Exposure Response Prevention Pdf 108083 | Concentrated Exposure And Response Prevention For Adolescents With Ocd

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Journal of Obsessive-Compulsive and Related Disorders 11 (2016) 13–21
Contents lists available at ScienceDirect
Journal of Obsessive-Compulsive and Related Disorders
journal homepage: www.elsevier.com/locate/jocrd
Concentrated exposure and response prevention for adolescents with
obsessive-compulsive disorder: An effectiveness study
a,b,c, a,b b,d,e c b
n
Eili N. Riise , Gerd Kvale , Lars-Göran Öst , Solvei Harila Skjold , Hans Hansen ,
Bjarne Hansena,b
a Department of Clinical Psychology, University of Bergen, Norway
b Haukeland University Hospital, OCD-team, Bergen, Norway
c Øyane Outpatient Clinic for Child and Adolescent Psychiatry, Haukeland University Hospital, Bergen, Norway
d Department of Clinical Neuroscience, The Karolinska Institute, Stockholm, Sweden
e Department of Psychology, Stockholm University, Sweden
articleinfo abstract
Article history: This study evaluated the effectiveness of a concentrated exposure and response prevention (ERP)
Received 24 May 2016 treatment for adolescents with obsessive-compulsive disorder (OCD). Twenty-two adolescents with OCD
Received in revised form (range 11–17 years) received therapist-assisted ERP during four consecutive days, followed by a three
16 July 2016 week period of self-administered ERP. Treatment was delivered to 2–3 patients and their parents si-
Accepted 19 July 2016 multaneously at an outpatient clinic for child and adolescent psychiatry as part of standard health care.
Available online 8 August 2016 OCD-symptoms were assessed at pre-treatment, post-treatment, 3- and 6-month follow-up. The results
Keywords: demonstrated that patients had signiﬁcant reduction in OCD-symptoms from pre- to post-treatment and
Children the gains were maintained at follow-up. 91% (n¼20) were classiﬁed as responders at post-treatment,
Obsessive-compulsive disorder and 77% (n¼17) at six-month follow-up. Remission rates were 73% (n¼16) at post-treatment and 68%
Exposure and response prevention (n¼15)atsix-month follow-up. OCD-related impairment and symptoms of anxiety and depressionwere
Cognitive-behavioral therapy signiﬁcantly reduced at post-treatment and follow-up. The results suggest that concentrated ERP is a
Intensive
promising treatment for adolescents with OCD.
&2016 Elsevier Inc. All rights reserved.
1. Introduction (McGuire et al., 2015; Öst et al., 2016) and the need for improving
recovery rates calls for alternative approaches of delivering CBT.
Obsessive-compulsive disorder (OCD) affects 1–2% of children For patients without local access to qualiﬁed CBT-therapists,
and adolescents (Canals, Hernández-Martínez, Cosi, & Voltas, attending weekly sessions for 10–14 weeks might be both costly
2012; Zohar, 1999) and about 75% have comorbid conditions and time consuming. Even for patients and parents living close to
(Geller et al., 2000; Geller et al., 2001). It causes functional im- the clinic, weekly sessions might be inconvenient, as it often leads
pairments in the family, at school and socially (Piacentini, Berg- to recurrent absence from school and work. A reduced number of
man, Keller, & McCracken, 2003). Cognitive-behavioral therapy clinic visits might be a possible solution to these practical chal-
(CBT) involving exposure and response prevention (ERP) is em- lenges. A brief CBT format for pediatric OCD with only 5 sessions
pirically supported in several RCTs and about 70% of patients re- over 12 weeks has been found to be as effective as standard CBT
spond to treatment (McGuire et al., 2015; Öst, Riise, Wergeland, (Bolton et al., 2011), however the ﬁndings are not consistent. In
Hansen, & Kvale, 2016). It is recognized as ﬁrst line treatment for POTS II, a brief version of CBT was investigated, and the results
OCDinchildrenandadolescents(Geller&March,2012).Individual demonstrated that the combination of SRIs and brief CBT was less
CBT is the most common treatment format for pediatric OCD and effective than SRIs combined with full CBT. The symptom severity
is typically delivered over 10–14 weeks, with weekly sessions at baseline in POTS II was higher than what was reported by
ranging from 45–90min (Öst et al., 2016). The empirical basis for Bolton et al. (2011), suggesting that brief CBT might not be a sa-
the standard format is well-documented (Skarphedinsson et al., tisfactory approach in more severe cases (Mataix-Cols & Marks,
2014). Still, symptom remission is seen in only 50–60% of patients 2006). One possible explanation might be the reduced number of
therapy sessions in brief CBT and the dependence on self- ad-
n Corresponding author at: Department of Clinical Psychology, University of ministered ERP, which has been found to be less effective than
Bergen, Norway. therapist-assisted ERP (Abramowitz, 1996; Rosa-Alcázar, Sánchez-
E-mail address: eili.riise@uib.no (E.N. Riise). Meca, Gómez-Conesa, & Marín-Martínez, 2008).
http://dx.doi.org/10.1016/j.jocrd.2016.07.004
2211-3649/& 2016 Elsevier Inc. All rights reserved.
14 E.N. Riise et al. / Journal of Obsessive-Compulsive and Related Disorders 11 (2016) 13–21
CBT delivered more intensively has the beneﬁt of reducing the to individually tailor treatment and to conduct therapist-assisted
duration of treatment while retaining the amount of therapist- ERP. Considering the beneﬁts of both individual and group treat-
assisted ERP. Intensive approaches have been successfully deliv- ment, it is possible that treatment delivered in a group combined
ered to adolescents with OCD lasting from ﬁve days (Whiteside & with one-to-one contact between patient and therapist during
Jacobsen, 2010) to three weeks (Lewin et al., 2005). Storch et al. ERP, would increase the efﬁcacy of treatment. This allows for
(2007) demonstrated that a three-week treatment with 14 daily greater ﬂexibility when tailoring and carrying out ERP, while the
sessions (90 min) was as effective as weekly CBT. The treatment therapeutic beneﬁts of group treatment are preserved.
produced large effect sizes even in samples of partial or non-re- Our research group has demonstrated that a concentrated Ex-
sponders to SRI's (Storch et al., 2010). However, attending daily posure Treatment (cET) format [developed by the second and last
sessions for three weeks might still be challenging to organize author (GK and BH)] delivered in a group-setting yields promising
within busy family schedules. Whiteside and Jacobsen (2010) re- results (Havnen, Hansen, Öst, & Kvale, 2014).1 The treatment is
duced the time span of the treatment further and reported pro- delivered over four consecutive days with individually tailored and
mising results from a ﬁve-day intensive treatment, which was therapist-assisted ERP. After a thorough psychoeducation on Day 1,
delivered to children and adolescents in 50-min sessions twice ERPis delivered Day 2 and 3 in prolonged sessions lasting a whole
daily (Whiteside & Jacobsen, 2010; Whiteside et al., 2014). They work day, with continued self-administered ERP tasks in the
found large effect sizes at post-treatment with continued reduc- evening. On the last treatment day patients are taught strategies
tion in symptoms from post-treatment to follow-up. Their ﬁndings for maintaining the change and further self-administered ERP
demonstrated that even in samples with severe OCD, treatment tasks for the next three weeks are planned. The treatment has
can be successfully delivered over only ﬁve days. This is especially demonstrated promising results in the treatment of adult OCD
encouraging in the treatment of pediatric OCD, as longer duration (Havnen et al., 2014; Havnen, Hansen, Öst, & Kvale, 2016). In the
of symptoms is associated with higher OCD-persistence (Stewart adult version, the treatment is delivered to groups of 5–6 patients
et al., 2004) and increased levels of comorbid disorders (Diniz with a patient-therapist ratio of 1:1. The treatment for adolescents
et al., 2004). If OCD patients can return to normal functioning after has the same patient-therapist ratio, but includes parents, and is
only ﬁve days of treatment, this might have important long-term delivered to 2–3 patients simultaneously. Further, the psychoe-
implications for the adolescents. ducation is customized to adolescents and both a parent and a
Intensive ERP treatment is a promising approach for children family session is conducted. The aim of the current paper is to
and adolescents, and might offer an attractive treatment alter- evaluate the treatment effect of cET delivered to adolescents. We
native for many patients as impairing symptoms may be treated in believe that the current study adds to the literature of pediatric
a short period of time. Another potential advantage of delivering OCD treatment both in terms of delivering therapy in an con-
the treatment over a few days is that the amount of distracting centrated all-day format, and by the unique approach of delivering
elements (e.g. school, social life) are reduced and ERP can be the individual treatment to patients and parents (with a one-to-one
patients’ primary focus during treatment. Previous trials of in- contact between patient and therapist) in a group-setting.
tensive treatment adhere to sessions of 90 min duration daily (e.g.
Storch et al., 2007) or 50 min sessions delivered twice daily (e.g.
Whiteside et al., 2014). The time limits of the standard sessions 2. Method
may potentially impede ﬂexibility when conducting therapist-as-
sisted ERP. Conducting exposures in multiple contexts, with 2.1. Participants
variability (Craske, Treanor, Conway, Zbozinek, & Vervliet, 2014)
and under supervision of a therapist (Abramowitz, 1996; Rosa- Thetreatmentinthecurrentstudywaspartofstandardclinical
Alcázar et al., 2008) have been underscored as important features outpatient care at the OCD treatment unit, Haukeland University
to improve the effect of treatment. Prolonged sessions permit Hospital, Bergen, Norway, which is part of the general national
greater ﬂexibility and facilitate the application of such elements. It health services. The unit serves OCD-patients younger than 18
allows for numerous variations of therapist-assisted ERP and years of age, and all OCD-patients in a catchment area of ap-
makes exposures across contexts (i.e. home, school, public places) proximately 420,000 inhabitants are referred to this unit from
more feasible. Prolonged exposure sessions has been successfully local psychiatric clinics for children and adolescents. All patients
applied for other anxiety disorders in children and adolescents fulﬁlling the DSM-IV/DSM-5 diagnosis (American Psychiatric As-
such as speciﬁc phobia (Davis, Ollendick, & Öst, 2012; Ollendick sociation,1994) of OCD were offered treatment, except for patients
et al., 2009), social phobia (Donovan, Cobham, Waters, & Occhi- who were suicidal, psychotic or in active substance abuse. Diag-
pinti, 2015), separation anxiety (Santucci & Ehrenreich-May, 2012), noses were based on the administration of K-SADS-PL (Kaufman
and panic disorder with agoraphobia (Gallo, Chan, Buzzella, et al., 1997). Patients under 11 years of age, patients who were
Whitton, & Pincus, 2012). To our knowledge, the use of prolonged hospitalized and patients with comorbid mental retardation or
sessions in the treatment of adolescents with OCD has not pre- pervasive developmental disorder were not offered cET, but stan-
viously been investigated. dard weekly ERP (March & Mulle, 1998).
CBT delivered to groups of adolescents with OCD has also A total of 65 patients were referred. Of these, 22 were offered
shown promising results (
Asbahr et al., 2005; Barrett, Healy-Far- cET, 19 did not have OCD, and 12 had OCD but were offered in-
rell, & March, 2004). Group treatment provides the possibility to dividual treatment [outside age range (n¼7), did not want group
share and get feedback on own efforts in ERP tasks and it has been treatment (n¼2), mental retardation (n¼1), autism (n¼1), hos-
argued that the group setting increases the patient's treatment pitalized (n¼1)]. 12 patients did not receive any treatment due to
adherence, motivation and effort (e.g. Farrell, Waters, Milliner, & the following reasons: recovered (n¼6), declined treatment (n
Ollendick, 2012). Barrett et al. (2004) found that adolescents re- ¼4), treatment postponed by patient (n¼1), psychosis (n¼1). The
ceiving group CBT had larger reductions in other anxiety symp- sample consisted of 15 males (68%) and 7 females (32%) in the age
toms as compared to individual CBT. Their ﬁndings suggest that range11–17 (M¼13.3,SD¼1.6).Sevenof thepatients had divorced
there might be additional beneﬁts of group treatment, a possible parents and lived with one of their parents part-time or full time,
explanation being the effect of peer normalization and support.
Nevertheless, group treatment provides less one-to-one therapist
contact than individual treatment and makes it more challenging 1 The cET manual is currently under translation to english.
E.N. Riise et al. / Journal of Obsessive-Compulsive and Related Disorders 11 (2016) 13–21 15
and 15 of the adolescents lived with both their parents. All the Higher scores indicate more anxiety symptoms. The GAD-7 is a
treated patients were Caucasian (mother or father Scandinavian). valid and reliable measure of anxiety for adults and adolescents
At pre-treatment, the mean CY-BOCS score was 28.0 (SD¼4.06). (Lowe et al., 2008; Spitzer et al., 2006). Cronbach's α was 0.88 in
Twopatients(9.1%) wereclassiﬁed with moderate OCD (16–23),14 the current sample.
patients (63.6%) with severe OCD (24–31), and 6 patients (27.3%) Child OCD Impact Scale – Revised (COIS-R) (Piacentini, Peris,
with extreme OCD (32–40). Mean duration of OCD symptoms, as Bergman, Chang, & Jaffer, 2007) assesses OCD-speciﬁc functional
reported by patients and parents, was 2.2 years (SD¼1.6) and 13 impairment of children and adolescents at home, school, and so-
patients (59.1%) had previously received psychological treatment. cially. There are separate child and parent questionnaires each
Of these 9 (69%) reported having received ERP, and 4 (31%) had consisting of 33 items, in which higher scores indicate more severe
undergone other forms of psychotherapy. functional impairment. Parents and patients are asked to rate how
Nine patients (40.9%) had comorbid disorders. Six patients much the OCD has caused problems in various tasks (e.g. “leaving
(27.3%) had one comorbid diagnosis and three patients (13.6%) had the house”, “concentrating on his / her work”). The questions are
two or more comorbid diagnoses. Comorbidity included depres- scored on a 4-point Likert scale from 0 (not at all) to 3 (very
sion (n¼4) speciﬁc phobia (n¼3), social phobia (n¼2), adjust- much). The parent version has four subscales measuring impair-
ment disorder (n¼1), Tourette's syndrome (n¼1), and agor- mentinfourdifferent areas; socially, school, daily living skills, and
aphobia (n¼1). Three patients (13.6%) currently received phar- family / activities and the child version is divided into three sub-
macological treatment. Two of them were on SSRI medication and scales: socially, school, and family. Both the child- and parent
one was on a low dose antipsychotic medication due to tics. forms have demonstrated good psychometric properties (Pia-
centini et al., 2007). The parent version in the current paper was
2.2. Measures rated by both parents, but due to a large amount of missing data
(48%) in the fathers’ ratings, analyses were performed on the
Schedule for Affective Disorders and Schizophrenia for mothers’ ratings only. Both the mother and adolescent rating had
School-Age Children – Present and Lifetime Version (K-SADS- good internal consistency (Cronbach's α¼0.93; 0.91).
PL) (Kaufman et al., 1997). The K-SADS-PL is a clinician-adminis-
tered, semi-structured diagnostic interview for DSM-IV diagnoses. 2.3. Procedure
It has good psychometric properties (Kaufman et al., 1997; Lauth
et al., 2010) with 98% inter-rater reliability and test-retest relia- 2.3.1. Assessment
bility for anxiety disorders with a kappa coefﬁcient of 0.80. The All 65 referred patients and their parents, met with a clinician
interview assesses current and lifetime psychopathology in chil- for an initial screening session. In this session, an unstructured
dren and adolescents, and was administered to determine princi- clinical interview aimed at assessing the presence of obsessions
pal and comorbid diagnoses. The interview was performed by one and / or compulsions was performed, a short psychoeducation
of the therapists at the OCD-unit and was administered to youth about the mechanisms maintaining OCD-symptoms was provided,
and parents separately. and motivation for treatment was addressed. If OCD symptoms
Children's Yale-Brown Obsessive Compulsive Scale (CY- werereported,pre-treatmentassessmentsessionswerescheduled
BOCS) (Scahill et al., 1997). The clinician-administered version of and self-report questionnaires (GAD-7, CDI, COIS) handed out,
the CY-BOCS was used to assess obsessive-compulsive symptom asking patients to return them at the next session. Assessment was
severity. The interview yields severity scores for obsessions and carried out in 1–3 sessions. Information about the developmental
compulsions based on ﬁve dimensions (time occupied by symp- history of the adolescent was collected and K-SADS-PL was ad-
toms, interference, distress, resistance and degree of control over ministered to determine whether the patient fulﬁlled criteria for
symptoms). The CY-BOCS is a widely used instrument with good OCD and comorbid disorders. OCD severity was assessed through
internal consistency (Cronbach's α¼0.90), test-retest reliability the clinician-administrated interview CY-BOCS. The assessment
(intra class correlation¼0.79) (Storch et al., 2004), and inter-rater was performed as part of routine clinical practice by therapists at
reliability (intra class correlation¼0.84) (Scahill et al., 1997). The the unit, with substantial experience in the use of the applied
internal consistency in the current sample was good (Cronbach's instruments. During the assessment, time was also spent on pro-
α¼0.90). viding brief information about the principles of ERP. Post-treat-
Children's Depression Inventory (CDI) was used to assess ment, and at three and six months follow-up the CY-BOCS inter-
depressive symptoms. The questionnaire has a total of 27 items viewwasadministeredbyanindependentrater.This clinicianwas
each consisting of three statements in which the patient indicates awareof the patients having received treatment, but had not been
whichonebestdescribestheirownthoughtsorfeelings (e.g. “Iam involved in the pre-treatment assessment or the treatment. Self-
sometimes sad/I am often sad/I am always sad”). The statements report questionnaires were handed out the last day of treatment,
correspond to a score of 0–2 which add up to a total severity score and collected at the post-treatment assessment occasion. At six
ranging from 0 to 54, where higher scores indicate more depres- monthsfollow-up, questionnaires were sent and returned by mail.
sion. The questionnaire is widely used in clinical and experimental
research and has demonstrated strong psychometric properties 2.4. Treatment
(Kovacs, 1992). A high level of internal consistency was found for
the CDI in the current sample (Cronbach's α¼0.91). Treatment was delivered over four consecutive days and fol-
The generalized anxiety disorder scale (GAD-7) (Spitzer, lowed the cET program, developed by the Bergen OCD-team (see
Kroenke, Williams, & Löwe, 2006) is a 7-item questionnaire de- Havnen et al. (2014) and Havnen, Hansen, Haug, Prescott, and
velopedtoscreenfor generalized anxiety disorder. It has also been Kvale (2013)). According to this treatment format there is a
validated as a measure of anxiety in clinical samples as well as in therapist patient ratio of 1:1 and it can be delivered as both group
the general population, and it performs well as a screening tool for and individual treatment. Since the treatment was developed for
other anxiety disorders such as social phobia or panic disorder adults, certain modiﬁcations were made to customize it to ado-
̈ lescents. First, parents participated in the treatment so the groups
(Kroenke, Spitzer, Williams, Monahan, & Lowe, 2007; Lowe et al.,
2008). The seven items (e.g. ”How often have you been bothered had a total of 6–9 participants (2–3 patients and 4–6 parents). At
by feeling nervous, anxious, or on edge” ) are rated from 0 (not at least one parent had to be present all four days of treatment, but
all) to 3 (nearly every day) giving a total score range from 0 to 21. the participation of both parents was encouraged. Parents were
16 E.N. Riise et al. / Journal of Obsessive-Compulsive and Related Disorders 11 (2016) 13–21
present during all parts of the treatment. However, in cases where 2.4.2. Day 2
the absence of parents augmented the effect of the ERP tasks, The second day the patients and parents met with the thera-
parents were given some “time off”. Second, the language of the pists for six hours. Before the therapist-assisted ERP started, pa-
psychoeducation was adjusted to the cognitive level of the ado- tients and parents met in the group for a brief repetition of the
lescents. Third, the treatment program for adolescents also in- psychoeducation. ERP lasted for 5 h interrupted by an hour long
cluded a parent session and a family session the ﬁrst day. lunch break. ERP was carried out in various locations of relevance
(home, school etc.) and there was emphasis on applying the ex-
2.4.1. Day 1 posures to all possible situations and locations. No hierarchies
Patients and parents met with the therapists for three hours. were created, rather patients were encouraged to start out with
Rules regarding conﬁdentiality between members of the group the most efﬁcient exposure tasks while they applied full response
were established and patients were encouraged to be supportive prevention and refrained from any anxiety reducing behavior.
and to help each other. The aim of day 1 was to provide psy- During the therapist-assisted ERP, therapists constantly asked the
choeducation for patients and parents and to plan the ERP tasks patients about the degree to which they were holding back, they
for the following days. commented on any anxiety reducing behavior, such as bodily
The ﬁrst hour was spent on psychoeducation in the group. posture or facial expressions, and demonstrated how to perform
Anxiety was explained as the body's alarm reaction; an adequate the task without holding back. Patients were instructed to not
response when facing actual danger. In order to protect us, the merely refrain from ritualizing, but to actively choose to do the
threshold for eliciting the alarm is low and false alarms are fre- opposite of what the OCD wanted them to do whenever they were
quently elicited. If we get scared of the alarm itself, and engage in tempted to start ritualizing or avoid. During the last 30 min of day
anxiety reducing behavior we will signal to the brain that the 2 patients and parents met in the group to summarize. The pa-
alarm was appropriate, rather than false. As a consequence, the tients reported to the group what tasks they had performed and
alarmwillbeelicitedatalowerthresholdinsimilarsituations, and were asked how satisﬁed they were with their own effort. The
a vicious circle of sensitization and repetitive anxiety reduction other patients and the parents gave feedback to the participants in
will maintain and worsen OCD-symptoms. It was further ex- front of the group. Self-administered ERP tasks continued in the
plained that in order to break the vicious circle, we must actively evening, and a detailed plan for these tasks, covering every hour,
behave in a way that is inconsistent with this pattern, through was prepared. Therapists were available for both adolescents and
performing anxiety-provoking exposure tasks without carrying parents on the phone in the evening, and patients were instructed
out rituals or other anxiety-reducing behavior. to send a text message to one of the therapists before going to bed,
It was underscored that the best strategy to get rid of their OCD evaluating their own efforts. Maximum effort was deﬁned as doing
was to seek out tasks that “the OCD disliked the most”. Such tasks all ERP tasks without holding back.
were considered efﬁcient as they would exclude the necessity for
training in a lot of different situations. It was emphasized that 2.4.3. Day 3
attempts of reducing anxiety during ERP would send ambiguous The third day the patients met for six hours. Patients and
signals to the brain and the tasks would be less powerful. Instead parents met in the group to summarize homework. The patients
the patients were encouraged to fully engage in ERP tasks without wereaskedtogiveasummaryoftheirself-administeredERPtasks
holding back and to consider anxiety and discomfort valuable re- from the evening before and to evaluate their own effort, and
medies that should be treasured during treatment. Rather than feedback was provided by both therapists and participants. After a
“putting the brake on”, they were encouraged to pretend to like the short repetition of the psychoeducation ERP continued. ERP lasted
tasks. A demonstration of ERP performed while holding back in for ﬁve hours including an hour long lunch break. During the day,
contrast to leaning in was carried out in front of the group. The the adolescents were given increased responsibility of what tasks
patients were also informed that they would not be forced to do to perform. At the end of the day patients met again to summarize
anything, but that the therapists would suggest useful ERP tasks and parents were given an opportunity to give feedback to their
and encourage them to carry these out. During the psychoeduca- adolescents in front of the group. A detailed plan for self-ad-
tion it was explained that whether they had previously fought the ministered ERP tasks for the evening was prepared, and partici-
OCDontheirown,orwiththehelpofatherapist,itwasimportant pants were instructed to evaluate their own effort in a text mes-
nottorepeatpreviouslycommittedmistakes.Itwasalsoexplained sage to one of the therapists before going to bed.
that the therapists would help them to plan and carry out a
winning strategy by individually tailoring their treatment and 2.4.4. Day 4
assisting them during ERP. The fourth day the patients met for three hours in the group.
After the psychoeducation parents were given an individual Patients summarized their self-administered ERP from the evening
session with one of the therapists. The main focus of the parent before and evaluated their own effort in front of the group. The
session was to externalize OCD by separating their child from the therapists and the other participants gave feedback. Psychoedu-
symptoms, and encouraging parents to help their child, and not cation focusing on relapse prevention was provided and daily self-
his/her OCD. Parents were also encouraged to stop all forms of administered ERP tasks for the next three weeks were planned.
family accommodation such as participating in rituals or adjusting Participants were instructed to continue to send reports as text
family routines to OCD symptoms. While parents had individual messagestothetherapistsforthenextthreeweeks.Thetreatment
sessions the adolescents had a small-group sessionwith one of the achievements were summarized and the adolescents received a
therapists and formulation of the treatment planwas initiated. The diploma for showing courage.
treatment plan was completed in the following family session,
allowing for parents to comment on the tasks in case the adoles- 2.4.5. Post-treatment session
cent had forgotten or avoided certain areas. The adolescents were Oneweekafter treatment, patients and parents met with their
also informed that in order to support them in the treatment therapist again for an individual session at the OCD-treatment
process all previous family accommodation to OCD would have to unit. The aim of the session was to discuss current status of OCD-
cease. At the end of the ﬁrst day the group met again for a sum- symptoms and ensure that patients continued to work on their
maryandeachpatientpresentedtheir treatment plan tothe other ERP tasks. No ERP was conducted in this session. Post-treatment
participants in the group. questionnaires were collected. The post-treatment CY-BOCS

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...Journal of obsessive compulsive and related disorders contents lists available at sciencedirect homepage www elsevier com locate jocrd concentrated exposure response prevention for adolescents with disorder an effectiveness study a b c d e n eili riise gerd kvale lars goran ost solvei harila skjold hans hansen bjarne hansena department clinical psychology university bergen norway haukeland hospital ocd team oyane outpatient clinic child adolescent psychiatry neuroscience the karolinska institute stockholm sweden articleinfo abstract article history this evaluated erp received may treatment twenty two in revised form range years therapist assisted during four consecutive days followed by three july week period self administered was delivered to patients their parents si accepted multaneously as part standard health care online august symptoms were assessed pre post month follow up results keywords demonstrated that had signicant reduction from children gains maintained classied responde...

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