Obsessive Compulsive Disorder (27 page)

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In clinical settings, there is often an assumption that many of the difficulties in treatment arise from secondary complications, such as poor motivation, and are down to the individual rather than the therapist. This can be seen as a type of self-serving cognitive bias on the part of the therapist. However, Stobie
et al.
’s (2007) study suggested that it was technical failures which were extremely common and advocated specialist training and supervision for clinicians in CBT, as well as the development and use of quality assurance measures to ensure that individuals are actually receiving what they are being offered. With young people in particular, it may be that some of these technical failures are related to difficulty with engagement and it is vital that clinicians are approachable, use the right language, listen respectfully and adapt therapy appropriately according to the age and development of the child.

Little is currently known about why some young people make little progress with adequate treatment, although comorbidity and family factors may be involved. The idea that ‘one size fits all’ in terms of therapy is, of course, risible. Research in adult OCD indicates that comorbidity (e.g. Axis II, ‘personality disorders’) does not usually prevent therapeutic change with treatment when the main problem is an anxiety disorder. However, such patients tend to have more severe problems and at the end of standardised treatment packages are more symptomatic than patients who do not show such comorbidity. Further treatment sessions typically result in further change and the achievement of a similar end state.

There have been some attempts to provide family CBT, where as well as attending the therapy sessions, parents are also given skills training.

However, there is not currently sufficient evidence that this is any more effective than individual CBT. Given that the family factors which appear to be relevant in understanding OCD in young people are poorly specified and understood, we remain unclear as to how family interventions might be deployed other than simply to deal with anxious parenting styles and encourage more adaptive behaviour in the affected young person. By the same token, if comorbidity is of particular relevance, we need to consider whether by addressing these factors in treatment we can improve outcome.

Future research needs to focus on the development of our theoretical understanding of these factors and then refining treatment to target particular issues.

• In order to improve treatment, we need to understand better what might define the problems experienced by those young people who do poorly in therapy.

• Future research needs to focus on the development of our theoretical understanding of factors that may be involved (such as comorbidity or family factors) and then refining treatment to target particular issues.

Issues and future directions in childhood OCD

149

The provision and dissemination of treatment

Studies on OCD in adults suggest that it is typically many years after obsessional symptoms significantly interfere before a diagnosis is made (e.g.

Hollander, 1997; Stobie
et al.
, 2007). With young people, as in adults, presentation to clinical services tends to be rather late in the natural history of the problem if it happens at all. A range of factors can contribute to unwillingness to seek professional help, including fear of or shame about revealing what they are experiencing to others. Families can sometimes actively ignore symptoms, trying to reassure themselves and their child that there is nothing wrong and resisting seeking treatment because of the concerns of what a diagnosis may bring in terms of stigma and blame. For professionals to reach a greater proportion of young people who would benefit from treatment, we need to change the way mental health problems are perceived. As mentioned already, the most obvious way of achieving this is likely to be through a greater awareness of OCD and the effectiveness of treatment in both educational and primary care settings. Strategies designed to reduce the stigma of mental health problems in general and OCD in particular are needed; careful media work and work with the anxiety disorder charities are promising in this respect. For young people in particular, it is especially beneficial when ‘celebrities’ whom they admire and identify with talk openly about having OCD.

Currently, guidelines from the National Institute for Health and Clinical Excellence (NICE) for the treatment of OCD recommend a stepped care approach. This approach advocates beginning with the least expensive and intrusive interventions and moving on to more intensive treatment as and when necessary. In OCD, NICE suggests beginning with self-help for young people where the OCD is mild, but as yet there is no evidence base for this and self-help literature for young people with OCD is not generally available.

There are risks associated with low-intensity treatments, in that a failure to respond could have a negative impact on the young person’s self-esteem and reduce their motivation to continue to try to change, discouraging them from seeking subsequent treatment. It may also undermine their response to further treatment or lead to them being seen as ‘untreatable’ by professionals if they have already received some version of CBT.

NICE guidelines recommend CBT for young people with moderate to severe OCD or for those with mild OCD for whom self-help has been ineffective. These recommendations are based on the evidence from randomised controlled trials. However, it is unclear how generalisable these findings are, as the therapy carried out in research trials is unlikely to reflect general clinical practice. Typically studies involve highly skilled therapists in specialist settings and this is not normally available in routine clinical settings. It is now recognised that we need to expand access to CBT, but to do this it is vital that therapists are qualified and adequately trained to ensure that young people with OCD get the best possible treatment.

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• We need to reach a greater proportion of young people who would benefit from treatment.

• In particular, strategies to reduce the stigma of mental health problems in general, and OCD in particular, are needed.

• We need to improve the availability of good quality CBT to ensure that young people with OCD get the best treatment possible.

In conclusion, the treatment of OCD in childhood has advanced greatly over the last decade from a state of stigmatising pessimism to heady optimism. There are many opportunities to extend our treatments to those who previously did not respond; for more effective and efficient treatment implementation; for disseminating effective treatments; and perhaps even early intervention and prevention. There seems now to be a real possibility that the work described in this book may have the effect of changing the epidemiology of OCD in children and young people. As if that were not good enough, it is also clear that doing so would reduce the prevalence of OCD throughout the age range. Now that would be a very fine thing to achieve.

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