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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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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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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.



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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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



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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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



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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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



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

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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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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



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


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.



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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