Behavioral Therapy Said to Treat Kids' Compulsive Disorder Best

CANBERRA, Australia, Oct. 19 -- Behavioral or cognitive behavioral therapy, with or without medication, is the top choice against obsessive-compulsive disorder in children and adolescents, according to a systematic Cochrane review.

While behavioral therapy alone was as good as Zoloft (sertraline), Anafranil (clomipramine) and Luvox (fluvoxamine) at reducing repetitive actions, the combination was significantly more effective than medication alone, said Richard O'Kearney, Ph.D., of the Australian National University here, and colleagues.

However, "there is still insufficient evidence to be able to specify the preferred sequence of treatments for pediatric obsessive compulsive disorder," noted the authors in the review published in the Oct. 18 issue of The Cochrane Library.

Behavioral therapy involves exposure to the anxiety-producing triggers and then preventing the compulsive behavior. It is recommended as the treatment of choice for pediatric obsessive-compulsive disorder by the American Academy of Child and Adolescent Psychiatry primarily on the basis of conclusions reached in adult studies.

Behavioral therapy was effective compared with no treatment. In the four studies reviewed, 37% to 88% fewer children had obsessive-compulsive disorder after treatment. This corresponded to a drop of eight points on the gold standard outcome measure of symptoms for the condition, the Children's Yale-Brown Obsessive Compulsive Scale, CY-BOCS.

Outcomes were not significantly different between behavioral therapy and medication (weighted mean difference -3.87, 95% confidence interval -8.15 to 0.41).

Compared with medication alone, the combination of behavioral therapy and psychotropic drugs significantly improved compulsive behaviors in children and adolescents (weighted mean difference -4.55, 95% CI -7.40 to -1.70). However, the combination was not superior to behavioral therapy alone (weighted mean difference -2.80, 95% CI -7.55 to 1.95).

The four randomized or quasi-randomized clinical trials included in the review involved 222 participants with ages ranging from seven years to 18 years two months. Boys and girls were equally represented in each study. Participants were diagnosed by clinical assessment or standardized diagnostic interview.

Behavioral interventions in the studies ranged from 12 to 20 sessions, each for 60 to 90 minutes, for a total of 30 hours, 21 hours, 14 hours, or 12 hours.

Three studies used a medication comparison group. One of these used both medication and pill placebo comparison arms. The fourth used individuals on a wait list as controls. Dosing was reported as:

• Zoloft at 150 mg daily for the combined group and 200 mg in the medication alone group,
• Anafranil at 2.5 mg/kg of body weight with a range of 1.4 mg/kg to 3.3 mg/kg, and
• Luvox at least 200 mg per day.

The researchers found that the number of participants who continued to have compulsive behaviors (defined as more than 10 points on the Children's Yale-Brown Obsessive Compulsive Scale) after behavioral treatment was:

• Significantly less than those receiving placebo in the least biased study (relative risk 0.63, 95% CI 0.46 to 0.86),
• Significantly reduced compared to children and adolescents on a wait list (RR 0.13, 95% CI 0.04 to 0.36) in one study, and
• Similarly fewer in another study compared to participants on a wait list (RR 0.24, 95% CI 0.13 to 0.46).

Compared with medication alone, Dr. O'Kearney and colleagues found that the efficacy of behavioral therapy was:

• Equivalent to that of Anafranil (weighted mean difference -8.50, 95% CI -17.44 to 0.44), and
• Not significantly different from Zoloft (weighted mean difference -2.50, 95% CI -7.37 to 2.37).

The studies also consistently found no difference in the number of participants who remained disordered after treatment between behavioral therapy and medication alone. The findings were:

• Behavioral therapy alone and medication alone had equivalent proportions continuing to have symptoms after treatment in the pooled analysis (RR 0.75, 95% CI 0.54 to 1.05),
• There was no difference between Anafranil and behavioral therapy (RR 0.69; 95% CI 0.30 to 1.61), and
• There was no difference between Zoloft and behavioral therapy (RR 0.77, 95% CI 0.54 to 1.10).

The combination of behavioral therapy and medication was superior to Luvox alone in symptom improvement (weighted mean difference -4.55, 95% CI -7.40 to -1.70). The combination with Zoloft was:

• Not significantly different compared with behavioral therapy alone for symptom improvement (weighted mean difference -2.80, 95% CI -7.55 to 1.95),
• Not significantly different compared with behavioral therapy alone for the number who continued to have the disorder after treatment (RR 0.76, 95% CI 0.47 to 1.26), and
• Significantly better compared with Zoloft alone for the number who still had the disorder after treatment (RR 0.59, 95% CI 0.38 to 0.92).

The investigators noted that they did not find a high rate of treatment refusal or drop-out (8.1% to 14.8% and 8.3% to 10.7%, respectively) with behavioral therapy, which has been one of its suggested disadvantages.

Health professionals need to consider this therapy, Dr. O'Kearney said, particularly in view of the controversy about prescribing psychotropic medications to children and adolescents.

However, the decision to try behavioral therapy may be influenced by other factors, such as patient preference, the availability of skilled practitioners, cost, and the patient's treatment history, he added.

The prevalence of obsessive-compulsive disorder in childhood is estimated as 0.5% to 4%.

The review was supported by the Australian National University.