Optimizing cognitive-behavioral therapy for childhood psychiatric disorders.

This issue of the Journal contains reports by Freeman et al. and Storch et al., which, taken together, significantly extend our understanding about the use of exposure-based cognitivebehavioral therapy (CBT) for treating childhood obsessivecompulsive disorder (OCD). Although CBT is considered the consensus frontline treatment for OCD in older children and adolescents, empirical data regarding the efficacy of this treatment approach for very young children with the disorder have been lacking. In the first controlled trial with this age group, Freeman et al. provide preliminary evidence for the efficacy of CBT in reducing OCD severity in 5to 8-year-old children. These authors used a treatment protocol that, although based on traditional exposure-based CBT, was adapted to address the developmental and contextual needs of their young sample. Most significantly, treatment involved an intensive family component designed to limit parental accommodation of their child`s symptoms and enhance parents` ability to tolerate their own distress when the child responds negatively to the limit setting. Family accommodation, or the extent to which family members are involved in or actually facilitate the child`s rituals (e.g., washing Bcontaminated^ articles, providing reassurance) has long been considered an important target in pediatric OCD treatment because this practice runs directly counter to the goals of exposure-based treatment by reinforcing both compulsive behaviors and anxiety avoidance. However, the extent to which the addition of structured family involvement actually increases the efficacy of individually focused treatment approaches for the disorder remains to be empirically tested. Nevertheless, the findings of Freeman and colleagues are consistent with prior work suggesting the potential value of family involvement in CBT treatment for older children and adolescents with OCD. Their report is also notable for their use of an active psychosocial control condition. Their use of family relaxation training as a comparison treatment raises the methodological bar for pediatric OCD CBT researchers, who, with limited exception, have relied primarily on less stringent waitlist control designs. In related fashion, Storch et al. report that children and adolescents with OCD and concurrent psychiatric comorbidity respond less well to CBT than those with OCD alone. Attention-deficit/hyperactivity disorder (ADHD), oppositional-defiant disorder (ODD), and major depressive disorder were each associated with lower response and/or remission rates, whereas the presence of comorbid Tourette disorder (TD) or non-OCD anxiety disorder had no impact on treatment outcome. The Storch et al. findings need to be tempered by the fact that outcome assessments were not completed blind to treatment or diagnostic status. However, these results are partially consistent with the pediatric psychopharmacology literature, in which OCD comorbid with ADHD, ODD, and/or TD has been associated with poorer response to selected serotonin reuptake inhibitor treatment than OCD in the absence of these disorders. The extent to which the mechanisms underlying the negative impact of disruptive behavior disorders on response to pharmacological and psychosocial interventions for OCD are similar or not, however, remains unknown. Storch et al. provide a number of potential explanations for how comorbid disorders may affect CBT efficacy, including reduced treatment focus on OCD symptoms, poorer treatment compliance and motivation, and/or diminished ability to comprehend and apply CBT concepts. Although many of these factors will likely resonate with psychotherapists, even those using manual-guided treatment approaches, they remain to be empirically tested, and their relevance to Accepted January 22, 2008. Dr. Piacentini is a Deputy Editor for the Journal and is with the University of California, Los Angeles. Correspondence to John Piacentini, Ph.D., University of California, Division of Child and Adolescent Psychiatry, UCLA-NPI, Room 68-251, 760 Westwood Plaza, Los Angeles, CA 90024-1759; e-mail: jpiacentini@mednet.ucla. edu. 0890-8567/08/4705-0481 2008 by the American Academy of Child and Adolescent Psychiatry. DOI: 10.1097/CHI.0b013e31816a0d8d E D I T O R I A L