Journal of Abnormal Child Psychology

, Volume 43, Issue 3, pp 543–552 | Cite as

Exposure and Response Prevention Process Predicts Treatment Outcome in Youth with OCD

  • Katharina Kircanski
  • Tara S. Peris


Recent research on the treatment of adults with anxiety disorders suggests that aspects of the in-session exposure therapy process are relevant to clinical outcomes. However, few comprehensive studies have been conducted with children and adolescents. In the present study, 35 youth diagnosed with primary obsessive-compulsive disorder (OCD; M age = 12.9 years, 49 % male, 63 % Caucasian) completed 12 sessions of exposure and response prevention (ERP) in one of two treatment conditions as part of a pilot randomized controlled testing of a family focused intervention for OCD. Key exposure process variables, including youth self-reported distress during ERP and the quantity and quality of ERP completed, were computed. These variables were examined as predictors of treatment outcomes assessed at mid-treatment, post-treatment, and three-month follow-up, partialing treatment condition. In general, greater variability of distress during ERP and completing a greater proportion of combined exposures (i.e., exposures targeting more than one OC symptom at once) were predictive of better outcomes. Conversely, greater distress at the end of treatment was generally predictive of poorer outcomes. Finally, several variables, including within- and between-session decreases in distress during ERP, were not consistently predictive of outcomes. Findings signal potentially important facets of exposure for youth with OCD and have implications for treatment. A number of results also parallel recent findings in the adult literature, suggesting that there may be some continuity in exposure processes from child to adult development. Future work should examine additional measures of exposure process, such as psychophysiological arousal during exposure, in youth.


Obsessive-compulsive disorder (OCD) Youth Exposure therapy Exposure and response prevention (ERP) Subjective distress 



This research was supported by grants from the International Obsessive Compulsive Foundation (Dr. Peris), a NARSAD Young Investigator Award (Dr. Peris), and the National Institute of Mental Health (NIMH Grant K32 MH 085058, Dr. Peris). The authors wish to acknowledge the study research team and the children and families who participated in this research. Additional disclosures: Dr. Kircanski has received research support from NIMH (NIMH Grant F32 MH 096385) and the Brain & Behavior Research Foundation (Young Investigator Award).

Conflict of Interest

The authors declare that they have no conflict of interest.


  1. Abramowitz, J. S. (1996). Variants of exposure and response prevention in the treatment of obsessive-compulsive disorder: A meta-analysis. Behavior Therapy, 27, 583–600.CrossRefGoogle Scholar
  2. American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders, text revision (4th ed.). Washington, DC: Author.Google Scholar
  3. American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC: Author.CrossRefGoogle Scholar
  4. Baker, A., Mystkowski, J., Culver, N., Yi, R., Mortazavi, A., & Craske, M. G. (2010). Does habituation matter? Emotional processing theory and exposure therapy for acrophobia. Behaviour Research and Therapy, 48, 1139–1143.CrossRefPubMedCentralPubMedGoogle Scholar
  5. Benito, K. G., Conelea, C., Garcia, A. M., & Freeman, J. B. (2012). CBT specific process in exposure-based treatments: Initial examination in a pediatric OCD sample. Journal of Obsessive Compulsive and Related Disorders, 1, 77–84.CrossRefPubMedCentralPubMedGoogle Scholar
  6. Bjork, R. A., & Bjork, E. L. (2006). Optimizing treatment and instruction: Implications of a new theory of disuse. In L.-G. Nilsson & N. Ohta (Eds.), Memory and society: Psychological perspectives (pp. 116–140). New York: Psychology Press.Google Scholar
  7. Craske, M. G. (1999). Anxiety disorders: Psychological approaches to theory and treatment. Boulder: Westview Press.Google Scholar
  8. Craske, M. G., Kircanski, K., Zelikowski, M., Mystkowski, J., Chowdhury, N., & Baker, A. (2008). Optimizing inhibitory learning during exposure therapy. Behaviour Research and Therapy, 46, 5–27.CrossRefPubMedGoogle Scholar
  9. Culver, N. C., Stoyanova, M., & Craske, M. G. (2012). Emotional variability and sustained arousal during exposure. Journal of Behavior Therapy and Experimental Psychiatry, 43, 787–793.CrossRefPubMedGoogle Scholar
  10. Faul, F., Erdfelder, E., Lang, A.-G., & Buchner, A. (2007). G*Power 3: A flexible statistical power analysis program for the social, behavioral, and biomedical sciences. Behavior Research Methods, 39, 175–191.CrossRefPubMedGoogle Scholar
  11. Foa, E. B., & Kozak, M. (1986). Emotional processing of fear: Exposure to corrective information. Psychological Bulletin, 99, 450–472.CrossRefGoogle Scholar
  12. Foa, E. B., & McNally, R. J. (1996). Mechanisms of change in exposure therapy. In R. Rapee (Ed.), Current controversies in the anxiety disorders (pp. 329–343). New York: Guilford.Google Scholar
  13. Foa, E., Steketee, G., Grayson, J., Turner, R., & Latimer, P. (1984). Deliberate exposure and blocking of obsessive compulsive rituals: Immediate and long-term effects. Behavior Therapy, 15, 450–472.CrossRefGoogle Scholar
  14. Freeman, J., Garcia, A., Frank, H., Benito, K., Connolea, C., Walther, M., et al. (2014). Evidence base update for psychosocial treatments for pediatric obsessive-compulsive disorder. Journal of Clinical Child and Adolescent Psychology, 43, 7–26.CrossRefPubMedGoogle Scholar
  15. Geller, D., & March, J. (2012). Practice parameter for the assessment and treatment of children and adolescents with obsessive-compulsive disorder. Journal of the American Academy of Child and Adolescent Psychiatry, 51, 98–113.CrossRefGoogle Scholar
  16. Green, B., Shirk, S., Hanze, D., & Wanstrath, J. (1994). The Children’s Global Assessment Scale in clinical practice: An empirical evaluation. Journal of the American Academy of Child and Adolescent Psychiatry, 33, 1158–1164.CrossRefPubMedGoogle Scholar
  17. Groves, P. M., & Thompson, R. F. (1970). Habituation: A dual process theory. Psychological Review, 77, 419–450.CrossRefPubMedGoogle Scholar
  18. Hayes, S. A., Hope, D. A., & Heimberg, R. G. (2008). The pattern of subjective anxiety during in-session exposures over the course of cognitive-behavioral therapy for clients with social anxiety disorder. Behavior Therapy, 39, 286–299.CrossRefPubMedCentralPubMedGoogle Scholar
  19. Hedtke, K. A., Kendall, P. C., & Tiwari, S. (2009). Safety-seeking and coping behavior during exposure tasks with anxious youth. Journal of Clinical Child and Adolescent Psychology, 38, 1–15.CrossRefPubMedGoogle Scholar
  20. Kendall, P., & Hedtke, K. (2006). Cognitive-behavioral therapy for anxious children: Therapist manual (3rd ed.). Ardmore: Workbook Publishing.Google Scholar
  21. Kendall, P. C., Robin, J., Hedtke, K., Suveg, C., Flannery-Schroeder, E., & Gosch, E. (2005). Considering CBT with anxious youth? Think exposures. Cognitive and Behavioral Practice, 12, 136–148.CrossRefGoogle Scholar
  22. Kircanski, K., Mortazavi, A., Castriotta, N., Baker, A. S., Mystkowski, J. L., & Yi, R. (2012). Challenges to the traditional exposure paradigm: Variability in exposure therapy for contamination fears. Journal of Behavior Therapy and Experimental Psychiatry, 43, 745–751.CrossRefPubMedGoogle Scholar
  23. Kircanski, K., Wu, M., & Piacentini, J. (2014). Reduction of subjective distress in CBT for childhood OCD: Nature of change, predictors, and relation to treatment outcome. Journal of Anxiety Disorders, 28, 125–132.CrossRefPubMedCentralPubMedGoogle Scholar
  24. Knox, L., Albano, A., & Barlow, D. (1996). Parental involvement in the treatment of childhood compulsive disorder: A multiple-baseline examination incorporating parents. Behavior Therapy, 27, 93–114.CrossRefGoogle Scholar
  25. Lang, A. J., & Craske, M. G. (2000). Manipulations of exposure-based therapy to reduce return of fear: A replication. Behaviour Research and Therapy, 38, 1–12.CrossRefPubMedGoogle Scholar
  26. Meyer, V. (1966). Modification of expectations in cases with obsessive rituals. Behavioral Research and Therapy, 4, 270–280.CrossRefGoogle Scholar
  27. Moore, P. S., Mariaskin, A., March, J., & Franklin, M. E. (2007). Obsessive compulsive disorder in children and adolescents: Diagnosis, comorbidity, and developmental factors. In E. A. Storch, G. R. Geffken, & T. K. Murphy (Eds.), Handbook of child and adolescent obsessive-compulsive disorder (pp. 17–45). Mahwah: Lawrence Erlbaum Associates Publishers.Google Scholar
  28. National Institute of Mental Health. (1985). Clinical global impression scale. Psychopharmacology Bulletin, 21, 839–843.Google Scholar
  29. Norton, P. J., Hayes-Skelton, S. A., & Klenck, S. C. (2011). What happens in session does not stay in session: Changes within exposures predict subsequent improvement and dropout. Journal of Anxiety Disorders, 25, 654–660.CrossRefPubMedCentralPubMedGoogle Scholar
  30. Peris, T. S., & Piacentini, J. C. (2013). Optimizing treatment for complex cases of childhood obsessive compulsive disorder: A preliminary trial. Journal of Clinical Child and Adolescent Psychology, 42, 1–8.CrossRefPubMedCentralPubMedGoogle Scholar
  31. Peris, T. S., Sugar, C. A., Bergman, R. L., Chang, S., Langley, A., & Piacentini, J. (2012). Family factors predict treatment outcome for pediatric obsessive compulsive disorder. Journal of Consulting and Clinical Psychology, 80, 255–263.CrossRefPubMedCentralPubMedGoogle Scholar
  32. Piacentini, J., Bergman, R. L., Keller, M., & McCracken, J. (2003). Functional impairment in children and adolescents with obsessive-compulsive disorder. Journal of Child and Adolescent Psychopharmacology, 13(Suppl. 1), 61–69.CrossRefGoogle Scholar
  33. Piacentini, J., Langley, A., & Roblek, T. (2007). Cognitive-Behavioral Treatment of Childhood OCD. New York: Oxford University Press.CrossRefGoogle Scholar
  34. Piacentini, J., Bergman, R. L., Chang, S., Langley, A., Peris, T., Wood, J., et al. (2011). Controlled comparison of family cognitive behavioral therapy and psychoeducation=relaxation-training for child OCD. Journal of the American Academy of Child and Adolescent Psychiatry, 50, 1149–1161.CrossRefPubMedCentralPubMedGoogle Scholar
  35. Rachman, S. (1994). The overprediction of fear: A review. Behaviour Research and Therapy, 32(7), 683–690.CrossRefPubMedGoogle Scholar
  36. Rachman, S., & Bichard, S. (1988). The overprediction of fear. Clinical Psychology Review, 8, 303–312.CrossRefGoogle Scholar
  37. Rescorla, R. A. (2006). Deepened extinction from compound stimulus presentation. Journal of Experimental Psychology: Animal Behavior Processes, 32, 135–144.PubMedGoogle Scholar
  38. Rescorla, R. A., & Wagner, A. R. (1972). A theory of Pavlovian conditioning: Variations in the effectiveness of reinforcement and nonreinforcement. In A. H. Black & W. F. Prokasy (Eds.), Classical conditioning II: Current research and theory (pp. 64–99). New York: Appleton.Google Scholar
  39. Rowe, M. K., & Craske, M. G. (1998). Effects of varied-stimulus exposure training on fear reduction and return of fear. Behaviour Research and Therapy, 36, 719–734.CrossRefPubMedGoogle Scholar
  40. Scahill, L., Riddle, M. A., McSwiggan-Hardin, M. T., Ort, S. I., King, R. A., Goodman, W. K., et al. (1997). Children’s Yale–brown obsessive compulsive scale: Reliability and validity. Journal of the American Academy of Child and Adolescent Psychiatry, 36, 844–852.CrossRefPubMedGoogle Scholar
  41. Shaffer, D., Gould, M. S., Brasic, J., Ambrosini, P., Fisher, P., Bird, H., et al. (1983). A children’s global assessment scale (CGAS). Archives of General Psychiatry, 40, 1228–1231.CrossRefPubMedGoogle Scholar
  42. Silverman, W., & Albano, A. M. (1996). Anxiety disorders interview schedule for DSM-IV: Parent version. San Antonio: Graywing.Google Scholar
  43. Silverman, W., Saavedra, L., & Pina, A. (2001). Test-retest reliability of anxiety symptoms and diagnoses with anxiety disorders interview schedule for DSM-IV: Child and parent versions. Journal of the American Academy of Child and Adolescent Psychiatry, 40(8), 937–944.CrossRefPubMedGoogle Scholar
  44. Stanley, M. A., & Turner, S. M. (1995). Current status of pharmacological and behavioral treatment of obsessive-compulsive disorder. Behavior Therapy, 26, 163–186.CrossRefGoogle Scholar
  45. Storch, E., Murphy, T., Geffken, G., Soto, O., Sajid, M., Allen, P., et al. (2004). Psychometric evaluation of the children’s Yale-brown obsessive-compulsive scale. Psychiatry Research, 129, 91–98.CrossRefPubMedGoogle Scholar
  46. Valleni-Basile, L. A., Garrison, C. Z., Jackson, K. L., Waller, J. L., McKeown, R. E., Addy, C. L., et al. (1994). Frequency of obsessive-compulsive disorder in a community sample of young adolescents. Journal of the American Academy of Child and Adolescent Psychiatry, 33, 782–791.CrossRefPubMedGoogle Scholar
  47. Van Hout, W. J., & Emmelkamp, P. M. (1994). Overprediction of fear in panic disorder patients with agoraphobia: Does the (mis) match model generalize to exposure invivo therapy? Behaviour Research and Therapy, 32, 723–734.CrossRefPubMedGoogle Scholar
  48. Wolpe, J. (1973). The practice of behavior therapy. London: Pergamon Press.Google Scholar

Copyright information

© Springer Science+Business Media New York 2014

Authors and Affiliations

  1. 1.Department of PsychologyStanford UniversityStanfordUSA
  2. 2.Division of Child and Adolescent PsychiatryUCLA-Semel Institute for Neuroscience and Human BehaviorLos AngelesUSA

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