Accepted Version
Accepted Version
Accepted Version
,
Heyman, I., Murphy, D. G. and Mataix-Cols, D. (2013) Cognitive
behavior therapy for comorbid Obsessive-Compulsive Disorder
in high functioning Autism Spectrum Disorders:A randomized
controlled trial. Depression and Anxiety, 30 (8). pp. 697-708.
ISSN 1091-4269
a
Russell, A.J*.,b Jassi, A.,c Fullana, M.A., b
Mack, H., abJohnston, K.,d
*Corresponding author
a
Dept. of Psychology, Kings College London, Institute of Psychiatry
b
South London and Maudsley NHS Trust
c
Dept. of Psychosis Studies, Kings College London, Institute of Psychiatry
d
Child and Adolescent Psychiatry, Kings College London, Institute of
Psychiatry
e
Dept. of Forensic and Neurodevelopmental Science, Kings College
Acknowledgements/Funding statements
1
This study was in part funded by NIHR-RP-PG-0606-1045
Dr Fullana was funded by a Marie Curie fellowship from the European Union
(no. 039668)
We would like to thank the South London and Maudsley NHS Foundation
2
Abstract
found effective for anxiety in young people with ASD but not been OCD
specific. One uncontrolled pilot study of individual CBT for OCD for adults
Methods: Forty-six adolescents and adults (mean age 26.9 years, 35 Males)
with ASD and comorbid OCD were randomized to CBT for OCD or Anxiety
in duration (mean of 17.4 sessions CBT; 14.4 sessions AM), the Yale Brown
within-group effect sizes of 1.01 CBT group and 0.6 for the AM group. There
sizes for self-rated improvement were small (0.33 CBT group; -0.05 AM
but not the CBT group. Family/carer factors were important for both groups,
3
in that increased family accommodation was associated with poorer
outcome.
4
Introduction
High rates of anxiety disorders have been reported in both young people 1
to be more likely related to fears in children with ASD than other groups7.
Co-morbid OCD has been reported to occur in 30% of young people with
ASD3,8 and high rates of OCD have also been reported in adults with ASD
both with and without intellectual disability9,10. OCD has considerable impact
on quality of life for both sufferers and carers and is listed in the World
5
There is emerging evidence that CBT may be effective in ameliorating
distressing and debilitating anxiety in people with ASD. Trials of Group CBT
interventions for anxiety symptoms 5 and anxiety disorders 13,14,15 adapted for
To date, most adult treatment studies of CBT in ASD have been confined to
single case reports – for example its effectiveness for depression16 and
from an uncontrolled pilot study of CBT for OCD in 24 adults with ASD and
co-morbid OCD: we found that of the 12 adults who received CBT for OCD,
response rates for behavior therapy (59%) and CBT (67%) in adults with
co-morbid OCD, in both young people and adults with ASD. Results of both
evidence that CBT may be effective for OCD in ASD as compared to TAU
but this requires replication and comparison with other potentially effective
6
The aims of the present study were to systematically evaluate CBT for OCD
adapted for people with ASD via a RCT comparing the new intervention with
METHODS
Participants
Participants were recruited from specialist ASD clinics, specialist adult and
pediatric OCD clinics and generic child and adult mental health services.
psychiatric medication was stable in the 6 weeks prior to study entry and if
severity rating of >16, typically used for inclusion in clinical trials 20. Diagnosis
7
Delineating anxiety based obsessions and compulsions from the repetitive
study10 which were detailed in the study manual. In brief, at the start of each
clinical interview care was taken to ensure that the participant was
basis for each potential OC symptom was clearly established using visual
each individual were also taken into account when administering the Y-
All participants read an information sheet and signed consent forms to take
8
Study design
A manual outlining ASD specific adaptations to standard CBT for OCD was
developed on the basis of a case note review of the pilot study18, expert
are reported. Standard cognitive behavior therapy (CBT) for OCD was
adapted by (i) ensuring the building blocks for treatment (i.e. understanding
moving on to present the rationale for treatment, (iii) visual tools and
(ERP) based and this was conducted in the usual hierarchal fashion both in
identified that an average of 10 (s.d. = 5.4) ERP homework tasks were set
and the compliance rate for ERP homework tasks was 79%. Cognitive
methods were also used to help individuals test out OCD and anxiety related
(AM) to ensure that any treatment effects were solely due to the adapted
CBT for OCD rather than therapist contact, psycho-education about anxiety
effectiveness.
The AM manual was developed for the present study by one of the authors
were adapted for ASD by including visual aides or concrete examples. The
about mood, healthy habits and problem-solving. The AM manual did not
related beliefs.
The treatments were matched for duration (up to 20 sessions) and amount of
Supplemental Material.
The treating therapists were all clinical psychologists (n=4) trained within a
OCD in both young people and adults. All had received post-qualification
basis. Three pilot cases (2 young people and 1 adult with ASD) were treated
with the CBT manual prior to commencing the RCT for feasibility and user
working more specifically with people with ASD and OCD. As therapists who
expertise in both adult and pediatric cases (DMC) provided supervision for
Randomization procedure
random numbers (1:1 ratio) managed by an investigator who was part of the
Review of the study protocol by the ethics committee recommended that the
treatment. Thus, participants were informed via the study information sheet
11
that they could try the other treatment at or after 1 month follow-up following
Outcome Measurement
commencing treatment (i.e. no more than 4 weeks before the 1st treatment
session), end of treatment (1 week after the final treatment session), and at
which they thought was the randomization group and if this was (a) a
12
group (i.e. cited (b) as the reason for their choice of treatment group). Blind
18 (45%) of cases clinical improvement was also cited as a reason for group
assignment.
Primary Outcome
rating was the primary outcome measure. In addition to the 10 item severity
scale, the insight item from the Y-BOCS (Y-BOCS item 11) was also
included with the interviewer being asked to document ‘what is the worst
thing that the patient worries will happen if she/he did not respond to
reasonable and will actually occur ranging from (0) ‘certain that the feared
consequence will happen’ to (5) ‘certain that the feared consequence will not
happen’.
define remission28 with remission lasting for longer than 1 month being
defined as recovery.
Secondary Outcome
13
A broad range of outcome measures, including assessment of other anxiety
Scales29
rated for severity (0-15) with a global rating considering severity overall and
Anxiety Inventory (BAI)33; Liebowitz Social Anxiety Scale (LSAS)34, and the
with the treatment they had received on an 8-point visual analogue scale
ranging from (0) ‘not at all satisfied’ to (8) ‘very much satisfied’.
14
Informant report (all participants) – A person who knew the participant well
impairment (0-24) and total impairment (0-48). Informants were also asked
home routines etc are rated on a 5 point scale with a possible maximum
There were modest but significant correlations between self and informant
15
Power analysis
Based on the data from the pilot study18 a sample size calculation showed
Data Analysis
changes in the AM and CBT groups. Effect sizes were calculated using
Cohen’s d. All of the analyses were intention to treat and where outcome
data was not available, pre-treatment scores were not carried forward 41.
Results
16
Participant flow
(22.6%) of these 75 individuals did not meet eligibility criteria for the study
(see Figure 1), 2 people were eligible but geography prevented participation
the study for equivalent periods of time. The mean number of weeks
(sd=10.37); CBT group =27.06 (sd=10.27). The mode or most usual length
17
Independent samples t-tests revealed no differences between the groups for
the mean domain and total scores on the ADOS, Verbal IQ, age, or pre-
The treatment groups did not differ with respect to gender distribution (AM
group 69.6%, CBT group 82.6% male), or the proportion of those under the
age of 18 (AM group n=6 (26.1%), CBT group n=3 (13%) youth protocol).
(39.1%) of the CBT group. The AM and CBT groups endorsed a mean of 3.1
Number of Sessions
18
The mean number of treatment sessions was marginally greater in the CBT
Table 3 shows, for blind clinical assessor, self and informant ratings, the
means and standard deviations for each measure at pre, post and 1 month
data, Y-BOCS and D-YBOCS ratings were available for all participants in
both groups at the start of treatment, 20 in the CBT group and 20 in the AM
group at the end of treatment, and 18 in the CBT and 17 in the AM group at
1 month follow-up. For the self-report measures, the OCI-R was completed
by 20, 17 and 17 in the CBT group and 19, 17 and 17 in the AM group at the
start, end and 1 month post treatment respectively. There was a similar rate
were completed by 15, 14 and 11 in the CBT group and 14, 11 and 9 in the
p=0.295).
Within-group treatment effect sizes on the YBOCS were large and could be
considered clinically meaningful in the CBT group (1.15) and medium in the
AM group (0.6).
response rate was not statistically significant (X2=1.72, df=1, p=.160). When
a more stringent rating of treatment response i.e. a CGI ‘much or very much
was considered, 6/20 (30%) of the CBT group achieved treatment response
compared with 2/20 (10%) of the AM group. Again the groups did not differ
participants in the CBT group were classified as remitted cases (i.e. with a
compared with the AM group (5/20 (20%) vs 3/20 (15%)) but this difference
20
was not statistically significant.
(mean CBT – mean AM/pooled). Effect sizes were 0.4 for the YBOCS total
severity rating, 0.4 for YBOCS obsessions severity, 0.2 for YBOCS
compulsions and 0.3 for Clinical Global Impression, all indicating a small
Treatment Satisfaction
In the CBT group, there were significant changes in YBOCS total severity
21
Cross-Over Cases
in the CBT group asked to ‘cross-over’ or try the other treatment either at or
CBT completed the second treatment and attended for symptom ratings
(AM+CBT). One participant was not available for end of treatment ratings
despite completing the treatment. There was a significant effect of this 2nd
treatment (F1,7= 7.703, p=.027) on the primary outcome measure when the
management.
did not vary by treatment group (F=2.28, df=1,34, p=.140). Figure 3 depicts
group rated as ‘much or very much improved’ (CBT group n=11; AM group
differences between pre-, post- and 1 month follow-up mean scores on any
Moderating Factors
Symptom Severity
(mean=26.8, sd=4.8; t=2.37 (df=17); p=.029, 95% C.I. 0.6-10.6). This was
not the case in the CBT group where responders and non-responders were
responder mean =24.8, sd=3.2; CBT non-responder mean =24.1, sd=4.4; t=-
df=15, p=.003, 95% C.I. 0.5-2.0). The AM responders did not differ in terms
Age was not significantly associated with treatment outcome. The main
entered the Youth protocol (Age 14-16) and this did not affect the pattern of
results.
Other variables
differ on the FAS at the end of treatment. There was a wide range of scores
on the FAS in the treatment response group at baseline and this reduced by
the end of treatment suggesting that family factors may have changed over
24
In terms of insight as ascertained by the Y-BOCS, 33 (71.7%) of all
Discussion
This is the first clinical trial to provide evidence for the effectiveness of CBT
for co-morbid OCD in young people and adults with ASD. The effect of CBT
people without ASD where aggregated effect sizes of 1.12 and 1.45 have
particularly those with milder symptoms. It was not possible to separate the
although there were twice as many responders in the CBT than in the AM
25
group. Comparison between the effect sizes of the two treatments afforded
This advantage for CBT was greater for ratings of obsessions. In an earlier
uncontrolled pilot study18 where CBT was compared with treatment as usual,
symptoms. Further, outcome for adults with ASD is known to be poor with
occupation, compulsive rituals may not present with a high level of daily
interference.
group than did CBT patients to the AM group after the 1-month follow-up
ratings, was not perceived as being as potentially useful as the ERP based
treatment. The 8 patients who crossed over from AM to CBT and provided
26
reductions in OCD severity, whereas those who crossed over from CBT to
Setting aside the not inconsequential issues of sample size and statistical
reducing obsessions with equivalent pre-post effect sizes for both treatments
based trial of self-help for panic and phobias 26, a similar anxiety
important to note that patients who responded to the control treatment had
27
Second, it is important to consider that OCD is not the only commonly
intervention in the present study (with its focus on education about anxiety
predictable and manageable emotion for some individuals. Risk factors for
sensitivity may be elevated in people with ASD who have a preference for
routine and sameness and this may represent a pathway to OCD. Increasing
about by uncertainty and anxiety may thus bring about a reduction in OCD
symptoms.
Further, the non-specifics of therapy may be more potent in this group who
can be socially isolated and lack support. The majority of clinical trials in
people with ASD have to date employed a wait list or treatment as usual
responders. Prior to their work on the present study, the majority of the
therapists had gained some experience of working with people with ASD as
part of generic anxiety/OCD clinic work. Only one of the therapists had
28
previously worked in an ASD-specific service. Thus the results should be
OCD.
and adults with ASD and this is consistent with findings from other studies47.
It is also important to note that many of the participants in the study had
good insight into their OCD and that OC related beliefs were prevalent.
There was some indication that family factors (family accommodation) were
associated with treatment outcome in the present study and this is consistent
treatment.
Limitations
particularly in individuals with mild OCD symptoms. This indicates that larger
between the groups. The results of the current trial will be useful to help
more accurate power calculations for future trials. However, the main
message of the current study is that standard CBT for OCD can be
difficult to treat.
symptoms in the CBT (60%) vs. the AM (40%) groups may also have
benefit from excluding any severe hoarding individuals from their samples.
The wide ranges of age and symptom severity may have had an impact on
the power available in a small pilot trial. However, we felt that as a proof of
(CBT) for longer than the 1-month follow-up and these patients had to be
treatment response.
both groups (15% AM and 10% CBT) were rated as minimally or much
It is possible that those lost to follow-up may also have deteriorated during
that period and thus the positive effects of the intervention may have been
for comorbid ASD and OCD. Further testing of these promising interventions
31
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Excluded (n=29):
Figure 1: Consort Flow Diagram
Assessed for Not meeting inclusion criteria:
eligibility (n= 75) No OCD (n=13) Epilepsy (n=1)
No ASD (n=2) VIQ< 70 (n=1)
Geography (n=2)
Refused to participate:
(n= 10)
Randomised
(n=46)
Attended (n=17)
Attended (n=18) 1 month follow- Did not attend (n=2)
Did not attend (n=2) up Cross-over to other treatment after
Cross-over to other treatment this point (n=9)
(n=3) Entered follow-up (n=11)
Entered follow-up( n=17)
37
Table 1: Correlations of Clinician, Informant and Self-report severity ratings of OC symptoms
Rating Informant Informant Informant Clinician Self- Self- Self- Self- Self-report
Obsessions Compulsions total total report report report report Neutralising
severity severity severity severity Washing Hoarding Ordering Obsessing
Clinician .481
Obsessions p=.020
severity n=23
Clinician .276
Compulsions p=.155
Severity n=28
Clinician total .576
severity p=.001
n=28
Self-report .482 .265
total severity p=.015 p=.108
n=25 n=38
Clinician .468
Contamination p=.003
severity n=39
Clinician .394
Hoarding p=.014
severity n=38
Clinician .374
Symmetry p=.019
severity n=39
Clinician .419 .462
Aggression p=.01 p=.003
Obs severity n=37 n=38
38
Table 2: Age, ADOS, Verbal IQ and Symptom Measures at pre-treatment
Anxiety CBT Group t (df) p
Management Mean (SD)
Group
Mean (SD)
39
Table 3; Pre and post treatment and 1 Month Follow-up clinician, self and informant ratings by group
Pre- Post 1 Month Pre-Post Pre-1MFUP Pre-Post % Pre-1MFUP Pre- Pre-
Treatment treatment FUP difference difference imp. % imp. Post 1MFU
Mean (SD) Mean (SD) Mean (SD) Mean 95% Mean 95% Mean (SD) Mean (SD) effect Effect
C.I. C.I. size size
CBT: Clinician ratings
YBOCS:
Total severity 24.8(3.7) 17.8(8.4) 18.7(8.2) 7.0 ** 3.2-10.7 5.8 ***. 2-9.7 27.8(33.2) 23.5(32.1) 1.078 .958
Obsessions severity 11.7(2.8) 8.7(4.1) 8.5(3.6) 2.9 ** 1.1-4.7 3.1 ** 1.4-4.7 24.0(34.7) 25.2(30.9) .854 .922
Compulsions severity 13.1(1.5) 9.0(4.6) 9.7(4.5) 4.0 ** 1.7-6.3 3.2 ** 0.9-5.5 29.7(36.5) 23.9(35.7) 1.198 1.013
CGI 4.2(0.8) 3.3(1.1) 3.5(1.3) 0.9 ***0.4-1.4 0.8 ** 0.2-1.4 21.4(21.8) 19.6(25.3) .935 .648
Dimensional YBOCS:
Contamination 7.3(4.1) 3.9(3.8) 4.5(3.8) 3.4 ** 1.4-5.3 2.6 ** 0.8-4.5 41.4(48.6) 34.2(41.3) .860 .708
Hoarding 3.5(3.9) 1.7(2.8) 1.7(2.8) 1.7 * 0.2-3.3 2.1 * 0.3-3.9 48.8(55.7) 53.4(49.5) .530 .530
Symmetry 5.3(4.5) 4.2(4.6) 4.6(4.4) 1.1 -.2-2.5 1.2 -.3-2.8 35.5(47.1) 34.9(48.0) .241 .157
Aggression/Harm 3.8(4.3) 2.6(4.0) 2.2(3.5) 1.2 -.1-2.5 1.8 * .2-3.4 29.9(61.7) 65.7(39.3) .288 .408
Sexual/Religious 2.0(3.1) 1.2(2.3) 1.3(2.5) 0.8 -.2-1.8 0.8 -.3-1.9 37.3(51.4) 34.7(52.8) .293 .248
Miscellaneous 3.2(4.1) 1.4(3.0) 1.6(3.5) 1.8 * 0.4-3.1 1.7 * .1-3.2 60.6(45.4) 58.5(52.6) .501 .419
Global total 20.7(3.8) 15.5(7.1) 15.8(7.0) 5.2 *** 2.5-7.8 5.0 ** 2.1-7.9 26.7(30.1) 25.4(30.9) .913 .870
CBT: Self-Ratings:
OCI-R total 31.5(12.7) 26.8(15.3) 29.3(12.9) 4.7 -1.3-10.7 1.3 -6.9-9.7 20.2(45.8) -32.1(97.4) .334 .171
BDI 16.2(13.8) 15.7(16.5) 17.5(15.1) -.5 -3.9-4.9 2.0 -2.9-6.9 17.9(58.3) 16.4(39.1) .032 -.089
BAI 16.4(10.6) 14.0(11.6) 13.6(10.1) 2.3 -0.8-5.5 1.5 -3.8-6.9 14.1(52.9) 26.5(36.0) .215 .270
Liebowitz total 74.7(27.1) 67.8(34.9) 66.2(35.7) 6.9 -9.8-23.7 -2.2-17.6-13 7.0(34.7) -20.3(46.2.1) .220 .268
Spence total 28.3(20.3) 49.0(n=1) 20.0 -28.9 -1.40
Work and Social 19.0(10.4) 22.4(11.7) 14.1(9.1) 3.4 -7.8-1.0 4.6 -3.9-13.1 -24.4(43.5) 8.4(53.5) -.307 .501
Adjustment Scale
CBT:Informant:
CHOCI severity 30.3(11.1) 25.8(10.5) 28.8(7.0) 4.5 2.1-11.1 2.7-7.5-13.0 4.9(41.1) -3.2(41.2) .416 .161
Family Acc. 26.9(15.2) 27.9(15.0) 21.1(9.3) -1 -11-8.9 6.3 -5.8-18.4 -33.1(90.1) 1.4(71.3) -.066 .460
40
Pre- Post 1 Month Pre-Post Pre-1MFUP Pre-Post % Pre-1MFUP Pre- Pre-
Treatment treatment FUP difference difference imp. % imp. Post 1MFU
Mean (SD) Mean (SD) Mean (SD) Mean 95% Mean 95% Mean (SD) Mean (SD) effect Effect
C.I. C.I. size size
AM: clinician ratings
YBOCS:
Total severity 25.1(5.1) 20.8(7.8) 20.7(5.4) 4.7 ***2.5-6.8 3.8 ***2.1-5.6 20.3(23.4) 16.2(14.3) .652 .837
Obsessions severity 12.4(3.0) 10.5(3.8) 11.9(2.3) 2.0 ** 0.9-3.0 2.2 ***1.2-3.3 17.6(21.9) 19.7(17.9) .554 .187
Compulsions 12.9(2.8) 10.3(4.7) 10.8(3.0) 2.7 ** 1.1-4.3 1.9 * 0.9-3.1 22.5(30.6) 13.1(20.8) .672 .723
CGI 4.2(0.8) 3.7(1.1) 3.7(1.2) 0.5 ** 0.2-0.8 0.6 ** 0.1-0.9 13.9(18.4) 14.9(19.6) .519 .490
Dimensional YBOCS:
Contamination 5.8(4.3) 4.8(4.8) 4.9(4.4) 1.0 -.5-2.5 0.8 -.6-2.2 22.3(69.6) 27.6(45.0) .219 .206
Hoarding 2.9(3.8) 2.5(3.6) 2.0(3.4) 0.3 -1.4-2.1 0.8 -1.4-3.1 54.9(36.0) 68.7(39.2) .108 .249
Symmetry 5.4(4.3) 4.6(3.9) 3.7(3.7) 0.8 -.6-2.2 2.0 * .2-3.7 21.8(40.8) 43.1(43.2) .194 .423
Aggression/Harm 6.5(4.4) 5.3(4.6) 4.5(4.1) 1.2 -.1-2.6 2.1 * .27-3.9 29.4(37.7) 36.8(41.7) .266 .470
Sexual/Religious 1.6(3.4) 2.2(4.2) 2.2(4.2) -.6 -2.4-1.2 -1.0 -2.8-.8 52.5(55.0) 19.5(14.7) -.157 -.157
Miscellaneous 3.3(4.2) 1.6(4.7) 1.1(2.2) 1.6 * 0 .2-3.0 1.9 * -0.2-3.9 58.9(46.8) 51.5(50.8) .381 .656
Global total 20.3(4.7) 17.1(7.5) 17(5.9) 3.2 ** 1.1-5.2 2.9 ** 1.3-4.5 18.5(27.1) 15.7(14.9) .511 .524
AM: self-ratings:
OCI-R total 30.3(11.9) 30.9(13.4) 31.1(14.4) -.5 -5.2-4.2 -.06 -4.6-4.5 -4.3(28.7) -.68(23.5) -.047 -.060
BDI 17.1(12.4) 17.5(12.0) 18.8(12.3) -.4 -5.2-4.3 -1.3 -7.2-4.6 -10.2(60.3) -16.7(85.9) -.032 -.137
BAI 16.6(12.2) 17.2(12.7) 15.4(13.1) -.5 -5.6-4.5 -.6 -4.0-5.4 -23.1(97.5) 4.3(60.2) -.048 .094
Liebowitz total 72.4(29.1) 78.8(43.7) 76.4(37.1) -5.7 -29-17.6 -3 -15.3-19.1 -11.0(56.9) -0.5(30.4) -.172 -.119
Spence total 27.5(3.5) 36.5(13.4) 36.0(14.1) -7 -95-81.9 -8.5-103-86.7 -23.3(32.9) -28.6(34.8) -.919 -.827
Work and Social 17.9(9.5) 17.2(7.5) 15.7(6.3) 0.6 -4.9-6.2 .92 -4.6-6.5 -28.6(85.9) -50.6(167.9) .081 .272
Adjustment Scale
AM:Informant:
CHOCI severity 27.8(12.7) 21.0(13.5) 20.3(15.4) 6.8 * -.1-13.7 4.1 -4.4-26.6 21.6(56.7) 19.9(48.1) .518 .531
Family Acc. 20.8(13.1) 22.3(17.2) 17.8(17.1) -1.5 -9.1-6.1 .2 -9.7-12.2 -7.0(50) 5.0 (55.7) -.098 .196
AM=anxiety management, 1MFUP=one month follow-up ratings
Significance of change on 2-tailed related test *<.05, **<.01, ***<.001
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Figure 2: YBOCS total severity (pre and end treatment, 1M FUP) by
treatment group and 3 (n=10), 6 (n=12) and 12M (n=11) FUP for CBT group
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YBOCS total severity
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AM
15
CBT
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Figure 3: Percentage of participants rated as ‘minimally improved, unchanged or
worse’ and ‘much or very much improved’ on the Clinical Global Improvement
Scale by treatment group
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Description of the treatments
CBT treatment
The duration of each session ranged from 41 to 74 minutes (mean session
length=60 minutes, s.d=7.5). Homework was set at every session, which
included reading materials from the session, completing OCD diaries and
exposure tasks. The compliance rate for homework was 90%, although this
included even partial completion of the homework tasks. On average 10
(s.d=5.4) ERP tasks were set as homework throughout treatment and the
compliance rate for these was 79%. The mean compliance rate for other
homework such as reading materials and keeping records was 89%. In
terms of session content and how the treatment was generally structured, a
mean of 2.7 sessions (s.d=1.6, range 1-6) comprised anxiety education;
OCD education was included in 3 to 13 sessions (mean=5.8, s.d.=2.9);
Exposure and Response Prevention (ERP) was covered in up to 16 sessions
(mean=8.6, s.d.=5.3) and a mean of 2.7 sessions (s.d.=3.2) included
cognitive intervention techniques. Relapse prevention took between 0 to 2
(mean=1, s.d.=0.7) sessions.
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‘more directive’ in sessions for 5 (25%) of participants, 1 (5%) participant
needed rules for the sessions, 6 (30%) needed reference to concrete
examples, 9 (45%) needed visual aids and 6 (30%) of participants’
parents/carers were directly involved in sessions.
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