Behavioural and cognitive behavioural therapy for obsessive compulsive disorder in children and adolescents

 

Abstract

Background

This is an update of a Cochrane Review first published in The Cochrane Library in Issue 4, 2006.

Obsessive-compulsive disorder (OCD) in children and adolescents is characterised by persistent intrusive thoughts, inappropriate impulses or images which cause marked anxiety, and/or by persistent repetitive behaviours such as hand washing, checking and ordering. Along with antidepressant medication, behavioural or cognitive-behavioural therapy (BT/CBT) is recommended as the treatment of choice for paediatric obsessive-compulsive disorder (OCD).

Objectives

This review examines the overall efficacy of BT/CBT for paediatric OCD, its relative efficacy against medication and whether there are benefits in using BT/CBT combined with medication.

Search methods

We searched CCDANCTR-Studies,CCDANCTR-References (16/3/2009), MEDLINE, EMBASE, PsycINFO, national trials registers, reference lists of all selected studies and handsearched journals related to cognitive behavioural treatment of OCD.

Selection criteria

Included studies were randomised or quasi-randomised controlled trials trials with participants 18 years of age or younger with a diagnosis of OCD, established by clinical assessment or standardised diagnostic interview. Reviewed studies included standard behavioural or cognitive-behavioural techniques, either alone or in combination, compared with wait-list, attention placebo, pill placebo or medication.

Data collection and analysis

The quality of selected studies was assessed independently by two review authors. Using Review Manager software, weighted mean differences were calculated for the total severity of OCD symptoms at post treatment and relative risks for having OCD at post treatment.

Main results

Eight studies with 343 participants were included. The review found evidence for lower post-treatment OCD severity and reduced risk of continuing with OCD for the BT/CBT group compared to pill placebo or wait-list comparisons. There was no evidence found that the efficacy of BT/CBT alone and medication alone differ in terms of post treatment symptom severity or in the risk of having OCD. There was some evidence of a benefit for combined BT/CBT and medication compared to medication alone but not relative to BT/CBT alone. The low rates of drop out suggested BT/CBT is an acceptable treatment to child and adolescent patients and their families.

Authors' conclusions

Although only based on a small number of studies which vary in quality, behavioural or cognitive-behaviour therapy alone appears to be an effective treatment for OCD in children and adolescents. It is as effective as medication alone and may lead to better outcomes when combined with medication compared to medication alone. Additional higher quality trials are needed to confirm these findings.

 

Plain language summary

Behavioural and cognitive-behavioural therapy for obsessive-compulsive disorder (OCD) in children and adolescents

The onset of obsessive-compulsive disorder often occurs in childhood and adolescence. Paediatric OCD can be an extremely debilitating disorder, resulting in high levels of distress, impairment and disruption of psychosocial development. It also has a considerable impact on other family members. While there is evidence that medication can reduce symptoms, behavioural and cognitive-behavioural therapy (BT/CBT) are often proposed as acceptable alternative treatments. These therapies include assisting the child to better tolerate the anxiety-provoking situations and thoughts without the use of compulsive behaviour to manage their anxiety, psycho-educationabout anxiety and OCD; cognitive therapy in which the child is helped to learn to identify and challenge unhelpful ways of thinking; and parental support.

This review identified eight randomised controlled trials involving 343 participants, evaluating the benefits of behavioural and cognitive-behavioural therapy. The results show that, compared to a wait-list or pill placebo, BT/CBT is an effective treatment for reducing OCD symptoms and lowering the risk of having OCD after treatment. Based on three studies that directly compared BT/CBT with medication, there was no current evidence to suggest that either BT/CBT or medication was superior to the other. When combined with medication, BT/CBT produces better outcomes than medication alone. Although based on a small number of studies, these findings provide support for the value of BT/CBT in the treatment of children and adolescents with OCD.

 

摘要

背景

兒童及青少年強迫症患者的行為治療和認知行為治療

考科藍回顧於2006年第一次發表在The Cochrane Library，第4期，而本篇則為其更新。兒童及青少年強迫症的特徵是持續的闖入式思想、不適切的衝動或影像，造成明顯的焦慮，與/或持續的重複性行為如洗手、檢查與排序。行為治療或認知行為治療，與抗憂鬱劑藥物治療並用，被建議用來治療罹患強迫症的兒童與青少年。

目標

這篇回顧檢視使用BT/CBT來治療兒童強迫症的整體效果，與藥物治療相比的相對效果，以及合併使用BT/CBT與藥物治療是否有助益。

搜尋策略

我們搜尋了CCDANCTRStudies 與 CCDANCTRReferences (在2009年3月16日搜尋), MEDLINE, EMBASE, PsycINFO，國家的試驗登錄，所有選擇研究的參考文獻，並手動搜尋與強迫症的認知行為治療有關的期刊。

選擇標準

納入的研究為隨機對照試驗或類隨機對照試驗，參與者為18歲以下，經過臨床評估或標準化的診斷性晤談後，符合強迫症的診斷。回顧的研究包括標準的行為或認知行為技巧，不管是單獨使用或合併使用，與等候名單、支持性安慰、藥物性安慰或藥物治療做比較。

資料收集與分析

兩位回顧者獨立地評估所選擇研究的品質。 使用Review Manager軟體，計算治療後強迫症症狀嚴重度的加權平均差，以及治療後持續有強迫症的相對風險。

主要結論

納入8個研究，共343個參與者。回顧發現BT/CBT組與藥物性安慰或等候名單相較，在治療後強迫症的嚴重度與持續有強迫症的風險降低。沒有證據顯示單獨使用BT/CBT，與單獨使用藥物治療，在治療後的症狀嚴重度或持續有強迫症的風險有差異。有一些證據顯示BT/CBT合併藥物治療，比起單獨使用藥物治療有更好的療效，但與單獨使用BT/CBT相比則無差異。退出率低顯示BT/CBT對兒童、青少年患者及其家屬來說，是一種可被接受的治療方式。

作者結論

雖然只有少數品質不一的研究，單獨使用行為治療或認知行為治療，對於兒童及青少年的強迫症患者來說似乎是一種有效的治療。BT/CBT與單獨使用藥物治療一樣有效，而且如果合併藥物治療，比單獨使用藥物治療，可能有更好的效果。將來還需要更多較高品質的試驗來確認這些發現。

翻譯人

本摘要由彰化基督教醫院陳美雀翻譯。

此翻譯計畫由臺灣國家衛生研究院(National Health Research Institutes, Taiwan)統籌。

總結

強迫症的發病年齡通常在兒童或青少年時期。它是種極度讓人受損的疾病，導致明顯的壓力、障礙，也阻礙了患者的心理社會發展。它也對其他家人有明顯的影響。雖然有證據顯示藥物治療可以減緩症狀，行為治療與認知行為治療(BT/CBT)通常被認為是可接受的替代療法。這些治療包括支持兒童更能忍受引起焦慮的情境及想法，而不使用強迫行為來處理其焦慮；關於焦慮以及強迫症的心理教育；學習去辨識及挑戰無益思考的認知訓練；以及父母的協助。本篇回顧找到8個隨機對照試驗，包括343位參與者，評估行為治療與認知行為治療的效益。結果顯示與等候名單或藥物性安慰相比，BT/CBT對於降低強迫症的症狀以及降低治療後持續有強迫症的風險性是有效的。3個研究直接比較BT/CBT與強迫症的藥物治療，目前沒有證據顯示BT/CBT或強迫症的藥物治療的療效有顯著差異。BT/CBT合併藥物治療，比單獨使用藥物治療有更好的效果。雖然只有少數研究，這些發現支持BT/CBT在治療兒童與青少年強迫症患者的價值。