Clinical

Case Studies
http://ccs.sagepub.com/

Introduction to the Special Issue: Treatment of Childhood Obsessive-Compulsive

Disorder
Dean McKay and Eric A. Storch
Clinical Case Studies 2014 13: 3
DOI: 10.1177/1534650113504486
The online version of this article can be found at:
http://ccs.sagepub.com/content/13/1/3

Published by:
http://www.sagepublications.com

Additional services and information for Clinical Case Studies can be found at:
Email Alerts: http://ccs.sagepub.com/cgi/alerts
Subscriptions: http://ccs.sagepub.com/subscriptions
Reprints: http://www.sagepub.com/journalsReprints.nav
Permissions: http://www.sagepub.com/journalsPermissions.nav
Citations: http://ccs.sagepub.com/content/13/1/3.refs.html

>> Version of Record - Dec 31, 2013

What is This?

Downloaded from ccs.sagepub.com at University of Bucharest on December 7, 2014

504486

research-article2013

CCS13110.1177/1534650113504486Clinical Case StudiesMcKay and Storch

Article

Introduction to the Special Issue:

Treatment of Childhood
Obsessive-Compulsive Disorder

Clinical Case Studies

2014, Vol 13(1) 38
The Author(s) 2013
Reprints and permissions:
sagepub.com/journalsPermissions.nav
DOI: 10.1177/1534650113504486
ccs.sagepub.com

Dean McKay1 and Eric A. Storch2

Obsessive-compulsive disorder (OCD) has long been considered a complex and disabling psychiatric condition, marked by intrusive and unwanted imagery (obsessions) that is usually accompanied by ritualized behavior designed to neutralize the obsessions. Treatment research has
shown that, for those who complete treatment, significant improvement can be achieved (Simpson
et al., 2011; Storch, Geffken, et al., 2007). There is a growing consensus that the first-line psychosocial treatment for OCD is exposure with response prevention (ERP; McKay et al., 2013;
Olatunji et al., 2013). In the case of children, meta-analyses have shown that ERP is highly efficacious, with large effect sizes (mean d = 1.98; Abramowitz, Whiteside, & Deacon, 2005).
Indeed, practice parameters recommend ERP monotherapy as the treatment of choice for mild
and moderate cases, and together with antidepressant medication for only the most severe presentation. Although this augurs well for the treatment of children with OCD, not all children respond
to treatment and ERP dissemination remains a challenge.
Accordingly, this special issue is devoted to cases involving variations in treatment delivery
and symptom presentation in childhood OCD. The articles that form this special issue address a
variety of special circumstances that take the reader beyond the findings from randomized controlled trials that evaluate the efficacy of ERP in general. Instead, these cases help the reader
understand the issue of comorbidity and how to successfully contend with it during treatment,
and provide a peek at several promising avenues that are emerging in the treatment of childhood
OCD. These include addressing family-related complications in treatment delivery, specific
developmental phases (i.e., in very young children), Also examined in this special are cases with
under severe stigmatizing conditions, when symptoms present with complex comorbidities, and
evaluation of interventios that by capitalizes on technological advances in service delivery.

Beyond ERP: Presenting Symptoms That Necessitate Additional

Interventions
As treatment delivery becomes more sophisticated, we have come to understand that symptom
presentations do not always immediately lend themselves to exposure. One prominent example is
hoarding, which is now a separate disorder in a broader category of obsessive-compulsive-related
disorders in the Diagnostic and Statistical Manual of Mental Disorders (5th ed.; DSM-V; American
Psychiatric Association, 2013). This was the result of extensive research showing that hoarding
1Fordham

University, Bronx, NY, USA

of South Florida, Tampa, FL, USA

2University

Corresponding Author:
Dean McKay, Department of Psychology, Fordham University, 441 East Fordham Road, Bronx, NY 10458, USA.
Email: mckay@fordham.edu

Downloaded from ccs.sagepub.com at University of Bucharest on December 7, 2014

Clinical Case Studies 13(1)

was highly dissimilar from other symptoms of OCD (Pertusa et al., 2010) and that ERP typically
resulted in poor outcome with hoarding (Abramowitz, Franklin, Schwartz, & Furr, 2003). While
initial hoarding symptoms are thought to onset during childhood for many (Storch, Rahman, Park,
Murphy, & Lewin, 2011), there are very few data on its treatment in pediatric patients. In the present case series, Ale, Arnold, Whiteside, and Storch (2014) present a case of pediatric hoarding
whereby family treatment was implemented to successfully use ERP, illustrating that ERP may be
viewed as an essential component, but not necessarily a sufficient condition, for improvement.
In clinical practice, most cases present with comorbidities (Ollendick, Jarrett, Grills-Taquechel,
Hovey, & Wolff, 2008). Nonetheless, treatment outcome is typically unaffected in cases of
comorbidities that do not substantially and additionally interfere with cognitive processing
(Storch et al., 2008). This is not always the case, and in children, OCD may be present with other
developmental disorders. One condition that is particularly challengingand receiving more
clinical and research attentionis when OCD is accompanied by autism spectrum disorders.
Nadeau, Arnold, Storch, and Lewin (2014) illustrate the utility of a modular-based family therapy
approach to alleviate symptoms in a child with OCD with autism. This case demonstrates yet
again that while exposure may be viewed as a necessary component, it is not necessarily sufficient for success, and indeed, using ERP without other methods for ensuring successful implementation may impede progress rather than facilitate it.

Speaking of Family Treatment . . .

Child-based treatment rarely takes place without being set in the context of the family environment. Interestingly, ERP has at times been viewed in the absence of the family environment,
particularly in the research with adults, but even in the meta-analysis of child treatment outcome
for OCD, there was virtually no mention of family interventions because the literature to that
point had ignored it, and it was cited as a potential avenue to evaluating potential mediators of
outcome (Abramowitz et al., 2005). These cases showcase the role of family-based interventions
in varying degrees in a young child (Labouliere, Arnold, Storch, & Lewin, 2014), as a result of
failed ERP when oppositional-defiant disorder was also present (Hughes-Scalise & Przeworski,
2014) and in a case of remote treatment delivery using web-camera (Ojserkis, Morris, & McKay,
2014). In all cases, functional assessment was crucial in determining family environment factors
that required intervention beyond simply ERP.

Technology and Treatment Delivery

Availability of expert treatment for OCD is a significant challenge for the profession, and there
have been efforts to address this problem, such as the behavior therapy training institute offered
by the International Obsessive Compulsive Disorder Foundation (Szymanski, 2012) that trains
new providers in the provision of ERP. One promising new frontier in this regard is the use of
web-camera delivered therapy (Storch, Caporino, et al., 2011and utilized in one of the cases in
this series (Ojserkis et al., 2014). This approach has the promise of reducing the impact of geographic and financial/academic barriers (e.g., parent and/or child missing a large amount of
work/school when traveling to sessions that are far away) that hinder treatment access. Additional
technological advances have momentary value for implementation such as through smartphone
applications. Whiteside, Ale, Douglas, Tiede, and Dammann (2014) illustrate the use of a smartphone app for treatment of mild obsessive-compulsive symptoms in children. This novel approach
provides a means for demonstrating cost-effective alternatives to treatment and serves as a potential preventive measure for early-onset OCD.

Downloaded from ccs.sagepub.com at University of Bucharest on December 7, 2014

McKay and Storch

The Implications of a Biological Model of OCD

For several years now, policy makers and the American Psychiatric Association have emphasized
the importance of biological models to the exclusion of perspectives that emphasize multiple
causes of behavior disorders. To wit, the recent Research Domains Criteria (RDoCs) explicitly
stress biological mechanisms. Indeed, in an editorial on the RDoCs, the following was offered:
. . . the RDoC framework conceptualizes mental illnesses as brain disorders. In contrast to
neurological disorders with identifiable lesions, mental disorders can be addressed as disorders of
brain circuits. (Insel et al., 2010, p. 749)

Paradoxically, the emphasis on biological models has increased the stigmatizing effects of
mental illness (Pescosolido et al., 2010).1 Mental health providers will likely observe a rise in
stigma complicating their efforts to offer relief to their clients in light of the increasing emphasis
on biological causes of mental illness. In this case series, a case of a child with OCD who faced
stigma associated with a physical handicap and that, based on functional analysis, revealed to be
a complicating feature in his or her presenting symptoms and was successfully treated with additional coping strategies to alleviate the stigma the child experienced (Babinski, Pelham, &
Waxmonsky, 2013). This case is instructive for future problems associated with stigma, whether
physical handicapping conditions or stigma imposed from the community or other agencies due
to observable symptoms of mental illness.

Where Do We Go Next?
As we hope is clear, ERP presents as a powerful treatment associated with robust effects in the
treatment of youth with OCD, as well as many other psychological disorders. However, not all
youth respond to this intervention and response is not always complete. Given this, the next generation of studies must consider how to tailor interventions to address comorbidity and how to
maximize treatment response. To this end, we highlight several specific directions for future
research and clinical attention.
First, there is a great need to improve on the degree of treatment response experienced by the
average child with OCD. Approximately, 40% to 50% of children with OCD who are treated with
ERP achieve remission, indicating that many others are partial responders or did not glean clinically significant benefit. Given this, efforts to enhance treatment response are greatly needed.
One promising avenue involves d-cycloserine (DCS) augmentation of ERP. Preliminary results
have been promising, demonstrating an advantage for DCS augmentation or ERP relative to
placebo (Storch et al., 2010). Beyond the overall treatment effects, this approach may accelerate
the rate of response (Chasson et al., 2010) and, importantly, do so in a very safe manner that is
acceptable to parents. We are currently in the middle of a large-scale randomized controlled trial
examining the efficacy of this approach in youth with OCD (McGuire et al., 2012). A second
approach to this issue involves how to incorporate family into treatment. For many providers,
individual child treatment means just thatthat the child is the exclusive focus of treatment, and
family members are included marginally if at all. We believe that having a robust family componentas shown in the Labouliere et al. (2014) articleis one method of enhancing treatment
outcome. In this model, parents are taught to be their childs therapist so that they are able to
implement exposure tasks and other therapeutic assignments independently in the natural environment (Storch, Geffken, et al., 2007). Because it is clear that homework is integrally related to
treatment outcome (Abramowitz, Franklin, Zoellner, & DiBernardo, 2002) and that parents are
able to effectively monitor compliance when involved in treatment, we believe this is one method

Downloaded from ccs.sagepub.com at University of Bucharest on December 7, 2014

Clinical Case Studies 13(1)

of enhancing overall response. Similarly, it is clear that OCD affects the entire family and that
family members are often involved in a childs symptoms (Storch, Merlo, et al., 2007). Inclusion
of family members allows the clinician to address family factors that are involved in treatment
that, without being addressed, would negatively influence treatment outcome (Merlo, Lehmkuhl,
Geffken, & Storch, 2009).
Second, as the above articles demonstrate, comorbidity in pediatric OCD is the rule rather
than the exception. It is relatively infrequent that a child presents with no comorbid conditions.
Many times it is easy to address the comorbidity in the context of treating the OCD. For example,
some data suggest that improving obsessive-compulsive symptoms is actually associated with
reduced depressive symptoms in children with OCD (Meyer et al., 2013). At other times, however, one must consider how to address the OCD and comorbid conditions in a theoretically
informed fashion that considers the available evidence base. In this vein, personalizing the treatment approach to address the OCD and the comorbid problem is likely to result in improved
outcomes. We believe that there are several particular comorbidities for which this may be most
relevant (Storch et al., 2008). In the case of disruptive behavior, addressing the disruptiveness
and defiance sequentially to the obsessive-compulsive symptoms may facilitate the treatment
process by reducing interference in exposure tasks due to oppositionality. Depressive symptoms
may impact the treatment course by the childs unwillingness or inability to participate in treatment due to his or her depression; there are some data that suggest that habituation may be
affected in those with OCD who are also depressed (Abramowitz, 2004).Thus, addressing depression sequentially and/or concurrently to OCD may be appropriate at times. Finally, many children with OCD also present with attention deficit hyperactivity disorder. Problematically, these
symptoms often interfere with the childs ability to engage during treatment as well as his or her
ability to independently utilize therapeutic skills. Consideration of evidence-based attention deficit hyperactivity disorder interventions may be one method of addressing these symptoms to
foster improved OCD treatment outcome.
Finally, as each of the articles point out, ERP is a very effective intervention for children with
OCD. However, dissemination is greatly lacking. Many providers are not engaging in evidencebased OCD interventions at all, and many of those who do provide some elements of evidencebased treatment are leaving out exposure therapy (Marques et al., 2010), which is the most robust
element of this approach. Because of this, antidepressants, either alone or with psychotherapy
(often not ERP), are used with frequency in youth with OCD despite more modest efficacy (but
greater dissemination) relative to ERP and the potential for side effects. In the absence of available ERP, families are left with precious few choices of how best to treat their childs OCD,
which is a scenario that we view as unacceptable.
In sum, we hope that the present series stimulates thoughtful discussion and consideration
about the nature of pediatric OCD and methods of effective treatment. Ultimately, it is our goal
to improve the well-being of children affected by this disabling condition so that they may continue their development with happiness and without the burden of a mental health problem.
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.

Note
1. Deacon (2013) provides a detailed analysis explaining why, despite the claims that ascribing biological causes to mental illness will decrease stigma, there is no compelling reason to expect this, and that

Downloaded from ccs.sagepub.com at University of Bucharest on December 7, 2014

McKay and Storch

the available research from medicine and social psychology clearly point to biological causes leading
to increased stigma. Furthermore, even within psychiatry, there are prominent voices who decry to
biological monoculture and instead emphasize the need for understanding mental illness in the context
of multiple causes (for a notable illustration, see Kendler, 2012).

References
Abramowitz, J. S. (2004). Treatment of obsessive-compulsive disorder in patients who have comorbid
major depression. Journal of Clinical Psychology, 60, 1133-1141.
Abramowitz, J. S., Franklin, M. E., Schwartz, S. A., & Furr, J. M. (2003). Symptom presentation and outcome of cognitive-behavioral therapy for obsessive-compulsive disorder. Journal of Consulting and
Clinical Psychology, 71, 1049-1057.
Abramowitz, J. S., Franklin, M. E., Zoellner, L. A., & DiBernardo, C. L. (2002). Treatment compliance and
outcome in obsessive-compulsive disorder. Behavior Modification, 26, 447-463.
Abramowitz, J. S., Whiteside, S. P., & Deacon, B. J. (2005). The effectiveness of treatment for pediatric
obsessive-compulsive disorder: A meta-analysis. Behavior Therapy, 36, 55-63.
Ale, C. M., Arnold, E., Whiteside, S. P. H., & Storch, E. A. (2014). Family-based behavioral treatment of
pediatric compulsive hoarding: A case example. Clinical Case Studies, 13, 9-21.
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.).
Washington, DC: Author.
Babinski, D. E., Pelham, W. E., & Waxmonsky, J. G. (2014). Cognitive-behavioral therapy for pediatric
obsessive-compulsive disorder complicated by stigma: A case study. Clinical Case Studies, 13, 95-110.
Chasson, G. S., Buhlmann, U., Tolin, D. F., Rao, S. R., Reese, H. E., Rowley, T., . . . Wilhelm, S. (2010).
Need for speed: Evaluating slopes of OCD recovery in behavior therapy enhanced with d-cycloserine.
Behaviour Research and Therapy, 48, 675-679.
Deacon, B. J. (2013). The biomedical model of mental disorders: A critical analysis of its validity, utility
and effects on psychotherapy research. Clinical Psychology Review, 33, 846-861.
Hughes-Scalise, A., & Przeworski, A. (2014). All in the family: Family-based behavioral treatment of child
obsessive-compulsive disorder & oppositional defiant disorder within the context of marital and family
discord. Clinical Case Studies, 13, 52-67.
Insel, T., Cuthbert, B., Garvey, M., Heinssen, R., Pine, D. S., Quinn, K., . . . Wang, P. (2010). Research
Domain Criteria (RDoC): Toward a new classification framework for research on mental disorders.
American Journal of Psychiatry, 167, 748-751.
Kendler, K. S. (2012). The dappled nature of causes of psychiatric illness: Replacing the organic-functional/
hardware-software dichotomy with empirically-based pluralism. Molecular Psychiatry, 17, 377-388.
Labouliere, C. D., Arnold, E. B., Storch, E. A., & Lewin, A. B. (2014). Family based cognitive-behavioral
treatment for a preschooler with obsessive compulsive disorder. Clinical Case Studies, 13, 37-51.
Marques, L., LeBlanc, N. J., Weingarden, H. M., Timpano, K. R., Jenike, M., & Wilhelm, S. (2010).
Barriers to treatment and service utilization in an internet sample of individuals with obsessive-compulsive symptoms. Depression and Anxiety, 27, 470-475.
McGuire, J. F., Lewin, A. B., Geller, D. A., Brown, A., Ramsey, K., Mutch, P. J., . . . Storch, E. A. (2012).
Advances in the treatment of pediatric OCD: Rationale and design for the evaluation of D-cycloserine
with exposure and response prevention. Neuropsychiatry, 2, 291-300.
McKay, D., Sookman, D., Neziroglu, F., Wilhelm, S., Simpson, H. B., Stein, D., . . . Veale, D. (2013).
Efficacy of cognitive-behavior therapy for obsessive-compulsive disorder. Manuscript submitted for
publication.
Merlo, L. J., Lehmkuhl, H., Geffken, G. R., & Storch, E. A. (2009). Decrease in family accommodation
is associated with improved cognitive-behavioral therapy outcome in pediatric obsessive-compulsive
disorder. Journal of Consulting and Clinical Psychology, 77, 355-360.
Meyer, J., McNamara, J. P. H., Reid, A. M., Storch, E. A., Geffken, G. R., Mason, D. M., . . . Bussing, R.
(2013). Prospective relationship between obsessive-compulsive and depressive symptoms during multimodal treatment in pediatric obsessive-compulsive disorder. Child Psychiatry & Human Development.
doi: 10.1007/s10578-013-0388-4
Nadeau, J., Arnold, E. B., Storch, E. A., & Lewin, A. B. (2014). Family cognitive-behavioral treatment for
a child with autism and comorbid obsessive compulsive disorder. Clinical Case Studies, 13, 22-36.

Downloaded from ccs.sagepub.com at University of Bucharest on December 7, 2014

Clinical Case Studies 13(1)

Ojserkis, R., Morris, B., & McKay, D. (2014). Pediatric obsessive-compulsive disorder: An illustration of
intensive family-based treatment delivered via web camera. Clinical Case Studies, 13, 68-71.
Olatunji, B. O., Rosenfield, D., Tart, C. D., Cottraux, J., Powers, M. B., & Smits, J. A. J. (2013). Behavioral
versus cognitive treatment outcome of obsessive-compulsive disorder: An examination of outcome and
mediators of change. Journal of Consulting and Clinical Psychology, 81, 415-428.
Ollendick, T. H., Jarrett, M. A., Grills-Taquechel, A. E., Hovey, L. D., & Wolff, J. C. (2008). Comorbidity
as a predictor and moderator of treatment outcome in youth with anxiety, affective, attention deficit/hyperactivity disorder, and oppositional/conduct disorders. Clinical Psychology Review, 28,
1447-1471.
Pertusa, A., Frost, R. O., Fullana, M. A., Samuels, J., Steketee, G., Tolin, D. F., . . . Mataix-Cols, D. (2010).
Refining the diagnostic boundaries of compulsive hoarding: A critical review. Clinical Psychology
Review, 30, 371-386.
Pescosolido, B. A., Martin, J. K., Long, J. S., Medina, T. R., Phelan, J. C., & Link, B. G. (2010). A disease
like any other? A decade of change in public reactions to schizophrenia, depression, and alcohol dependence. American Journal of Psychiatry, 167, 1321-1330.
Simpson, H. B., Maher, M. J., Wang, Y., Bao, Y., Foa, E. B., & Franklin, M. (2011). Patient adherence
predicts outcome from cognitive-behavioral therapy in obsessive-compulsive disorder. Journal of
Consulting and Clinical Psychology, 79, 247-252.
Storch, E. A., Caporino, N. E., Morgan, J. R., Lewin, A. B., Rojas, A., Brauer, L., . . . Murphy, T. K.
(2011). Preliminary investigation of a web-camera delivered cognitive-behavioral therapy for youth
with obsessive-compulsive disorder. Psychiatry Research, 189, 407-412.
Storch, E. A., Geffken, G. R., Merlo, L. J., Mann, G., Duke, D., Munson, M., . . . Goodman, W. K. (2007).
Cognitive-behavioral therapy for pediatric obsessive-compulsive disorder: Comparison of intensive
and weekly approaches. Journal of the American Academy of Child & Adolescent Psychiatry, 46,
469-478.
Storch, E. A., Merlo, L. J., Larson, M. J., Fernandez, M., Jacob, M. L., Geffken, G. R., . . . Goodman, W. K.
(2007). Family accommodation in pediatric obsessive-compulsive disorder. Journal of Clinical Child
& Adolescent Psychology, 36, 207-216.
Storch, E. A., Merlo, L. J., Larson, M., Geffken, G. R., Lehmkuhl, H. D., Jacob, M. L., . . . Goodman,
W. K. (2008). The impact of comorbidity on cognitive-behavioral therapy response in pediatric obsessive
compulsive disorder. Journal of the American Academy of Child & Adolescent Psychiatry, 47, 583-592.
Storch, E. A., Murphy, T. K., Goodman, W. K., Geffken, G. R., Lewin, A. B., Henin, A., . . . Geller, D. A.
(2010). A preliminary study of D-cycloserine augmentation of cognitive-behavioral therapy in pediatric obsessive-compulsive disorder. Biological Psychiatry, 68, 1073-1076.
Storch, E. A., Rahman, O., Park, J. M., Murphy, T. K., & Lewin, A. B. (2011). Compulsive hoarding in
children. Journal of Clinical Psychology, 67, 507-516.
Szymanski, J. (2012). Using direct-to-consumer marketing strategies with obsessive-compulsive disorder in
the nonprofit sector. Behavior Therapy, 43, 251-256.
Whiteside, S. P. H., Ale, C. M., Douglas, K. V., Tiede, M. S., & Dammann, J. E. (2014). Case examples of
enhancing pediatric OCD treatment with a smartphone application. Clinical Case Studies, 13, 80-94.

Author Biographies
Dean McKay, PhD, is a professor of psychology at Fordham University. His primary areas of interest are
anxiety disorders and their treatment.
Eric Storch, PhD is the All Childrens Hospital Guild Endowed Chair and Professor in the Department of
Pediatrics at the University of South Florida. His primary research and clinical interests are in the phenomenology and treatment of children and adults with obsessive-compulsive and related disorders and anxiety
disorders.

Downloaded from ccs.sagepub.com at University of Bucharest on December 7, 2014