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Cognitive-Behavioral Therapy for Pediatric Obsessive-Compulsive Disorder

Complicated by Stigma: A Case Study
Dara E. Babinski, William E. Pelham, Jr. and James G. Waxmonsky
Clinical Case Studies 2014 13: 95 originally published online 24 October 2013
DOI: 10.1177/1534650113507744
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research-article2013

CCS13110.1177/1534650113507744Clinical Case StudiesBabinski et al.

Article

Cognitive-Behavioral Therapy for

Pediatric Obsessive-Compulsive
Disorder Complicated by Stigma: A
Case Study

Clinical Case Studies

2014, Vol 13(1) 95110
The Author(s) 2013
Reprints and permissions:
sagepub.com/journalsPermissions.nav
DOI: 10.1177/1534650113507744
ccs.sagepub.com

Dara E. Babinski1, William E. Pelham, Jr.2,

and James G. Waxmonsky2

Abstract
Nearly 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.
Keywords
OCD, 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 firstline 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, PA

International University, Miami, USA

2Florida

Corresponding Author:
Dara E. Babinski, Penn State College of Medicine, Hershey, PA 17033, USA.
Email: dbabinski@hmc.psu.edu

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(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 experience 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 treatment 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 outcome 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/religious 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 experiencing 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 impairments, 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 northeastern United States, where he was in a regular-education classroom. He lived with his biological 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 provided 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 treatment, 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 experiencing 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 bedtime 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 preschool 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 declassified, 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.

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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 selfhelp 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 touching 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 reassuranceseeking 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 parents 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 excessively. 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 tantrums, 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 indicated 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 position 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 happening 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 psychologist, 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 determine 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 psychometric properties (Fabiano et al., 2006) and has been shown to accurately identify impairment in

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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-evaluation (Gifford-Smith & Brownell, 2003) and that these social processes are fundamental in establishing 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 influenced 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 situations 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 ideation. 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 treatment are described below.

Psychoeducation
The first two treatment sessions taught Isaac about OCD and were aimed at helping him differentiate 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 likelihood 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 accurately 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 obsessions on this initial hierarchy. At the beginning of ERP, Isaac was instructed to resist the compulsions 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, progressive 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/touching corners), and when in-session practice was not feasible (e.g., nighttime behaviors), he appropriately 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

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Figure 1 Obsessive-Compulsive Specific Measures.

related to his OCD, including touching people = 4; touching his toothbrush in a certain way; thinking 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 distress 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 reassurance 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 frequent tantrums that were related to his obsessions and compulsions and/or his inability to complete 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

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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 consistently 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 anxiety 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 positive 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 sessions 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

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80
70

Clinical cut-off

60
50
Pre-Treatment

40

Post-Treatment
Maintenance

30
20
10
0

CGAS-parent

CGAS-clinician

Impairment Rang Scale

3.5
3

Clinical cut-off

2.5
2
Impairment Rang
Scale

1.5
1
0.5
0

Pre-Treatment

Post-Treatment

Maintenance

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 Rating 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.

able to defeat them. Performance on his daily self-report card was associated with weekly parental 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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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 understanding 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 consistently 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 transitioned 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 prominent physical handicaps. With the manualized weekly treatment, he experienced clinically significant 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 descriptions, 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

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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 compulsions, 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 maintenance 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 manage 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 success. 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 accommodating 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 experience 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 incorporate 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 sessions 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

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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 protective 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 conceptualized 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 development. Therefore, it would be important that he be able to recognize his OCD and challenge it relatively 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 appropriate 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 measures of his progress (e.g., hierarchy, worry journal) provided a more comprehensive and clinically 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 understanding 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.

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This case study also provides preliminary support for booster sessions in the treatment of pediatric 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 pediatric 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 experiencing 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 recognizing his anxiety in the future. Furthermore, we believe that these sessions were critical in encouraging 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 follow 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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