Pediatric Obsessive Compulsive Disorder (OCD) is among the most common disorders of childhood, affecting between 1 and 3% of the youth population. The disorder is associated with substantial impairment in academic, social, and family functioning, and it carries a host of risks as youth age into adulthood. Cognitive behavioral therapy (CBT) has emerged as the treatment of choice for pediatric OCD, with typical treatment protocols involving exposure to feared stimuli, identification and evaluation of maladaptive beliefs, relaxation training, and behavioral rewards. Although these techniques have produced favorable results, one third of youth with OCD do not demonstrate significant response to treatment and many of those who do respond continue to evidence some degree of symptoms and impairment.
Efforts to improve therapy outcomes for youth with OCD increasingly have attempted to augment individual CBT with greater family involvement. These programs typically involve psychoeducation about OCD as well as general behavioral strategies for enhancing adherence to treatment. Although current family-focused treatments vary with regard to the nature and extent of parent involvement, to date, the incremental benefit of adding a family treatment component to traditional individual treatment remains unclear. Indeed, there does not appear to be a relation between the degree of family involvement and degree of treatment response, and current family treatments do not appear to affect change in family beliefs or behaviors.
This picture suggests that either family involvement does not contribute to significant improvement in child outcomes or that current treatments may not be sufficiently focused on features of the home environment that are relevant for shaping and maintaining OCD symptoms. Building from theoretical literature which identifies familial blame and accommodation as key characteristics that are important for course and outcome in OCD, we have developed a novel family intervention for use in treating pediatric OCD. Using techniques that are well established, Positive-Family Interaction Therapy (P-FIT) attempts to reduce family blame, accommodation, and conflict and to enhance family cohesion in high stress, high conflict families.
The goals of this study are to investigate a manualized P-FIT program for youth with OCD first with a small open trial of up to ten families to investigate the feasibility and tolerability of the treatment and then with a randomized trial (the main study) to assess its incremental efficacy over usual care (i.e., individual cognitive behavioral therapy). For the initial pilot stage, up to four children between the ages of 9-17 will be treated with P-FIT through the UCLA Child OCD, Anxiety, and Tic Disorders Program after completing a diagnostic evaluation to confirm eligibility. During this pilot study, procedures and materials for the manual will be refined and finalized for the controlled trial. The treatment will consist of 12 sessions of standard cognitive behavioral therapy that is augmented with a novel 6-session family focused treatment module. Assessments involving interviews, questionnaires, and several short tasks will be conducted at the beginning, midpoint and end of the treatment. We will also follow up with families 3 months following treatment in order to assess durability of any treatment gains. Study staff will meet weekly to discuss each open trial therapy session, including the feasibility, efficacy, and acceptability of the treatment manual, and make adjustments as needed. Once this group reaches consensus regarding the suitability of the manual, recruitment into the open trial will end and subsequent eligible families will be invited to participate in the randomized controlled trial (the main study).
Over the course of the main study, 40 youngsters will be randomized to receive either individual child-centered cognitive behavioral therapy (ICBT) or the P-FIT intervention (ICBT + 6 sessions of family treatment). All subjects regardless of response status will be evaluated at all scheduled assessment points. In addition to comprehensive parent, child, and clinician reports, the primary outcome variables will be assessed by blind independent evaluators. Manualized intervention and assessment protocols plus state-of-the art quality assurance (i.e., weekly supervision with an expert clinician specializing specifically in OCD treatment) and adverse event monitoring procedures will insure participant safety. Results from this investigation will be used to support a larger controlled comparative trial comparing the degree to which P-FIT improves outcomes for youth with OCD above and beyond current available treatments.
