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Cognitive-behavioral therapy (CBT) is the first-line treatment for mild to moderate cases of OCD in children. Since the publication of a CBT treatment manual that operationalized and systematized this method (March and Mulle 1998), numerous studies have consistently shown its acceptability and efficacy (March et al. 2001; Piacentini et al. 2003). Severe OCD, concurrent psychopathology (e.g., comorbid anxiety or major depressive or disruptive behavior disorders), lack of family cohesion, poor insight, or lack of skilled CBT practitioners are factors to consider in deciding when to use medication. Scores of >23 on the CY-BOCS or Clinical Global Impressions—Severity scale (CGI-S) scores of "marked" to "severe" impairment provide a threshold for consideration of drug intervention. In addition, any situation that could impede the successful delivery of CBT should be cause for earlier consideration of medication treatment. Poor insight into the irrational nature of the obsessions and associated compulsions can lead to resistance to CBT. Chaotic or nonintact family situations will make close family involvement in implementation of CBT more difficult. Finally, there is a dire shortage of skilled CBT practitioners. Site-specific differences in CBT outcomes in the National Institute of Mental Health (NIMH)–funded Pediatric OCD Treatment Study (POTS; March et al. 2004) suggest that expert training will improve response rates to CBT. In the POTS study, CBT alone did not differ from sertraline alone and both were better than placebo.

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FIGURE 23–2. Theoretical basis of cognitive-behavioral treatment (exposure and response prevention).
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TABLE 23–3. Dosage range for serotonin reuptake inhibitors in children with obsessive-compulsive disorder (OCD)
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TABLE 23–4. Effect size by drug in meta-analysis of pediatric obsessive-compulsive disorder trials

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