isaac initially denied experiencing any
obsessions, but with probing from the therapist, it appeared that
his game plan was related to an obsession about something bad
hap-pening at school. With further prompting, Isaac also admitted
to experiencing excessive thoughts about being dirty. He denied any
symptoms of social phobia or depression, with the exception of
passive suicidal ideation.
Reports of School Personnel
Isaacs teacher and school social worker completed the Impairment
Rating Scale (Fabiano et al., 2006) to assess impairment in areas
of daily functioning. Both reported no impairment at school.
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Babinski et al. 99
Review of Records
Psychoeducational testing, including the Stanford Binet
Intelligence Scale: Fourth Edition and the NEPSY Developmental
Neuropsychological Assessment, had been conducted by a
psycholo-gist, who had referred Isaac for treatment. Isaacs scores
indicated average intellectual abilities. It was noted that he was
particularly careful during the evaluation, needed time to
acclimate to tasks, and performed less well on timed tests,
suggestive of anxiety.
Treatment Outcome Measures
To evaluate treatment progress, measures were administered on a
weekly or biweekly schedule, as described below. These ratings
include clinician, parent, and child self-reports.
Obsessive-Compulsive Specific Measures
The Childrens Yale-Brown Obsessive-Compulsive Scale (CY-BOCS;
Scahill et al., 1997) is considered the gold standard of assessing
OCD, as it has demonstrated good to excellent reliability and
validity (Scahill et al., 1997). Both obsessions and compulsions
are assessed by five separate dimensions, including time consumed,
distress, interference, degree of resistance, and control. Scores
on the CY-BOCS range from 0 to 32, with higher scores indicative of
higher levels of distress. Scores are interpreted as 40 to 32 =
extreme, 31 to 24 = severe, 23 to 16 = moderate, 15 to 8 = mild,
and 7 to 0 = subclinical. A symptom reduction of at least 25% to
50% and a score of 14 or below have been shown to indicate
remission (Storch, Lewin, De Nadai, & Murphy, 2010). For this
study, the clinician met with the parent and child to deter-mine
biweekly CY-BOCS scores. At intake, Isaacs CY-BOCS score was 30,
consistent with severe symptomology.
The NIMH Global Obsessive-Compulsive Scale (NIMH GOC; Goodman
& Price, 1992) was completed by the clinician at the end of
each session and measures impairment related to OCD from 1 (minimal
symptoms) to 15 (very severe). NIMH GOC scores are clustered into
five main groups (i.e., 1 to 3, 4 to 6, 7 to 9, 10 to 12, and 13 to
15), with scores higher than 7 indicative of clinically impairing
levels of OCD (Goodman & Price, 1992). At intake, Isaacs score
was 10, indicating clinically significant impairment.
The Clinical Global Improvement Scale (CGI; Guy, 1976) assessed
clinician report of weekly progress from 1 (very much improved) to
4 (no change) to 7 (very much worse). Scores of 1 (very much
improved) and 2 (much improved) indicate OCD remission (Piacentini,
Bergman, Jacobs, McCracken, & Kretchman, 2002).
Global Measures of Daily Life Functioning
Biweekly parent and clinician Childrens Global Assessment Scale
(CGAS; Setterberg, Bird, Gould, Shaffer, & Fisher, 1992)
ratings assessed overall severity, need for treatment, and effects
of treatment in a 1 to 100 score. Lower scores indicate poorer
functioning, and scores above 70 indicate functioning of a
typically developing child. At intake, Isaacs clinician rated his
CGAS a 45, and his parents rated him a 51; both indicated
clinically significant impairment.
The Impairment Rating Scale (IRS; Fabiano et al., 2006) measured
biweekly impairment in peer, sibling, and parent relationships,
academic progress, self-esteem, family functioning, and overall
need for treatment from 1 (definitely not), 2 (probably not), 3
(maybe), 4 (probably yes), to 5 (definitely yes). Thus, higher
scores indicate greater impairment. The IRS has good psycho-metric
properties (Fabiano et al., 2006) and has been shown to accurately
identify impairment in
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100 Clinical Case Studies 13(1)
children with behavior problems (i.e., score of 3 or more;
Fabiano et al., 2006). At intake, Isaacs parents rated his overall
impairment as a 3.10.
6 Case Conceptualization
Visible physical handicaps, such as Isaacs ulnar dysplasia, are
associated with a high risk for internalizing problems, such as
OCD, social anxiety, and low self-concept (Berk et al., 2001).
Given that school-aged children are developmentally capable of
social comparison and self-eval-uation (Gifford-Smith &
Brownell, 2003) and that these social processes are fundamental in
estab-lishing peer relationships, Isaacs handicap was likely a
salient contributing factor in others perceptions of him. Although
his parents reported that he appeared to cope well with his
handicap and that he had always been very motivated to not allow it
to interfere with his life, Isaac likely perceived negative
evaluation from his peers and possibly even school personnel which
influ-enced his current difficulties with OCD. Individuals with
physical handicaps are often avoided by others who may be
uncomfortable with or insensitive to the handicap, and such
interactions have been associated with inhibited social interaction
for children with physical challenges (Rubin & Wilkinson,
1995). Isaac experienced negative interactions because of his
handicap and/or became anxious that other people were evaluating
him, which perpetuated his discomfort at school. Not surprisingly,
Isaacs OCD symptomology was notably displayed in anticipation of
school, before bed, and in the morning before school, where he
would confront these negative evaluations. This conceptualization
also fits with his subthreshold symptoms of social phobia and
avoidance of situ-ations when he may face potential negative social
evaluation. Engaging in compulsions such as touching corners,
indenting sentences, and dressing in certain ways provided a
distraction from thinking about these potentially negative
evaluations and may have furthered his magical thinking of If I do
things a certain way, the school day will be better. Other studies
have also highlighted negative peer influences in the development
and exacerbation of OCD (Storch et al., 2005).
Several factors prevented earlier detection of Isaacs OCD. He
initially lacked insight into the nature of his distress and had
difficulty discerning physical symptoms from anxiety. In addition,
Isaac was able to complete many of his rituals without others
noticing. School staff, for example, did not indicate that he was
experiencing any difficulty, and the secrecy of his obsessions and
compulsions could have provided him with increased opportunity to
engage in them. Furthermore, Isaac and his parents were intent on
not allowing his ulnar dysplasia to interfere with his life. Isaac
played on several baseball teams and based on his and his parents
reports was very valued by his teammates. His athletic ability and
acceptance on the teams likely prevented his social impairments
from being seen, as other research has shown that athletic ability
mitigates social impairment for some children (Lopez-Williams et
al., 2005).
Given the large to very large immediate (Watson & Rees,
2008) and long-term (Barrett, Farrell, Dadds, & Boulter, 2005)
effects of CBT, it was chosen as the most appropriate treatment for
Isaac. Isaacs parents also preferred CBT over medication. They
reported that he had been successful and motivated in previous
interventions (e.g., occupational therapy, psychological
consultation), and believed that CBT would be appropriate because
of his intelligence, ability to think rationally, and his high
level of motivation to decrease his worry.
7 Course of Treatment and Assessment of Progress
The first phase of treatment was based on the CBT protocol
described by March and Mulle (1995). It includes 16 weekly
individual sessions and booster sessions at least into the 22nd
week. Two of the initial 16 sessions include the parent to
reinforce and generalize treatment. The goal of this phase was to
reduce Isaacs clinically significant OCD symptoms and suicidal
ide-ation. In addition, Isaac set a more personal goal of being
able to enjoy his annual family vacation
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Babinski et al. 101
to the beach without impairment due to worry. Specific
components of the first phase of treat-ment are described
below.
Psychoeducation
The first two treatment sessions taught Isaac about OCD and were
aimed at helping him differenti-ate his OCD from himself.
Psychoeducation was deemed particularly important for Isaac given
his and his parents confusion about his symptoms versus physical
illness. Isaacs parents were eager to seek treatment for Isaac and
frequently asked questions about the course of CBT and the
likeli-hood of OCD remission and the efficacy of CBT versus
medication. At this time, Isaac and his parents also consulted with
a child psychiatrist at the same treatment facility to learn more
about their medication options, although they decided not to pursue
medication and instead to wait to determine his response to CBT.
Isaac named his OCD, Mean Man, and he was taught to boss Mean Man
out of his life. He learned to differentiate feelings of worry from
feeling hungry, tired, and sick; used a fear thermometer to rate
his subjective units of distress (SUDS; Wolpe, 1969) from 0 (no
anxiety) to 10 (feeling unbearably bad); and began a daily worry
journal illustrating Mean Mans influence on his life throughout
treatment. The purpose of this journal was to further differentiate
Isaac from his OCD and keep him motivated to challenge his OCD on a
daily basis. This journal was also used as a tool to monitor Isaacs
progress. While he had several initial entries indicating how he
hated his OCD (e.g., I hate Mean Man), after beginning exposure and
response therapy (described below), his journal entries became more
optimistic (e.g., I have so much to look forward to today). Isaacs
journal was reviewed at the beginning of each session throughout
treatment and provided an opportunity to reinforce his treatment
gains, monitor his continued use of strategies, and update his
hierarchy. Isaac and his parents indicated increased confidence in
the course of treatment for Isaac with psychoeducation.
Exposure and Response Prevention (ERP)
Beginning in the third session, a hierarchy of obsessions and
compulsions was developed. Isaac listed the following items on his
initial hierarchy and provided each a SUD rating: touching his
Spiderman poster at night = 2; touching or looking at corners in a
room = 2.5; touching a stuffed animal bear at night = 3; washing
his hands = 3; touching the bed pillows = 4; opening bathroom doors
and cabinets in a certain way = 4; putting a bear on an hourglass =
5; dressing without his clothes touching his body = 6; thinking
that his hands are dirty = 6; morning reassurance-seeking
statements to his parents = 7; repeating his game plan = 9; and
thinking about having a bad day = 9. Isaac required some prompting
from his parents and his therapist to generate this list and to
accu-rately rate each item, as he had initially provided SUDs of 2
for almost all items. He also initially required significant
prompting from the therapist and his parents to recognize that his
behaviors and thoughts were related to OCD. Notably, he included
mostly compulsions and relatively few obses-sions on this initial
hierarchy. At the beginning of ERP, Isaac was instructed to resist
the compul-sions on the lower end of his hierarchy. A new strategy
was introduced, discussed, and modeled for him each week to help
him resist these behaviors. Isaac was taught diaphragmatic
breathing, pro-gressive muscle relaxation, and talking back to his
OCD (e.g., Mean Man, get out of here) to help control his OCD.
Isaac practiced resisting these compulsions in session (e.g., not
looking at/touch-ing corners), and when in-session practice was not
feasible (e.g., nighttime behaviors), he appropri-ately practiced
ERP at home on his own or with his parents. Daily homework
requiring Isaac to practice the strategy as it related to a
specific compulsion was assigned. Isaac and his parents reported
immediate relief in his symptoms and further increase in his
confidence to defeat his OCD (see Figure 1 for ratings across
treatment). After the fourth week of ERP, Isaac and his parents
reported additional compulsions and obsessions that they had not
previously recognized were
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102 Clinical Case Studies 13(1)
related to his OCD, including touching people = 4; touching his
toothbrush in a certain way; think-ing that he had touched people
when he had not = 5; putting on socks a certain way = 5; thinking
about feeling sick = 6; and doubting whether he had recited his
game plan = 7. These obsessions and compulsions were treated
similarly to previous sessions, and additional strategies were also
introduced, including positive self-talk (e.g., I can do this vs.
Ill never feel better) and satiation (i.e., repeating the obsessive
thought until distress related to it decreased). Isaac described
his obsessions and compulsions more easily than he had initially
and appeared to rate the items more accurately. Isaac appeared to
have little difficulty resisting compulsions, although several
reminders to be aware of symptoms before they became larger
problems were needed. Isaac had considerably more difficulty
identifying and challenging his obsessions and stated a preference
for using positive self-talk rather than satiation.
Parental Involvement
Consistent with the manualized treatment protocol, Isaacs
parents attended Sessions 6 and 12. The purpose of their
involvement was to discuss their perception of Isaacs progress, as
well as family accommodation to Isaacs behavior. It is common for
parents to react to their childs dis-tress by becoming overly
involved and accommodating their childrens rituals (Storch et al.,
2007), although this parental accommodation has been shown to
maintain OCD (Merlo, Lehmkuhl, Geffken, & Storch, 2009). In the
case of Isaac, his parents responses to his reassur-ance seeking
questions, as well as the schedule changes they made to his morning
and bedtime schedule, appeared to reinforce Isaacs rituals and
provide him with additional time to engage in them. They had also
participated in his rituals by leaving certain cabinets open in
certain ways and answered his persistent reassurance-seeking
questions. It was also clear that Isaac had fre-quent tantrums that
were related to his obsessions and compulsions and/or his inability
to com-plete his rituals to precision. His mother expressed concern
about managing these behavior problems given his anxiety and her
desire to not exacerbate these problems. She discussed that because
of their earlier lack of understanding that his problems were
consistent with OCD, they
Figure 1 Obsessive-Compulsive Specific Measures.
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Babinski et al. 103
had been cautious about going certain places, fearing he may
become sick or worried. Isaacs parents were encouraged to expose
him to these situations. In addition, they were encouraged to
encourage other family members to similarly care for him and to
celebrate his successes and progress throughout treatment. Isaacs
mother attended these sessions and reported that these sessions
were helpful in providing her with guidance on how to best help
Isaac.
Although CBTs for child anxiety disorders, including the manual
used with Isaac, do not con-sistently include parents, parental
involvement in pediatric OCD treatment is critical because of
bidirectional parentchild influences (Barrett et al., 2004). Thus,
a parental component was added to Isaacs manualized treatment. At
the end of every session, Isaac and the therapist reviewed the
session material with his mother or father for approximately 10
min, and Isaac was given worksheets that described the content of
the session so that his parents could continue to reinforce his new
strategies at home and with other family members. They were also
encouraged to discuss any concerns and were reinforced for their
commitment to the therapy. Isaacs parents were also encouraged to
continue facilitating social activities for Isaac to help manage
his anxi-ety and OCD in social setting, including school. His
parents provided several additional social exposures for Isaac,
including enrolling him in Sunday School.
Phase 1 Treatment Outcome
After the 22 weekly sessions, Isaacs symptoms on the CY-BOCS
reduced from 26 to 10, NIMH GOC went from 10 to 3, and CGI went
from 4 to 1. Reductions in overall impairment included CGAS parent
from 52 to 64, CGAS clinician from 46 to 66, and parent IRS from
3.14 to 2.57 (see Figures 1 and 2). The goals that had been set
(i.e., reducing clinically significant compulsions and suicidal
ideation and Isaacs own goal of enjoying a worry-free vacation)
were met. Other posi-tive outcomes, including a report from Isaacs
doctor that his weight had normalized and his mothers observations
that he was able to spend more time at friends houses suggest that
the reduction in OCD symptoms had triggered additional global
functioning improvements. Although his compulsions were virtually
nonexistent, some obsessions were still problematic. In addition,
treatment occurred during the summer, when he was out of school and
therefore was experiencing a lower level of worry. Isaac often said
that his worry would be more difficult to control during the school
year, and he believed that his worry would return then. Therefore,
treatment continued in biweekly maintenance sessions with the goal
of increasing Isaacs self-confidence in defeating his worry during
school and with a particular goal in reduction of his emerging
obsessions.
8 Complicating Factors
Treatment Phase 2: Maintenance
Due to remaining obsessions, and his and his parents desire to
continue treatment, additional booster sessions extended the
manualized treatment for Isaac. Booster relapse prevention
ses-sions have been successful in preventing the recurrence of OCD
symptomology (Hiss, Foa, & Kozak, 1994). Biweekly sessions
reinforced Isaacs positive strategies and focused on Isaacs
learning to self-monitor his OCD.
Daily Self-Report Card
To provide an additional tool to monitor Isaacs daily progress,
he was given an idiographic daily monitoring card for his rituals
(Fabiano et al., 2009). Each week with the therapists facilitation,
he would list the rituals that he still needed to defeat and would
monitor each day whether he was
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104 Clinical Case Studies 13(1)
able to defeat them. Performance on his daily self-report card
was associated with weekly paren-tal rewards, including weekend
trips and extra computer time. The therapist taught Isaac to decide
which rituals to include so that at the time of termination, he was
self-sufficient in his monitoring and ERP efforts.
Cognitive Restructuring
To further target Isaacs obsessions, cognitive restructuring was
introduced. Although Isaac had been provided with some cognitive
strategies within the manualized treatment, it was believed that a
more thorough discussion of cognitive strategies was necessary to
help Isaac challenge his automatic negative thoughts. Given the
likelihood of relapse for children with OCD, it was also thought
that these strategies would equip Isaac with more healthy ways of
thinking to decrease
0
10
20
30
40
50
60
70
80
CGAS-parent CGAS-clinician
Pre-Treatment
Post-Treatment
Maintenance
0
0.5
1
1.5
2
2.5
3
3.5
Pre-Treatment Post-Treatment Maintenance
Impairment Rang Scale
Impairment RangScale
Clinical cut-off
Clinical cut-off
Figure 2 Global Measures of Daily Functioning.Note: CGAS =
Childrens Global Assessment Scale (Setterberg et al., 1992); CGAS
scores of 70 or above are typically indicative of normative
functioning; Pre-Treatment = baseline scores; post-treatment = 22
sessions (at the end of the manualized treatment); maintenance =
after 6 months of follow-up biweekly booster sessions; IRS =
Impairment Rat-ing Scale (Fabiano et al., 2006); Higher scores on
the IRS indicate greater impairment, and scores of 3 or higher are
indicative of clinical behavior problems. The IRS was completed
only by Isaacs parents.
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Babinski et al. 105
the likelihood of relapse. During treatment, Isaac engaged in
several cognitive distortions such as magical thinking. Isaac
believed that if he did certain rituals, said certain statements,
or thought certain ideas, he could help to ensure that he would
have a good day. Another recurring cognitive distortion for Isaac
was catastrophizing. Isolated events, such as a child sneezing
would trigger Isaacs belief that he would become sick. A handout
listing several automatic negative thoughts was provided to and
reviewed with him. He was also provided with thought records and
was taught how to challenge his thoughts by generating more
rational thoughts. These worksheets were reviewed with Isaacs
parents to help generalize and reinforce these skills outside
therapy, and Isaac was assigned thought records to complete for
homework to further reinforce his under-standing of cognitive
restructuring. In addition, when Isaac made a statement that may
reflect an automatic negative thought in session, the therapist
stopped and made him complete a thought record together.
Phase 2 Treatment Outcome
In 12 biweekly booster sessions (6 month), Isaac showed more
symptom and impairment improvement: CY-BOCS, 10 to 8; NIMH GOC, 3
to 2; CGI remained at 1; CGAS parent, 64 to 72; CGAS clinician, 66
to 74, and IRS, 2.57 to 2.43 (see Figures 1 and 2). Isaac remarked
that, overall, he now trusted that he was able to defeat his worry
and was able to target worries on his own without the support of
the therapist.
9 Access and Barriers to Care
There were no significant access barriers to treatment for
Isaac. He and his parents were consis-tently on time for
appointments and did not cancel any appointments. Isaacs family
indicated no financial burden from the cost of treatment.
10 Follow-Up
Isaacs family was contacted 1 year following completion of his
treatment and his treatment gains were maintained at 1-year
follow-up. Isaacs mother reported that he had successfully
tran-sitioned to middle school and was continuing to monitor his
own progress. She indicated that he did not need treatment at this
time.
11 Treatment Implications of the Case
This case study illustrates the use of CBT for a 9-year-old boy
with OCD complicated by promi-nent physical handicaps. With the
manualized weekly treatment, he experienced clinically sig-nificant
improvements in symptoms and impairment, and with maintenance
booster sessions, he experienced additional gains. Some symptoms
and impairment persisted even after 6 months of maintenance
treatment as is typically the case with OCD; however, Isaacs
quality of life was significantly improved to the degree that he
was able to successfully manage his OCD on a daily basis with
minimal impairment.
Consistent with other studies of pediatric OCD treatment (e.g.,
Barrett et al., 2004; March et al., 2004), Isaac demonstrated a 50%
reduction in symptoms and his scores on a variety of standardized
measures were in the nonclinical range. According to his and his
parents descrip-tions, as well as journal entries, he was also
experiencing improved functioning overall. For example, he no
longer reported suicidal thoughts or felt hopeless about the future
and often used the phrase I have so much to look forward to to
defeat his worry. His mother reported that he
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106 Clinical Case Studies 13(1)
was engaging in new behaviors, such as going over new friends
houses, riding his bike without reassurance seeking from his
parents, and speaking positively about school. His overt
compul-sions, such as tapping corners in a room, dressing himself
in a certain way, and touching items in his bedroom were largely
nonexistent at the end of treatment. He was also now equipped with
language to describe his feelings and skills to defeat residual and
future worries.
While at the end of the treatment, Isaac had demonstrated marked
improvement and had reached remission status based on his CGI score
of 1 (very much improved; Piacentini et al., 2002), NIMH GOC score
(Goodman & Price, 1992), and his CY-BOCS score (Storch et al.,
2010), he was still experiencing some impairment and obsessions.
Biweekly sessions to enhance his gains were delivered (Hiss et al.,
1994). Isaacs symptoms remained fairly stable throughout the
booster sessions, but his functioning appeared to further improve,
suggesting that mainte-nance treatment furthered his progress and
reinforced the skills he had learned in the initial weekly
treatment. The maintenance treatment also allowed Isaac more
practice with CBT and application of the strategies independently.
For most of the manualized treatment, Isaac relied on the therapist
to direct treatment. However, by the end of the maintenance
treatment, Isaac had taken more responsibility for and was
confident in his problem-solving skills. For example, the
idiographic daily monitoring was completed by the therapist at
first, but, during the maintenance phase of treatment, Isaac was
able to list on his own the behaviors he wanted and needed to
man-age for the upcoming week.
Although research on predictors of CBT response for children
with OCD is rather limited, emerging research suggests that factors
such as early age, poor insight (Storch et al., 2008), and
experiencing related stigma predict poorer CBT outcomes, and Isaac
experienced all three of these factors. Therefore, it is somewhat
surprising that CBT was so effective in reducing Isaacs severe OCD
presentation so immediately. Several components of the treatment
were likely responsible for Isaacs progress throughout
treatment.
First, parental involvement was likely critical to Isaacs
success, particularly his initial suc-cess. His parents helped him
practice resisting his compulsions at home, modeled appropriate
coping strategies, and rewarded him for his progress. They also
ensured that he followed through with his daily practice at home
and that they no longer accommodated his OCD. Isaacs parents, with
his permission, also discussed his treatment and ways of supporting
rather than accommo-dating his OCD with his teacher, school
guidance counselor, and close family and friends, which created a
broader support network for Isaac and his treatment progress.
Although the amount of parent involvement in treatment in the
manual used in Isaacs treatment (March & Mulle, 1995) was
relatively limited with parents attending only 2 of the 22
sessions, we believe that including his parents more directly in
treatment greatly facilitated his progress.
In addition, the majority of the treatment relied heavily on
behavioral principles (March & Mulle, 1995; Watson & Rees,
2008). Therefore, despite Isaacs initial lack of insight into his
problems, and his inability to discern his OCD from somatic
complaints, he was able to experi-ence benefit from CBT. In
particular, the majority of the initial sessions (i.e., ERP) were
very behavioral. Thus, his initial success may very well be due to
the behavioral component alone, although because cognitive and
behavioral strategies were simultaneously introduced, there was no
way to determine whether this is true. We believed that Isaacs
initial progress, his parents support, and his exposure to CBT
principles over time provided him with increased confidence to
adhere to CBT and a strong foundation to increase his understanding
of the treatment to incor-porate more complex, cognitive strategies
into his repertoire.
We believe that the booster sessions also added to his progress.
It was helpful for Isaac to have a period of extended progress. Not
only did his mother report that she believed the booster ses-sions
improved his self-esteem but also it appeared that prolonged
exposure to CBT allowed Isaac to more thoroughly master the
concepts. For example, in the manualized-treatment phase, Isaac had
a considerably difficult time with the cognitive strategies. He
would use positive
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Babinski et al. 107
self-talk without a clear understanding of the purpose of its
rationale, and it had initially become ritualistic behavior, as he
often repeated positive self-talk and experienced distress when he
did not. With additional practice, which was demonstrated in the
booster sessions, it appeared that Isaacs ability to apply
cognitive strategies was correct and more sophisticated. He also
was able to apply these strategies to negative thought processes
that were not specifically related to OCD. His continued use and
broad application of these healthy cognitions potentially would be
a pro-tective factor against the development of future
psychopathology (Hiss et al., 1994).
Along these lines, we believe that the emphasis on self-directed
care was also important to Isaacs treatment outcome. Although we
believed that the involvement of Isaacs parents was critical to his
success, it was also important that Isaac be responsible for his
care. It was concep-tualized that Isaacs problems centered on his
experiences with stigma and others judgment that he experienced at
school. Therefore, the support of his parents was limited by their
inability to support and reinforce him at school. Furthermore, at
the time of treatment, Isaac was moving into middle school, where
peer influences and judgment would be even more critical to his
develop-ment. Therefore, it would be important that he be able to
recognize his OCD and challenge it rela-tively independently.
Isaacs own motivation was also a unique characteristic that
likely affected his success in treatment. It was clear that his
parents were highly motivated for his treatment, but had Isaac
himself not been motivated for treatment his progress would likely
have not been as notable. It appeared that Isaac was intrinsically
motivated for treatment, setting goals for himself such as enjoying
a worry-free vacation without any prompting from the therapist or
his parents, which suggests that assessment of child motivation may
be a critical component in determining appro-priate treatment for
pediatric OCD. Although rewards were introduced as recommended by
the treatment manual, Isaac performed well in treatment regardless
of the reward and mentioned that he did not need rewards to defeat
his worry. His motivation was also seen in his perception of his
physical handicap. Isaac did not regard himself as handicapped and
has excelled in many areas, such as sports, at the same level of
the children around him.
While Isaacs improvement illustrates the progress of only one
child using CBT for OCD, it serves as additional evidence that CBT
is an acceptable and effective treatment for pediatric OCD that can
lead to sizable improvements in symptom reduction and functioning.
Furthermore, when complicating factors exist in the presentation of
pediatric OCD, attending to these factors during CBT can lead to
success. Given the chronic nature of pediatric OCD, this study
illustrates that factors such as child motivation, family
involvement, and long-term maintenance treatment are important
components for the treatment of pediatric OCD.
12 Recommendations to Clinicians and Students
The findings of this case study support three specific
recommendations for those considering CBT for a child with physical
disabilities. First, it is imperative to conduct a thorough
evaluation to determine the efficacy of the intervention. Although
Isaac quickly demonstrated a reduction in symptoms and had met
clinical criteria for remission by the sixth week of treatment (see
Figure 1), we believe that assessing his symptoms and impairment,
as well as collecting qualitative mea-sures of his progress (e.g.,
hierarchy, worry journal) provided a more comprehensive and
clini-cally meaningful evaluation of his functioning and treatment
progress. These ratings also helped to direct treatment and
determine the need and content of booster sessions. Had Isaacs
progress been solely based on the remission criteria of some
clinical trials, he may have inappropriately discontinued treatment
while still experiencing some obsessions and without adequate
under-standing and autonomy over his treatment. To reduce
data-collection burden on Isaac and his family, we collected some
measures weekly (e.g., journal) but others (e.g., CY-BOCS, CGAS) on
a biweekly schedule.
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108 Clinical Case Studies 13(1)
This case study also provides preliminary support for booster
sessions in the treatment of pedi-atric OCD. It may appear that
Isaac could have terminated treatment at the conclusion of the
manualized treatment, given that he met remission criteria used in
previous clinical trials for pedi-atric OCD (e.g., Barrett et al.,
2004; March et al., 2004), and the therapist frequently discussed
the short-term nature of CBT and Isaacs progress toward
termination. However, he was still experi-encing some obsessions at
the end of treatment, and his parents believed that he would
benefit from further treatment. Booster sessions allowed Isaac to
have maintenance of his treatment and become more independent in
the management of his OCD. Given his age, we believe that these
booster sessions helped to increase the likelihood that Isaac would
be more independent in recog-nizing his anxiety in the future.
Furthermore, we believe that these sessions were critical in
encour-aging Isaac to take responsibility for his treatment and
maintenance of his gains, which would be important given the
likelihood that children experiencing OCD were likely to
relapse.
The commitment of Isaacs family to CBT was also critical to his
progress. As described above, his parents reinforced treatment
gains outside session, provided encouragement and fol-low through
with his homework, and created additional social exposures for
Isaac. Isaac was also notably committed to adhering to the
treatment and practicing on his own, and he and his family were
committed to attending all sessions even with their busy school,
work, and extracurricular activities. He and his family indicated
that he was motivated to complete treatment and did not necessarily
require incentives to adhere with the treatment. CBT with less
adherent families may require additional treatment components, such
as motivational interviewing or a more intensive reinforcement
schedule.
Altogether, these results confirm that CBT is a promising
treatment for children with OCD, even for a child with several
factors indicative of poor response. The results of a case study
clearly limit generalizability, and controlled studies are needed
to determine the efficacy of CBT for children. Other limitations
include longer than expected treatment as well as the simultaneous
use of several behavioral and cognitive therapy components, which
make it difficult to determine which components of the treatment
were most clinically meaningful for Isaac. Furthermore, while we
did not include measures of other potentially meaningful treatment
outcome variables, including assessments of depressive symptoms or
family accommodation (Merlo et al., 2009), our assessment battery
was fairly comprehensive and is excessive for clinical care.
Furthermore, the extent of assessment at 1-year follow-up was
qualitative in nature, and empirically validated measures of
functioning are needed. However, given that little is known about
more complicated cases of pediatric OCD, and that no
well-established treatments yet exist, we believe that this case
study extends our knowledge base at this time in a meaningful
direction.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with
respect to the research, authorship, and/or publication of this
article.
Funding
The author(s) received no financial support for the research,
authorship, and/or publication of this article.
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Author Biographies
Dara E. Babinski, PhD, is a post-doctoral fellow in the
Department of Psychiatry at the Penn State College of Medicine. Her
interests are in the assessment and treatment of children and
adults with ADHD.
William E. Pelham, Jr., PhD, is a professor of Psychology and
Psychiatry at Florida International University. He directs the FIU
Center for Children and Families and is chair of the FIU Psychology
Department.
James G. Waxmonsky, MD, is an associate professor of Psychiatry
and director of the Division of Child and Adolescent Psychiatry at
the Penn State College of Medicine. His interests are in the
assessment and treatment of children and adults with ADHD.
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