Psychiatry Research 220 (2014) 441–446

Contents lists available at ScienceDirect

Psychiatry Research
journal homepage: www.elsevier.com/locate/psychres

A baseline controlled examination of a 5-day intensive treatment

for pediatric obsessive-compulsive disorder
Stephen P.H. Whiteside a,n, Dean McKay b, Alessandro S. De Nadai c, Michael S. Tiede a,
Chelsea M. Ale a, Eric A. Storch c,d,e
a
Department of Psychiatry and Psychology, Mayo Clinic, Rochester, MN, USA
b
Department of Psychology, Fordham University, Bronx, NY, USA
c
Departments of Pediatrics and Psychiatry & Behavioral Neurosciences, University of South Florida, St. Petersburg, FL, USA
d
Rogers Behavioral Health – Tampa Bay, Tampa, FL, USA
e
All Children's Hospital – Johns Hopkins Medicine, St. Petersburg, FL, USA

art ic l e i nf o a b s t r a c t

Article history: This study extends support for a 5-day intensive exposure and response prevention (ERP) treatment
Received 6 September 2013 protocol for pediatric obsessive compulsive disorder (OCD). Twenty-two children with OCD received ERP
Received in revised form treatment twice daily for 5 days. The treatment also emphasized teaching children and parents how to
30 June 2014
conduct ERP independently after they returned home. Symptoms were assessed at four time-points:
Accepted 6 July 2014
Available online 12 July 2014
Baseline, 4 weeks later at pre-treatment, one week after the intensive treatment 5-day treatment, and at
3 month follow-up. Changes on the primary outcome measure, clinician severity ratings on the Anxiety
Keywords: Disorders Interview Schedule for Children, and secondary measures, indicated that OCD symptoms
Child remained stable from the evaluation to baseline and improved significantly from baseline to follow-up.
Cognitive behavioral therapy
Moreover, parental accommodation of OCD decreased significantly from baseline to post-treatment and
Anxiety disorders
from post-treatment to follow-up. These data suggest that the 5-day intervention demonstrates efficacy
Outcome study
Exposure/response prevention in reducing OCD symptoms and may initiate change in parent accommodation that continues to improve
after the family returns home.
& 2014 Elsevier Ireland Ltd. All rights reserved.

1. Introduction Until the quantity of specially trained mental health providers can
be increased, other methods to expand the accessibility of effective
Obsessive-compulsive disorder (OCD) occurs in approximately treatments need to be pursued. One such alternative is to modify
1–2 of every 100 children and adolescents (Flament et al., 1988; existing treatments to be administered in a time-limited period. By
Valleni-Basile et al., 1994,1996) and is associated with significant providing intensive treatment (i.e., daily sessions over a short time-
impairment in social, academic, and family functioning (Piacentini frame), families may be able to travel to a specialty OCD clinic and
et al., 2003). Exposure and response prevention (ERP), the most reside in that location for the duration of treatment. Although an
well-researched psychosocial intervention for OCD (e.g., March extended stay associated with intensive treatment adds additional
and Leonard, 1996), has been demonstrated to be effective in costs, it may be more feasible than weekly office visits, or the only
children (POTS, 2004; Abramowitz et al., 2005; Watson and Rees, option for families that live at significant distance from a treatment
2008; Storch et al., 2013) and is considered a first-line treatment center. It also may be more cost-effective in the long run compared to
(American Academcy of Child and Adolescent Psychiatry, 2012). ongoing suboptimal or non-empirically supported treatment. In
Despite its established efficacy, ERP is not widely available in addition, providing treatment in an intensive format may actually
community outpatient settings (Goisman et al., 1993; Valderhaug increase its effectiveness, at least initially, by maximizing learning
et al., 2004; Storch et al., 2007b) and efforts to disseminate through massed practice, focusing the patient's attention on treat-
empirically supported treatments have been met with consider- ment, and allowing close monitoring of compliance (Schmidt and
able obstacles, such as the cost of training, the questionable Bjork, 1992; Storch et al., 2007b). However, one drawback is that
influence of continuing education courses, and negative beliefs massed learning may also be associated with greater return of fears
held by practitioners (Addis, 2002). (Abramowitz et al., 2003; Storch et al., 2007b). Thus, specific research
into intensive formats for ERP is necessary.
The currently existing intensive protocols that provide daily
n
Corresponding author. ERP for OCD over three to four weeks have been found to be of

http://dx.doi.org/10.1016/j.psychres.2014.07.006
0165-1781/& 2014 Elsevier Ireland Ltd. All rights reserved.
442 S.P.H. Whiteside et al. / Psychiatry Research 220 (2014) 441–446

comparable effectiveness to treatment delivered once or twice (i.e., Storch et al., 2007b). However, this initial study had several
a week (Franklin et al., 1998; Abramowitz et al., 2003; Storch et al., limitations, including being uncontrolled, having the majority of
2007b). Franklin et al. (2001) suggested that intensive ERP may be the patients treated by a single therapist, and relying on child- and
the treatment of choice for patients that have severe symptoms, parent-report at follow-up.
have not responded to traditional treatment, or are not available Demonstrating the effectiveness of a 5-day treatment protocol
for daily sessions. In the only randomized trial to date, Storch et al. would have a number of benefits. First, since seeking intensive
(2007b) compared a 3-week program for pediatric OCD to 14 treatment away from home requires considerable costs to the
weekly sessions of ERP. In this study of 40 patients, intensive and family (e.g., travel, lodging, time away from school and work)
weekly treatments were associated with equivalent decreases in reducing the duration to a single work week will substantially
the Children's Yale-Brown Obsessive Compulsive Scale (CY-BOCS; decrease the burden of receiving care. Second, the successful
m ¼15.7 and 15.6, respectively). Similarly, in the largest study of integration of ERP and training parents to be exposure coaches
intensive OCD treatment to date, Storch et al. (2008) found that a would provide additional support for a model of using parents to
similar percentage of adults no longer met the criteria for OCD increase the efficiency and effectiveness of standard weekly
following a 3-week intensive treatment, 40.7%, and weekly treatment for OCD and related anxiety disorders.
treatment, 52.3%. The present study provides a more rigorous examination of the
Despite the success of these intensive programs, a three- to four- efficacy of the intensive 5-day treatment for pediatric OCD than
week treatment protocol places a considerable burden on families has been previously conducted. Patients were recruited from two
staying away from home. Specifically, receiving specialty care out- geographically different sites and treated by multiple therapists.
side one's home area involves travel expenses, missed school, Data was collected at baseline, after a four-week waiting period,
missed work for one or both parents, lodging, and meals away from one-week after the intensive treatment, and 3-months after the
home. Such costs are substantial for the most researched treatment intensive treatment. It was hypothesized that pediatric OCD
protocols that last 3 weeks (Storch et al., 2007b,2008). To decrease symptoms would remain stable during the waiting period,
these ancillary costs by at least two-thirds we developed a protocol decrease moderately following the week of intensive treatment,
to be administered twice daily over 5 days (Whiteside et al., 2008). and continue to decline after the children returned home. With
Similar to some non-intensive protocols (e.g., Barrett et al., 2004), regards to secondary outcomes, it was expected that participants
parents are included in every session, but with a specific emphasis would experience improvements in OCD-related impairment,
on receiving hands-on training in exposures coaching to maximize reduced family accommodation, and reduced anxiety and depres-
generalizability and increase the likelihood that therapeutic tasks sive symptoms.
will be implemented after the intensive week. In addition, including
parents directly targets family accommodation. Addressing accom-
2. Methods
modation is essential given that research has shown that it functions
to maintain and potentially increase obsessive-compulsive symptom
2.1. Participants
severity (Lewin et al., 2005).
An initial feasibility study of the 5-day treatment protocol
Participants included 22 children and adolescents seen across two sites (Mayo
suggested that the treatment was tolerable (i.e., 15 of the 16 Clinic, n¼ 14, and Fordham University n¼ 8). Participants learned of the intensive
patients participated in all sessions) and effective (Whiteside and treatment from a variety of sources including other providers, professional organ-
Jacobson, 2010). Specifically, scores on the Children's Yale-Brown izations, and/or listings on websites (e.g., Mayo Clinic, The International OCD
Obsessive Compulsive Scale (CY-BOCS) decreased significantly Foundation, clinical trial registries). Fig. 1 provides a full accounting of recruitment
and eligibility.
from pre-treatment to post-treatment (d ¼2.07) and from post- The youth consisted of 15 males and 7 females ages 7 to 18 (m¼ 12.59,
treatment to follow-up (d ¼0.91) with reductions comparable to S.D.¼ 3.1), all of whom met criteria for OCD. The patients were primarily
those with standard weekly and 3-week intensive ERP protocols Caucasian (90.5%) from intact families (75%) with educated parents (90% some

Received Received Baseline Enrolled Tx Completer

information Evaluation N = 22 (14) n = 20 (12)
N = 85 (54) N = 27 (17)

Not interested Failed phone Failed Baseline Tx dropout

n = 35 (19) screening Assessment n = 2 (2)
n = (23) 18 n = 5 (3)

Reasons Reasons Reasons

e.g., later 14 (12)-Med 2- OCD not
date, found tx change primary
closer to 5 (3)-prev 2- CSR <4
home, no ERP 1-med change
reason given 2 (2)-outside
age range
1 (1)- in
hospital
1 (0)-suicidal

Fig. 1. Overview of recruitment and eligibility for total sample (Mayo Clinic site in parentheses).
 S.P.H. Whiteside et al. / Psychiatry Research 220 (2014) 441–446 443

post-secondary). Diagnoses were based on a clinical assessment conducted by an with OCD symptom severity, impairment, and familial stress, and negatively
independent evaluator which included a structured diagnostic interview correlated with family organization and functioning (Calvocoressi et al., 1995;
(Silverman and Albano, 1996). Sixteen of the patients had one or more comorbid Storch et al., 2007a; Peris et al., 2008; Storch et al., 2010).
diagnoses, the most common being generalized anxiety disorder (n ¼6), attention
deficit/hyperactivity disorder (n¼ 5), specific phobia (n¼ 4) and major depressive
2.3. Procedure
disorder (n ¼4). All patients had a primary diagnosis of OCD based on the
symptoms emphasized by the family, the clinical interview, and severity ratings
on the structured interview of 4 or greater. 2.3.1. Assessment
The majority (n¼ 19; 86%) of the patients had received some previous All potential participants were initially screened during a telephone conversa-
treatment (18 therapy, 13 medication, 13 both therapy and medication). Thirteen tion with a parent and ruled out if there was psychosis, bipolar disorder, significant
of the patients had a current or previous trial of a selective serotonin reuptake suicidal ideation, low intellectual functioning, or a history of adequate ERP. After
inhibitor, four of a atypical antipsychotic, three of a benzodiazepine, three of a obtaining informed parent consent and child assent, the child and the parent were
stimulant, two of clomipramine, and one each of an anticonvulsant, buproprion, interviewed via videophone with the ADIS:C, CY-BOCS, and family accommodation
and diphenhydramine. Of the 13 patients that had received medications, eight had items, and were asked to return the completed questionnaires via mail (baseline).
taken more than one (range 1–13, m¼ 3). Previous and current psychotherapy Treatment was then scheduled four weeks later. Upon arrival at the clinic, after the
included general psychotherapy (13), non-ERP cognitive behavioral therapy (5), baseline waiting period, the child's symptoms were reassessed (pre-treatment)
incomplete ERP (2), and one each of biblical therapy, eye-movement desensitiza- with the OCD portion of the ADIS:C, CY-BOCS, and family accommodation items
tion and reprocessing, and a wilderness camp. For participants concurrently taking administered in a face-to-face evaluation that included a clinical interview and
medication, it was required that medication dosage remain stable for at least questionnaires. Approximately 7 days after returning home (post-treatment) and
3 months prior to the initial assessment and throughout the study period until the 3 months later (follow-up) the OCD portion of the ADIS:C, CY-BOCS, and family
3 month follow-up. accommodation items were completed with the child and parent via webcam
and the family returned questionnaires via mail. The post-treatment evalua-
tion assessed the patients’ symptoms over the past 7 days since the end of the
intensive week.
2.2. Measures
An independent evaluator not involved in the patient's treatment completed all
assessments. Following a study start-up meeting in which the first, second, and last
Anxiety Disorders Interview Schedule for DSM-IV: Child Version (ADIS:C; authors established inter-rater reliability and procedures for clinician-administered
Albano and Silverman, 1996). The ADIS:C is a semi-structured diagnostic interview assays (i.e., ADIS:C, family accommodation items, CY-BOCS), site specific indepen-
of childhood anxiety disorders as well as mood and externalizing disorders. The dent evaluators (clinical psychology graduate students or post-doctoral fellows)
ADIS:C has good interviewer–observer reliability, test–retest reliability, and con- were trained and supervised by the first and second authors.
struct validity (Wood et al., 2002). Diagnostic decisions were based on interview of
the child and parent together. For all endorsed diagnoses the interviewer provided
2.3.2. Treatment
a clinician's severity rating (CSR), which ranges from 0 to 8 with scores 4 and above
The 5-day intensive treatment program consisted of traditional ERP as
considered to be indicative of the presence of a disorder. Re-administration of the
described in commonly-used OCD treatment protocols for adult and pediatric
ADIS CSR as an outcome measures is common in the treatment outcome literature
OCD (Kozak and Foa, 1997; March and Mulle, 1998). Following reassessment the
for childhood anxiety disorders (e.g., Beidel, Turner, & Morris, 2000; Simon, Bogels,
morning of day 1, a total of 10 individual 50-min sessions occurred during the week
& Voncken, 2011; Spence, Holmes, March, & Lipp, 2006; Wuthrich et al., 2012),
(one each morning, one each afternoon), although sessions could last longer (up to
including after intervals as short as one-week in the assessment intensive
75 min) in order to give anxiety time to decrease with exposures (a total of
treatments (e.g., Ost et al., 2001; Santucci and Ehrenreich-May, 2013).
6 session exceeded 62 min, one at Mayo Clinic, five at Fordham University). Each
Children's Yale-Brown Obsessive Compulsive Scale (CY-BOCS; Scahill et al., 1997).
family met with the same therapist at each session. Given the brevity of treatment,
The CY-BOCS is a semi-structured clinical interview that includes a 10-item OCD
added emphasis was placed on training the youth and the parent to conduct
severity scale. Obsessions and compulsions are rated on five-point Likert-type
exposures independent of the therapist. Between sessions 3 and 9 the parent
scales from zero (no symptoms) to four (severe symptoms) along five dimensions.
gradually transitioned from observing the therapist conduct exposures to conduct-
Two sub-scores (obsessions and compulsions) are added to produce a total score
ing the full-exposure under therapist's supervision. The families were instructed to
(range 0–40). The CY-BOCS has satisfactory reliability (internal consistency¼ 0.90,
conduct one exposure after each of these sessions. Two phone calls were scheduled
test–retest ¼0.79) and validity (correlation with the a parent rating of OCD symp-
over the 10-days following the intensive week to help the family continue ERP at
toms¼0.70; Storch et al., 2004). The CY-BOCS correlates with self-reported OCD
home. Therapists were subsequently available via phone as needed. Therapists
symptoms (0.62; Scahill et al., 1997) and is sensitive to change with treatment
documented an average of 1.6 contacts (phone or email) with the families over the
(POTS, 2004; Storch et al., 2013). Due to an administrative error, CY-BOCS data is
3 months following the intensive week (range 0–8).
only available from the Mayo Clinic site.
The treatment had three goals: a) Educate the parent and youth on the cognitive-
Spence Children's Anxiety Scale-Child and Parent Versions (SCAS-C/P; Spence,
behavioral conceptualization of OCD, its maintenance, and treatment through ERP;
1998). The SCAS-C/P are Likert-type self- and parent-report questionnaires
b) Provide the adolescent with initial symptom reduction through exposure,
designed to measure anxiety in children and adolescents. The SCAS-C/P yield a
response prevention, and habituation to feared stimuli; and c) Train the parent to
total score with six subscales: panic attacks and agoraphobia, separation anxiety,
plan and coach the child through exposures by participating in both in-session and
physical injury fears, social phobia, obsessive-compulsive, and generalized anxiety.
between-session exposures. The general structure of therapy did not differ based on
Only the total subscale was included in the current study as a measure of overall
the child's age as younger children and older adolescents were all seen with their
anxiety symptoms. Reliability and validity data are robust (Spence, 1998; Muris et
parents. The manner in which parents interacted with their children and the degree
al., 2000,2002).
of indepdence provided to the patients reflected the child's developmental level and
Child Obsessive Compulsive Impact Scale (COIS; Piacentini and Jaffer, 1999). The
engagement in therapy. Treatment was provided by therapists with varying back-
COIS is a child self- (COIS-C) or parent-report (COIS-P) measure used to assess OCD-
grounds (master's level clinicians, post-doctoral psychology fellows, and psychology
related functional impairment in children with OCD. COIS items address difficulties
doctoral students), under the supervision of child psychologists specializing
in academics (16 items), social functioning (19 items), and home/family functioning
in OCD. Further detail of the treatment protocol is available in Whiteside and
(17 items). There are four additional questions that assess global impairment
Jacobson, 2010.
related to the previously mentioned domains. The COIS has demonstrated good
Therapy integrity was monitored through therapists completing a session
treatment sensitivity (Piacentini et al., 2002; Storch et al., 2007b), construct validity
checklist of 58 treatment components and through audio recordings of sessions.
(Piacentini et al., 2003), and internal consistency (for parent and child versions,
On average the therapists indicated that they provided 57 of the 58 items (range
Cronbach's alpha ¼ 0.97; (Piacentini et al., 2002).
47–58). The one low score likely reflects a recording error. In addition, the session
Children's Depression Inventory (CDI; Kovacs, 2003). The CDI is a 27-item self-
recordings for 29 sessions (13%) were reviewed to rate therapist completion of
report questionnaire used to assess depressive symptoms in children over the past
assigned tasks and overall competence. On a scale ranging from 0 (not at all/no
2 weeks. Each item measures a single depressive symptom using groups of
competence) to 4 (completely/expert) the therapists were rated an average of 3.77
3 statements and the sum of all items yields a total score. The CDI has been shown
(adequately to completely) for completed session tasks and 3.35 for competence
to have good internal consistency (Cronbach's alpha¼ 0.91; (Wagner et al., 2003).
(highly to expert). Patients were instructed not to receive additional treatment
Family Accommodation Items (FAI). Family accommodation was measured via
(therapy or medication changes) during the course of the study, including the 1-
interview using items from Calvocoressi et al. (1999). These 13 items are designed
month before treatment and the 3 months following the intensive week. The one
to assess family members’ involvement in the child's OCD symptomology (e.g.,
patient that reported seeking treatment prior to the 3-month follow-up assessment
participating in or enabling rituals, providing reassurance, and altering family
also withdrew from the study.
schedules) and the degree of distress when symptoms are not accommodated.
Items are assessed on a 0 to 4 scale over the past month, with higher scores
corresponding to more family accommodation. The measure has good internal 2.3.3. Analytic plan
consistency (Cronbach's alpha ¼0.88) and construct validity (Caporino, et al., 2012; Changes over time in symptoms and functioning for continuous variables were
Storch et al., 2007a; Peris et al., 2008). Total scores have been positively correlated evaluated via dependent t-tests, with sequential comparisons conducted between
444 S.P.H. Whiteside et al. / Psychiatry Research 220 (2014) 441–446

baseline, pre-treatment, post-treatment, and 3-month follow up. In addition, to observed for the ADIS CSR, t(12.6) ¼5.06, p o0.001, d ¼1.34; CY-
consider longer-term gains, we compared pre-treatment scores to 3-month follow
BOCS, t(10.9)¼7.25, p o0.001, d ¼1.98; COIS-P, t(14.6) ¼3.66,
up scores. Dichotomous remission rates were compared across time points via tests
of the difference between binomial proportions. Effect sizes for continuous p¼ 0.002, d¼ 0.90; COIS-C, t(12.5)¼2.64, p ¼0.021, d¼ 0.70; SCAS-
variables were computed in the metric of Cohen's d where d values of 0.2, 0.5, C, t(14.6)¼3.38, p ¼ 0.004, d ¼0.83; SCAS-P, t(15.1) ¼4.45, p ¼0.001,
and 0.8 correspond to small, medium, and large effect sizes, respectively (Cohen, d¼ 1.07; and family accommodation items, t(15.8)¼ 5.38,
1988), and the p o 0.05 level was used to determine statistical significance. Site po 0.001, d ¼1.27. In considering the percentage of patients who
differences at pre-treatment were evaluated via independent t-tests, and site
differences as a direct result of treatment (i.e., from pre-treatment to post-
continued to have clinical severity of OCD symptoms (i.e., ADIS
treatment) were evaluated via ANCOVAs with site and pre-treatment scores as CSRZ 4), imputed models found that 94.9% of patients met this
predictors of post-treatment scores. criterion at pre-treatment, whereas 49.0% and 34.7% met this
Missing data was addressed by PROC MI in SAS 9.3 (SAS Institute, 2011) using criterion at post-treatment and follow up, respectively. The
predictive mean matching via the fully conditional specification method, where
decrease in those meeting criteria for OCD was significant from
scores from the measure under consideration (e.g., ADIS CSR) at all measured time
points were included in imputation models. Following recommendations by pre- to post-treatment (p o0.001) and from pre-treatment to
Graham (2009), missing data was in the acceptable range for multiply-imputed follow-up (p o0.001).
models (34%) and all time points were included in imputation models to serve as
auxiliary covariates, which can take data that is not missing at random and produce
estimates that are consistent with those that meet the missing at random
assumption (Donaldson and Moinpour, 2005). Degrees of freedom for multiply 4. Discussion
imputed hypothesis-testing models were adjusted based on recommendations by
Barnard and Rubin (1999) (which can result in fractional degrees of freedom), and The current study increases support for the efficacy of a 5-day
100 imputations were employed. Due to an administrative error, CY-BOCS data is intensive treatment for pediatric OCD. As in the previous feasi-
only available from one of the two sites, and only data from the site that
administered the CY-BOCS were used for analyses involving the CY-BOCS (n¼ 14).
bility study (Whiteside and Jacobson, 2010), youth and their
parents were able to tolerate and benefit from the 10 h of ERP
over 5 consecutive days. The current study extends the previous
findings by increasing the methodological rigor of the assess-
3. Results ments, demonstrating change with multiple therapists across two
sites, and including a baseline control period.
All the 22 participants who began the 5-day intensive treat- One weakness of the previous feasibility study was the reliance
ment completed all 10 sessions. Two participants declined to on data collected as part of routine clinical practice by the
participate in follow up data collection. Descriptive statistics and therapist, including the sole use of self- and parent-report without
effect sizes for differences between all time points can be found structured interview for post-treatment and follow-up data. The
in Table 1. There were no differences in age or sex between sites. data in the current study were collected by an independent
There was no effect of age on outcome. Site differences at the evaluator at each time-point who, while unblinded, was not
baseline assessment were observed for ADIS CSR ratings [t(20.0) ¼ involved in treatment. By including a no-treatment waiting period,
2.27, p ¼0.035, d¼ 1.13], but not for any other analyzed variables. the current study suggests that the changes observed with treat-
Significant improvements in symptoms from baseline to pre- ment were not attributable to the passage of time. The clinician
treatment assessment were observed for the CDI-SF, t(11.2) ¼ rated outcome variables of symptom severity and family accom-
2.93, p ¼0.014, d ¼0.82, and SCAS-C, t(14.4) ¼2.44, p ¼0.028, modation, as well as parent- and child-report of OCD impairment,
d ¼0.60, but not for the other study measures. did not improve significantly during the baseline period, but did
In considering the immediate effects of treatment, changes change with treatment (with the exceptions of depressive symp-
from pre- to post-treatment were observed for the ADIS CSR, toms). The lack of improvement with no-treatment is consistent
t(15.6)¼ 3.63, p ¼ 0.002, d¼ 0.86; CY-BOCS, t(11.0)¼ 5.05, p o0.001, with previous studies demonstrating that OCD symptoms do not
d ¼1.37; SCAS-P, t(15.9) ¼3.18, p¼ 0.006, d ¼0.75; and family tend to improve spontaneously over time (Barrett et al., 2004;
accommodation items, t(15.8)¼4.39, p ¼0.001, d ¼1.04. Site differ- POTS, 2004). The current study also increases the generalizability
ences from pre- to post-treatment were not detected for any study of the treatment protocol. While primarily one practitioner saw
variables. Continued reduction in symptoms from post-treatment the participants in the initial feasibility study, the current study
to follow up was significant for the CY-BOCS, t(10.4) ¼3.58, included multiple therapists with different levels of training across
p ¼0.005, d ¼1.00, and family accommodation items, t(13.3) ¼ multiple sites. These results suggest that a variety of therapists
2.49, p¼ 0.027, d ¼ 0.65. With regard to the longer-term effects of (with previous training in ERP for OCD) can successfully imple-
treatment, improvement from pre-treatment to follow up were ment the 5-day protocol.

Table 1
Descriptive statistics and effect sizes computed from the present sample.

Measure Baseline M (S.D.) Pre-treatment M (S.D.) d1 Post-treatment M (S.D.) d2 Follow up M (S.D.) d3 d4

ADIS CSR 5.95(1.36) 5.65(1.45) 0.30 3.98(2.31) 0.86 2.83(2.20) 0.43 1.34
CY-BOCSa 24.79(4.28) 25.00(5.55)  0.05 15.67(5.24) 1.37 10.11(4.81) 1.00 1.98
COIS-P 28.78(15.28) 27.93(13.27) 0.07 18.79(13.87) 0.55 15.30(8.72) 0.24 0.90
COIS-C 26.61(16.19) 24.81(15.64) 0.13 23.33(15.41) 0.09 15.21(11.44) 0.50 0.70
CDI-SF 6.57(4.60) 4.71(4.82) 0.82 4.19(3.78) 0.19 4.35(3.50)  0.04 0.08
SCAS-P 34.95(18.07) 36.66(17.82)  0.13 22.73(15.56) 0.75 17.83(13.98) 0.40 1.07
SCAS-C 45.56(18.97) 37.33(17.72) 0.60 30.61(18.13) 0.34 21.87(12.03) 0.53 0.83
FAI 20.76(9.87) 23.46(9.09)  0.41 13.46(8.95) 1.04 7.67(9.15) 0.65 1.27

Note: d1 ¼ Effect size for difference between baseline and pre-treatment; d2 ¼ Effect size for difference between pre-treatment and post-treatment; d3 ¼ Effect size for
difference between post-treatment and follow up, and d4 ¼ Effect size for difference between pre-treatment and follow up.
Abbreviations: ADIS CSR ¼ Anxiety Disorders Interview Schedule Clinical Severity Rating; CY-BOCS ¼Child Yale-Brown Obsessive-Compulsive Scale; COIS-P/C ¼ Child
Obsessive-Compulsive Impact Scale Parent and Child Versions; CDI-SF ¼Children's Depression Inventory-Short Form; SCAS-P/C ¼ Spence Children's Anxiety Scale Parent and
Child Versions; FAI ¼Family Accommodation Items.
a
Due to an administrative error, CY-BOCS data is only available from the Mayo Clinic site (n¼14).
 S.P.H. Whiteside et al. / Psychiatry Research 220 (2014) 441–446 445

With the more rigorous methodology, the current study docu- information regarding inter-rater reliability would strengthen the
mented improvement with the 5-day intensive treatment in three results and allow for examination of inter-site differences. Finally,
areas: symptom severity, functional impairment, and family the lack of CY-BOCS data from one site limits the ability to bench-
accommodation. First, symptom severity decreased based on mark symptom improvement across sites to that found with other
clinician interview with parents and children, with models indi- studies.
cating that at follow-up 65% of the sample no longer meet the Within these limitations, the current study increases the
criteria for OCD. Second, the intervention improved functioning support for the efficacy of the 5-day intensive treatment for
due to OCD. This is a particularly important achievement as pediatric OCD. Because of its short duration, this protocol provides
reduction of symptoms without return to normal life activities is a more feasible option for families that do not have access to
an inadequate outcome. Finally, parental accommodation of their effective care in their home area, rather than providing a replace-
child's OCD symptoms decreased. Moreover, the lack of an age ment for weekly therapy. In addition, the approach to training
effect suggests that including parents in treatment is feasible with parents to implement exposures provides a template for improv-
adolescents as well as with children. ing the efficacy and efficiency of standard weekly therapy for
It is interesting to note that all symptom measures, with the pediatric OCD and other anxiety disorders.
exception of depression, continued to decrease from post-
treatment to follow-up, including the number of patients no
longer meeting diagnostic criteria. It is hypothesized that provid- References
ing parents in-session training to be exposure coaches and
discussing how to generalize those coaching principles to replace Abramowitz, J.S., Foa, E.B., Franklin, M.E., 2003. Exposure and ritual prevention for
obsessive-compulsive disorder: effects of intensive versus twice-weekly ses-
accommodation with exposure contributed to this continued sions. Journal of Consulting and Clinical Psychology 71, 394–398.
improved. This theory is supported by a significant decrease in Abramowitz, J.S., Whiteside, S.P., Deacon, B.J., 2005. The effectiveness of treatment
family accommodation from post-treatment to follow-up. How- for pediatric obsessive-compulsive disorder: A meta-analysis. Behavior Therapy
36, 55–63.
ever, because engagement in exposure exercises was not measured Addis, M.E., 2002. Methods for disseminating research products and increasing
directly, the current study cannot confirm this hypothesis. The evidence-based practice: promises, obstacles, and future directions. Clinical
pattern of decreasing symptoms after sessions have been discon- Psychology: Science and Practice 9, 367–378.
Albano, A.M., Silverman, W.K., 1996. Anxiety Disorders Interview Schedule for
tinued is in contrast to other OCD studies where gains are
DSM-IV Child Version: Clinical Manual. Graywind Publications Incorporated,
maintained at follow-up, but do not continue to improve (e.g., USA.
Barrett et al., 2004). However, in standard weekly-ERP more American Academcy of Child and Adolescent Psychiatry, 2012. Practice parameter
for the assessment and treatment of children and adolescents with obsessive-
complete improvement may be achieved at post-treatment,
compulsive disorder. Journal of the American Academy of Child and Adolescent
usually around week 14, potentially creating a floor effect. Psychiatry 51, 98–113.
Overall, the current data support the effectiveness of therapy Barnard, J., Rubin, D.B., 1999. Small-sample degrees of freedom with multiple
directly involving parents in the completion of exposures. Not only imputation. Biometrika 86, 948–955.
Barrett, P.M., Healy-Farrell, L., March, J.S., 2004. Cognitive-behavioral family treat-
does this approach have the potential to increase the accessibility ment of childhood obsessive-compulsive disorder: a controlled trial. Journal of
of ERP by shortening its length, it also has implications for the American Academy of Child and Adolescent Psychiatry 43, 46–62.
exposure treatment delivered in a traditional format. Specifically, Beidel, D.C., Turner, S.M., Morris, T.L., 2000. Behavioral treatment of childhood
social phobia. Journal of Consulting and Clinical Psychology 68 (6), 1072–1080.
the number of sessions required to administer weekly exposure Calvocoressi, L., Lewis, B., Harris, M., Trufan, S.J., Goodman, W.K., McDougle, C.J.,
therapy for OCD (typically over 3–4 months), or other anxiety et al., 1995. Family accommodation in obsessive-compulsive disorder. The
disorders, could potentially be decreased by training parents to American Journal of Psychiatry 152, 441–443.
Calvocoressi, L., Mazure, C.M., Kasl, S.V., Skolnick, J., Fisk, D., Vegso, S.J., Van Noppen,
implement exposures with their child. Minimizing the number of B.L., Price, L.H., 1999. Family accommodation of obsessive-compulsive symp-
required treatment sessions decreases treatment-related burden toms: Instrument development and assessment of family behavior. Journal of
for the family, including time and money, while also increasing Nervous and Mental Disease 187, 636–642.
Caporino, N.E., Morgan, J., Beckstead, J., Phares, V., Murphy, T.K., Storch, E.A., 2012. A
access to well-trained providers. structural equation analysis of family accommodation in pediatric obsessive-
The current study has limitations. To begin with, the design compulsive disorder. Journal of Abnormal Child Psychology 40, 133–143.
does not compare outcomes for the 5-day treatment to other Cohen, J., 1988. Statistical Power Analysis for the Behavioral Sciences. Lawrence
Erlbaum Associates, Hillsdale, NJ.
intervention options. Further research should compare the 5-day
Donaldson, G.W., Moinpour, C.M., 2005. Learning to live with missing quality-of-life
approach to longer 3-week intensive protocols and to treatment- data in advanced-stage disease trials. Journal of Clinical Oncology 23,
as-usual in the children's home areas, which would also allow for 7380–7384.
the inclusion of blind assessors. Without a comparison group it is Flament, M.F., Whitaker, A., Rapoport, J.L., Davies, M., Berg, C.Z., Kalikow, K., Sceery,
W., Shaffer, D., 1988. Obsessive compulsive disorder in adolescence: an
impossible to determine the degree to which symptom change epidemiological study. Journal of the American Academy of Child and Adoles-
was attributable to general therapeutic contact. Moreover, it will cent Psychiatry 27, 764–771.
be important to extend the results to a more diverse sample, given Franklin, M.E., Kozak, M.J., Cashman, L.A., Coles, M.E., Rheingold, A.A., Foa, E.B.,
1998. Cognitive-behavioral treatment of pediatric obsessive-compulsive dis-
that the present sample was predominately Caucasian and highly order: an open clinical trial. Journal of the American Academy of Child and
educated. Adolescent Psychiatry 37, 412–419.
The current study also does not examine what actions families’ Franklin, M.E., Tolin, D.F., March, J., Foa, E.B., 2001. Treatment of pediatric obsessive-
compulsive disorder: a case example of intensive cognitive-behavioral therapy
took, other than decreasing accommodation, during the post- involving exposures and ritual prevention. Cognitive and Behavioral Practice 8,
treatment phase that may have contirbuted to the continued 297–304.
decline in symptoms. Although patients were asked to refrain from Goisman, R.M., Rogers, M.P., Steketee, G.S., Warshaw, M.G., Cueneo, P., Keller, M.B.,
1993. Utilization of behavioral methods in a multicenter anxiety disorders
receiving treatment outside the study and no families reported such study. Journal of Clinical Psychiatry 54, 213–218.
treatment, this information was not systematically recorded, nor Graham, J.W., 2009. Missing data analysis: making it work in the real world. Annual
were families prohibited from seeking care if needed. Thus, further Review of Psychology 60, 549–576.
Kovacs, M., 2003. Children's Depression Inventory (CDI): Technical Manual Update.
studies should more thoroughly examine family engagement in
Multi-Health Systems Inc, North Towanda, NY.
exposure and additional treatment during the follow-up period. Kozak, M.J., Foa, E.B., 1997. Mastery of Obsessive-Compulsive Disorder: A Cognitive-
Moreover, further studies should examine whether more struc- Behavioral Approach. Graywind Publications Inc., San Antonio.
tured follow-up such as booster sessions or use of technology for Lewin, A.B., Storch, E.A., Merlo, L.J., Adkins, J.W., Murphy, T., Geffken, G.A., 2005.
Intensive cognitive behavioral therapy for pediatric obsessive compulsive
problem-solving exposures in the home environment could lead to disorder: a treatment protocol for mental health providers. Psychological
more post-treatment symptom improvement. In addition, more Services 2, 91–104.
446 S.P.H. Whiteside et al. / Psychiatry Research 220 (2014) 441–446

March, J.S., Leonard, H.L., 1996. Obsessive-compulsive disorder in children and Storch, E.A., Geffken, G.R., Merlo, L.J., Jacob, M.L., Murphy, T.K., Goodman, W.K.,
adolescents: a review of the past 10 years. Journal of the American Academy of et al., 2007a. Family accommodation in pediatric obsessive-compulsive dis-
Child and Adolescent Psychiatry 35, 1265–1273. order. Journal of Clinical Child and Adolescent Psychology 36, 207–216.
March, J.S., Mulle, K., 1998. OCD in Children and Adolescents: A Cognitive- Storch, E.A., Geffken, G.R., Merlo, L.J., Mann, G., Duke, D., Munson, M., Adkins, J.,
Behavioral Treatment Manual. Guilford Press, New York. Grabill, K.M., Murphy, T.K., Goodman, W.K., 2007b. Family-based cogntive-
Muris, P., Merckelbach, H., Ollendick, T., King, N., Bogie, N., 2002. Three traditional behavioral therapy for pediatric obsessive-compulsive disorder: comparison of
and three new childhood anxiety questionnaires: their reliability and validity in intensive and weekly appraoches. Journal of the American Academy of Child &
a normal adolescent sample. Behaviour Research and Therapy 40, 753–772. Adolescent Psychiatry 46, 469–478.
Muris, P., Schmidt, H., Merckelbach, H., 2000. Correlations among two self-report Storch, E.A., Larson, M.J., Muroff, J., Caporino, N., Geller, D., Reid, J.M., Morgan, J.,
questionnaires for measuring DSM-defined anxiety disorder symptoms in Jordan, P., Murphy, T.K., 2010. Predictors of functional impairment in pediatric
children: the screen for child anxiety related emotional disorders and the spence obsessive-compulsive disorder. Journal of Anxiety Disorders 24, 275–283.
children's anxiety scale. Personality and Individual Differences 28, 333–346. Storch, E.A., Merlo, L.J., Lehmkuhl, H., Geffken, G.R., Jacob, M., Ricketts, E.,
Ost, L.G., Svensson, L., Hellstrom, K., Lindwall, R., 2001. One-session treatment of Murphy, T.K., Goodman, W.K., 2008. Cognitive-behavioral therapy for obses-
specific phobias in youths: a randomized clinical trial. Journal of Consulting and sive–compulsive disorder: a non-randomized comparison of intensive and
Clinical Psychology 69, 814–824. weekly approaches. Journal of Anxiety Disorders 22, 1146–1158.
Pediatric OCD Treatment Study (POTS), 2004. Cognitive-behavior therapy, sertra- Storch, E.A., Murphy, T.K., Geffken, G.R., Soto, O., Sajid, M., Allen, P., Roberti, J.W.,
line, and their combination for children and adolescents with obsessive- Killiany, E.M., Goodman, W.K., 2004. Psychometric evaluation of the Children's
compulsive disorder: the pediatric ocd treatment study (pots) randomized Yale-Brown Obsessive-Compulsive Scale. Psychiatry Research 129, 91–98.
controlled trial. Journal of the American Medical Association 292, 1969–1976. Storch, E.A., Bussing, R., Small, B.J., Geffken, G.R., McNamara, J.P., Rahman, O.,
Peris, T.S., Bergman, L., Langley, A., Chang, S., McCracken, J.T., Piacentini, J., 2008. Lewin, A.B., Garvan, C.S., Goodman, W.K., Murphy, T.K., 2013. Randomized,
Correlates of accommodation of pediatric obsessive-compulsive disorder: placebo-controlled trial of cognitive-behavioral therapy alone or combined
parent, child, and family characteristics. Journal of the American Academy of
with sertraline in the treatment of pediatric obsessive-compulsive disorder.
Child and Adolescent Psychiatry 47, 1–9.
Behaviour Research and Therapy 51, 823–829.
Piacentini, J., Bergman, R.L., Jacobs, C., McCracken, J.T., Kretchman, J., 2002. Open
Valderhaug, R., Gotestam, K.G., Larsson, B., 2004. Clinicians’ views on management
trial of cognitive behavior therapy for childhood obsessive–compulsive dis-
of obsessive-compulsive disorders in children and adolescents. Nordic Journal
order. Journal of Anxiety Disorders 16, 207–219.
of Psychiatry 58, 125–132.
Piacentini, J., Bergman, R.L., Keller, M., McCracken, J., 2003. Functional impairment
Valleni-Basile, L.A., Garrison, C.Z., Jackson, K.L., Waller, J.L., McKeown, R.E.,
in children and adolescents with obsessive-compulsive disorder. Journal of
Addy, C.L., Cuffe, S.P., 1994. Frequency of obsessive-compulsive disorder in a
Child and Adolescent Psychopharmacology 13, S61–S69.
community sample of young adolescents. Journal of the American Academy of
Piacentini, J., Jaffer, M., 1999. Measuring Functional Impairment in Youngsters with
Child and Adolescent Psychiatry 33, 782–791.
OCD: Manual for the Child OCD Impant Scale (COIS). UCLA Department of
Valleni-Basile, L.A., Garrison, C.Z., Waller, J.L., Addy, C.L., McKeown, R.E.,
Psychiatry, Los Angeles.
Santucci, L.C., Ehrenreich-May, J., 2013. A randomized controlled trial of the child Jackson, K.L., Cuffe, S.P., 1996. Incidence of obsessive-compulsive disorder in a
anxiety multi-day program (camp) for separation anxiety disorder. Child community sample of young adolescents. Journal of the American Academy of
Psychiatry and Human Development 44, 439–451. Child and Adolescent Psychiatry 35, 898–906.
SAS Institute, 2011. SAS/STAT User's Guide. SAS Institute, Cary, NC (Version 9.3). Wagner, J.L., Chaney, J.M., Hommel, K.A., Page, M.C., Mullins, L.L., White, M.M., et al.,
Scahill, L., Riddle, M.A., McSwiggin-Hardin, M., Ort, S.I., King, R.A., Goodman, W., 2003. The influence of parental distress on child depressive symptoms in
Cicchetti, D., Leckman, J.F., 1997. Children's yale-brown obsessive compulsive juvenile rheumatic diseases: the moderation effect of illness intrusiveness.
scale: reliability and validity. Journal of the American Academy of Child and Journal of Pediatric Psychology 28, 453–462.
Adolescent Psychiatry 36, 844–852. Watson, H.J., Rees, C.S., 2008. Meta-analysis of randomized, controlled treatment
Schmidt, R.A., Bjork, R.A., 1992. New conceptualizations of practice: common trials for pediatric obsessive-compulsive disorder. Journal of Child Psychology
principles in three paradigms suggest new concepts for training. Psychological and Psychiatry 49, 489–498.
Science 3, 207–217. Whiteside, S.P., Brown, A.M., Abramowitz, J.S., 2008. Five-day intensive treatment
Silverman, W.K., Albano, A.M., 1996. The Anxiety Disorders Interview Schedule for for adolescent OCD: a case series. Journal of Anxiety Disorders 22, 495–504.
Children for DSM-IV: (Child and Parent versions). Psychological Corporation, Whiteside, S.P., Jacobson, A.B., 2010. An uncontrolled examination of a 5-day
San Antonio, TX. intensive treatment for pediatric OCD. Behavior Therapy 41, 414–422.
Simon, E., Bogels, S.M., Voncken, J.M., 2011. Efficacy of child-focused and parent- Wood, J.J., Piacentini, J.C., Bergman, R.L., McCracken, J., Barrios, V., 2002. Concurrent
focused interventions in a child anxiety prevention study. Journal of clinical validity of the anxiety disorders section of the Anxiety Disorders Interview
child and adolescent psychology 40, 204–219. Schedule for DSM-IV: Child and Parent Versions. Journal of Clinical Child and
Spence, S.H., 1998. A measure of anxiety symptoms among children. Behaviour Adolescent Psychology 31, 335–342.
Research and Therapy 36, 545–566. Wuthrich, V.M., Rapee, R.M., Cunningham, M.J., Lyneham, H.J., Hudson, J.L.,
Spence, S.H., Holmes, J.M., March, S., Lipp, O.V., 2006. The feasibility and outcome of Schniering, C.A., 2012. A randomized controlled trial of the cool teens CD-
clinic plus internet delivery of cognitive-behavior therapy for childhood ROM computerized program for adolescent anxiety. Journal of the American
anxiety. Journal of Consulting and Clinical Psychology 74, 614–621. Academy of Child and Adolescent Psychiatry 51, 261–270.