Family-Based Behavioral Treatment of Pediatric Compulsive Hoarding

Abstract

Although compulsive hoarding may pose health, social, and developmental impairment for children, there are few phenomenological and treatment studies to guide assessment and treatment. Current evidence-based questions the link between hoarding and obsessive compulsive disorder (OCD) and the effectiveness of cognitive behavioral therapy protocols for OCD to adequately address the unique challenges of poor insight, poor emotion regulation, and increased family accommodation in children with compulsive hoarding. This case study seeks to illustrate a family-based behavioral approach to outpatient treatment of compulsive hoarding with a 9-year-old girl (pseudonym Lily). Treatment included psychoeducation, exposure to discarding items, exposure to acquiring cues, and parent behavior management techniques.

Keywords

compulsive hoarding CBT family-based treatment childhood

1 Theoretical and Research Basis for Treatment

Compulsive hoarding is characterized by excessive acquisition of possessions, failure to discard possessions of limited value, and significant impairment from clutter or restricted functioning (Frost & Hartl, 1996). Although there is little research into the prevalence of compulsive hoarding in children, 80% of adults with compulsive hoarding report that it began in childhood (Grisham, Frost, Steketee, Kim, & Hood, 2006). Although currently classified as a subtype of obsessive compulsive disorder (OCD), recent research suggests that majority of individuals with compulsive hoarding do not meet criteria for OCD. Thus, hoarding will likely be a distinct disorder in the forthcoming Diagnostic and Statistical Manual of Mental Disorders (DSM-5; Mataix-Cols et al., 2010; Rachman, Elliot, Shafran, & Radomsky, 2009; Wheaton, Abramowitz, Fabricant, Berman, & Franklin, 2011; Wu, 2011). Compared with non-hoarding OCD, people with compulsive hoarding exhibit more severe comorbid anxiety and higher rates of inattention and hyperactivity (Grisham, Brown, Liverant, & Campbell-Sills, 2005). These distinctions appear to apply to pediatric compulsive hoarding as well. Storch and colleagues (2007) found that children with compulsive hoarding exhibited higher rates of panic symptoms, poorer insight, and more externalizing problems compared to children with non-hoarding OCD. Children in particular may present with an “abnormal personification of inanimate objects and exaggerated ‘essentialism’” beyond the hypersentimentality seen in adults with compulsive hoarding (Frost, Hartl, Christian, & Williams, 1995; Plimpton, Frost, Abbey, & Dorer, 2009). They may have difficulty discarding even perishable items and report great associated distress (Plimpton et al., 2009).

Children likely also require substantial family involvement in order to acquire and save items. Referred to as family accommodation, parental behaviors which aim to reduce child anxiety by helping them to avoid or escape from anxiety provoking situations have actually been related to greater symptom severity, more rage outbursts, and worse impairment (Peris et al., 2008; Storch et al., 2012). Similarly, child–parent conflict and child disruptive behavior negatively impact treatment outcome for OCD (Garcia et al., 2010). For these reasons, when treating compulsive hoarding in children, it may be particularly important to incorporate parent behavior management skills (see Forehand, Kotchick, Shaffer, & McKee, 2010) into treatment to addresses acting out behavior potentially increasing adherence to exposure treatment, as in Sukhodolsky, Gorman, Scahill, Findley, and McGuire (2013).

Although there is a growing evidence-base for the treatment of compulsive hoarding in adults which focuses on training in decision-making and categorization, exposure and habituation to discarding, and cognitive restructuring (e.g., Hartl & Frost, 1999; Tolin, Frost, & Steketee, 2007), there is sparse evidence to guide treatment in children. Given a rethinking of the relationship between OCD and hoarding and the fact that children with the hoarding subtype of OCD respond less well to exposure-based cognitive-behavioral treatment (CBT) for OCD (e.g., Masi et al., 2005), a more tailored approach may be necessary. The current case implemented a family-based behavioral treatment approach focusing on psychoeducation, exposure to discarding, exposure to acquiring cues, and parent contingency management strategies.

2 Case Introduction

The following case seeks to illustrate a family-based behavioral approach to the treatment of compulsive hoarding in childhood. Lily (pseudonym) was a 9-year-old European American female who presented with her mother to a university hospital-based anxiety specialty clinic for the treatment of compulsive hoarding.

3 Presenting Complaints

Lily was first seen in the company of her parents for an assessment at the end of the summer and was eager to seek treatment prior to starting the fall semester of school. Although she had been successful academically in the previous school year, she had been experiencing significant problems with her peers due to hoarding and her parents were considering homeschooling her for the next school year to avoid further peer conflict. Lily recalled two incidents at school which had drawn negative peer attention. First, Lily began collecting scrap paper in art class because she was very distressed by the idea of it being thrown away. She was very embarrassed when a boy in her class saw that she was collecting scraps and asked her about it. He then took a piece of paper from her and attempted to throw it away. She screamed at him and shoved him, getting in trouble with her teacher. A similar incident occurred on the playground when peers noticed that Lily spent recess putting wood chips into her pockets. Over the summer, Lily had also stopped engaging in many activities that she had once enjoyed. For example, she no longer played outside with her dog because she could not “rescue” leaves floating down a nearby canal or visited the beach where she would became preoccupied with collecting seaweed. She also no longer invited friends to her home for fear that they would see her collections and her cluttered bedroom.

In addition to acquiring items, Lily had significant difficulty discarding items. Lily’s mother had discovered a hidden bag of used toilet paper in Lily’s closet and Lily explained that she found it very distressing to flush a part of herself. During a Girl Scout trip over the summer, Lily’s mother had helped her save used toilet paper and paper towels in baggies to avoid negative peer attention. One incident that prompted seeking treatment was when Lily saw a gnat go down the sink drain and was very upset for several days because she did not save it despite her parents reassurance that the gnat went on to a better place and may be reincarnated into something else.

As the above example suggests, Lily’s parents had been increasingly accommodating her hoarding. They spent considerable effort each day preparing meals and recycling all household products including telling Lily that they saved all food and house waste products in their garage. Although Lily had previously “allowed” her parents to recycle waste products in the past, she had become increasingly distressed by any items leaving her family’s possession and gone into an episode of intense rage when her father tried to take the trash out. Lily’s father, a reportedly gentle man, had yelled back at her to stop. She reported feeling scared of him since and he had avoided all interactions related to hoarding behaviors. After that incident, Lily’s parents had been going to great lengths to conceal any discarding from her (e.g., putting fallen tree limbs and yard waste for pick-up at their neighbor’s house). They would also bring baggies to restaurants so that Lily could take home uneaten food, napkins, and straws from restaurants. These behaviors had been going on for the past year and had a significant impact on Lily’s relationship with her parents and were beginning to impact her parents’ relationship by the time they presented for treatment.

4 History

Lily resided in an affluent community with her married parents. Lily had two adult half-siblings who lived out-of-state and saw her infrequently. Her parents were self-employed and worked from home. Lily described having had a very close relationship with her parents since she was effectively an only child. Lily’s was the product of an uncomplicated birth and met early developmental milestones within normal limits. She “taught herself” to read at age 4 and had always been a very verbal child. Lily’s mother reported having focused on creating a “secure attachment” with Lily by granting her autonomy and allowing her to separate from her parents at her own pace throughout her development. At 9 years of age, this meant that Lily’s mother slept in the bed with Lily and rarely separated from her. Although her mother saw this as a behavior to address over the next few years, she did not feel Lily’s avoidance of separation was abnormal or warranted treatment.

Although Lily had never undergone formal psychoeducational testing, her mother reported that she read at the high school level and excelled at her schoolwork. Lily presented as a verbally mature, but emotionally dysregulated child. At the time of assessment, her parents were considering homeschooling Lily due to teasing at the end of the previous school year related to hoarding. Lily’s parents were encouraged to keep her in school and chose to have her skip the fourth grade and begin the fifth grade shortly after treatment began. Lily was excited for this transition because she had felt that her third-grade peers were immature and not interested in the same things she liked. Lily enjoyed horses, reading, and doing agility training with her new dog.

5 Assessment

Following an unstructured clinical interview conducted by the fourth author, Lily and her mother completed assessment measures administered by a trained research assistant (second author) prior to beginning treatment with the first author. No teacher-report data were collected due to the family wishing not to release health information to the school.

Parent-Report Measures

Multidimensional Anxiety Scale for Children–Parent (MASC-P)

The MASC-P (March, 1998) is a standardized 39-item measure of anxiety with excellent psychometric properties including discriminative validity (Wood, Piacentini, Bergman, McCracken, & Barrios, 2002) and treatment sensitivity (Wood et al., 2008). The parent rates how often various statements are true of their child from “never” to “often.” The measure contains four factor scores (Physical Symptoms, Harm Avoidance, Social Anxiety, and Separation Anxiety) and a total anxiety score, which is comprised from the four factor scores. Lily’s mother indicated an elevated score on the Separation subscale (T-score = 68). All other subscales fell within normal range.

Children’s Saving Inventory (CSI)

The CSI (Storch, Muroff, Lewin, et al., 2011) is a 23-item self-report measure designed to evaluate child hoarding behaviors. The CSI has demonstrated strong internal consistency (α = .84-.96) as well as strong convergent and discriminant validity (Storch et al., 2011). The CSI prompts parents to rate the frequency (none, a little/moderate, some/moderate, most/much, almost all/completely) and severity (not at all, mild, moderate, considerable/severe, extreme) or each item on 5-point ordinal scales. The CSI provides 4 subscales: Discarding, Clutter, Acquisition, and Distress/Impairment. Lily’s mother reported a total score of 46 out of a possible score of 80. The Discarding subscale was rated substantially higher than the other subscales (mean rating of 3.6), which is consistent with the difficulty discarding item she reported on the Children’s Yale–Brown Obsessive-Compulsive Scale (CY-BOCS).

Self-Report Measures

The MASC

The MASC (March, Parker, Sullivan, Stallings, & Conners, 1997 ) is a widely used 39-item measure that was developed to assess child anxiety symptoms in community and clinical populations. The MASC is comprised of 39 items which children rate on a 0 (never true about me) to 3 (often true about me) scale. A total score is derived by summing all responses. The MASC has demonstrated acceptable psychometric properties (March, Parker, Sullivan, Stallings, & Conners, 1997). The self-report total score closely matched that of that parent in that the only elevated subscale was the Separation subscale (T-score = 68). All other subscales fell within normal range.

Obsessive Compulsive Inventory–Child Version (OCI-CV)

The OCI-CV (Foa et al., 2010) is a 21-item questionnaire, based on the OCI-R (Foa et al., 2002), that assesses obsessive-compulsive symptom presence and frequency in children and adolescents over the past month (Foa et al., 2010). The OCI-CV produces six subscales (Doubting/Checking, Obsessions, Hoarding, Washing, Ordering, and Neutralizing) that are summed to yield a total score. Because there are no established norms for the OCI-CV, the researchers created z-scores derived from the means and standard deviations provided in the development study of children with clinically significant OCD (Foa et al., 2010). Lily’s self-report of OCD revealed a z-score of −.38. This score suggests that Lily’s OCD presence and severity does not differ overall from other kids with OCD. Upon closer examination of the subscales, Lily’s self-report led to scores much higher than the comparison sample on the Doubting/Checking (z-score = 4.07), Obsessing (z-score = 3.52), and Hoarding (z-score = 4.76) subscales.

Clinician Administered Measures

CY-BOCS

The CY-BOCS (Scahill et al., 1997) is a 10-item semistructured measure of obsession and compulsion symptom presence and severity over the previous week. The CY-BOCS contains a symptom checklist that encompasses common obsessions and compulsions that are grouped according to content such as contamination obsessions and cleaning/washing compulsions. At the initial visit, mother and child reported a clinically significant score of 28. Each subscale (Obsessions and Compulsions) had a score of 14. Consistent with self-report on the OCI-CV, Lily and her mother reported intrusive thoughts about harm befalling self (child), fears of acting on unwanted impulses, a fear of losing things, a need to know or remember things, and a fear of not being perfect. Concerning the compulsion checklist, Lily and her mother reported difficulty throwing things away; rituals involving other people; a need to tell, ask, or confess; and a need to do things until they feel just right. Many of these obsessions and compulsions were related to discarding or a need to acquire objects. In addition, Lily experienced significant distress and interference due to these obsessions and compulsions.

Rage Outbursts and Anger Rating Scale (ROARS)

The ROARS (Budman et al., 2008) is a 0- to 9-point scale measuring frequency, intensity, and duration of rage and anger. Clinicians rate the ROARS based on all available information gained from their observations of the family and other formal assessment information. Lily had experienced between 1 and 2 rage outbursts in the week prior to the interview, but her outbursts were of high intensity and duration. Overall, Lily was given a score of 1 for frequency and scores of 3 on the intensity and duration items, resulting in a total score of 7. The total score fell within the severe range.

Anxiety Disorders Interview Schedule for DSM-IV: Parent Version (ADIS-IV-P)

The ADIS-IV-P (Silverman & Albano, 1996) is a clinician-administered, semistructured interview that assesses for the presence and severity of DSM-IV anxiety disorders as well as other co-occurring disorders (e.g., oppositional defiant disorder). The ADIS-IV-P yields separate diagnoses and severity ratings based on the youth and parent interviews. Clinician’s make a composite diagnosis based on youth and parent report using guidelines recommended by the creators (Silverman & Albano, 1996). Excellent psychometric properties have been reported (e.g., Wood et al., 2002). After an interview with Lily’s mother, an assessor concluded the following diagnoses, in order of severity, for Lily: OCD, Separation Anxiety, and Social Phobia.

6 Case Conceptualization

Based on the clinical interview, parent-report data, and self-report data, Lily met criteria for a primary diagnosis of OCD (predominantly hoarding subtype) and secondary separation anxiety disorder. Although she reported some symptoms of social anxiety, these fears were directly related to negative peer interactions related to hoarding behaviors. Based on history provided by Lily’s mother, Lily had always been sentimental about items and had collected many trivial things. The death of the family’s dog in the spring prior to seeking treatment was a significant stressor that likely exacerbated Lily’s hoarding behaviors. While family accommodation was aimed at reducing Lily’s anxiety, it likely contributed to her disruptive behavior and increased impairment. Given the level of family and social impairment experienced as a result of hoarding, family-based behavioral therapy for compulsive hoarding was initiated.

7 Course of Treatment and Assessment of Progress

Following assessment, the family consented to participate in treatment for compulsive hoarding. The first four sessions were conducted twice weekly after which Lily and her mother were seen weekly. Lily’s father attended two sessions to observe in-session exposure tasks but was not able to attend others due to his work demands and Lily’s initial reluctance to have him present. What follows is an overview of the psychoeducation (Sessions 1 and 2), contingency management (Session 2), and exposure (Sessions 3-15) treatment components and a maintenance phase.

Psychoeducation

During the first treatment session, Lily’s mother was asked to come alone so that she could learn about treatment, discuss modifying parenting behaviors, and be able to guide Lily in future sessions. She was provided psychoeducation about OCD and compulsive hoarding. A particular emphasis was placed on understanding the negative reinforcement cycle (e.g., Frost & Hartl, 1996) by which saving and acquiring is reinforced by providing an escape from distressing and anxious feelings. With an understanding of her intentions to limit Lily’s suffering, the role of family accommodation was explained as actually maintaining the negative reinforcement cycle and making Lily feel more anxious over time. Lily’s mother was very upset and blamed herself for perpetuating the problem. Before proceeding in treatment, it was important to show empathy for her loving intentions and help her understand that she was doing what she thought was best for Lily at the time and then had sought treatment to learn different ways to help her.

At the second session, the concept of exposure was discussed with Lily and her mother as a way to retrain Lily’s body to not get as stressed out about collecting things. She was resistant to the idea of discarding any possessions but stated that she did want to return to school and face the embarrassment of collecting things.

Parent contingency management

In the first session, Lily’s mother discussed Lily’s screaming and trantrumming when her parents have tried to throw things away in the past. Differential attention was introduced as a parenting tool to decrease undesirable behaviors (i.e., screaming and saying mean things) by withdrawing parental attention or ignoring and conversely to increase desirable behaviors (e.g., discarding items or talking about feelings in a kind voice) by giving positive parental attention, such as praising, smiling, hugging. In order to further motivate Lily to engage in the difficult exposure tasks of discarding and not acquiring, a reward program was introduced. At the second session, Lily and her mother decided that she would earn points toward horseback riding lessons, a new laptop, and new dolls. Although these were expensive items that would typically be discouraged, small nominal items would have been difficult for Lily to ever discard and would have contributed to her bedroom clutter. Given this aim and the family’s financial situation, Lily earned a point for each exposure she participated in outside of session and cashed in points for tangible rewards. Contingency management strategies were introduced in Sessions 1 and 2, but discussed and monitored throughout treatment.

Exposure tasks

During the second session, an initial hierarchy of items to discard and ways to discard them was created using a 10-point subjective unit of distress scale. Lily had a very difficult time brainstorming items that were not either 0 or 10 (termed as “impossible”). For this reason, the therapist encouraged Lily to engage in an experimental exposure to try to gauge the level of difficulty of tasks that Lily reported were extremely easy. First, the therapist blew her nose and threw out a tissue. Lily appeared calm and reported no distress. Lily’s mother was then encouraged to repeat the same task and threw away her tissue. While Lily reported no initial distress, she began crying and stated that the tissue “had some of her mother on it” and was akin to throwing out a piece of her mother because she had blown her nose in it. Lily began crying, screeching very loudly, and yelled that she did not know which tissue was the therapists and which one was her mothers and she did not want to have to take both of them home. Lily’s mother was encouraged to remain as calm as possible, praising Lily for not collecting the tissues, and ignoring the screaming in a neutral manner. The screaming and crying persisted for about 30 min when Lily calmed down enough to state that she just wanted to go home. Although the exposure task had been more difficult than was intended and was not ideal for an initial exposure, it was very important that Lily not be allowed to escape from the task once it was started. This accidental flooding allowed the therapist to model differential reinforcement and for Lily’s mother to practice these skills in-session. In addition, Lily learned that she could not escape from a task with disruptive behavior.

Lily’s mother reported that it was very difficult for Lily to return to the next appointment because she was embarrassed by her behavior and scared of future exposure tasks. With this in mind, Lily was praised for returning to session and an easier exposure was chosen so that she could experience mastery of a task. Lily was given a number of easy exposure options (e.g., watching someone else throw away a piece of paper, seeing leaves and not picking them up) and chose to walk around outside and look at leaves without picking them up. She did this with seemingly low distress and was praised for her accomplishment. She and her mother were asked to monitor potential acquiring situations that Lily encountered and track whether or not she collected anything in between sessions. At the following session, Lily requested that she not be given monitoring forms because she felt compelled to save them once they were given to her and it was very challenging to give them back. This was viewed as progress since Lily was assertively trying not to acquire new items.

Exposure tasks progressed in difficulty by transitioning tasks in-session with the therapists to home with the guidance of Lily’s mother and later her father (see Table 1). While Lily initially had not wanted her father to witness exposures, after achieving initial success she asked her father to come observe an in-session exposure and participate in home exposures. In-session exposure tasks continued to focus on discarding personal items, especially items which could be construed as part of Lily (e.g., hair).

Table 1.

Example Exposure Tasks.

Difficulty level	Exposure task	Setting
Low	Therapist recycling a scrap piece of paper	In-session
	Therapist throw out a paper that Lily had made a mark on	In-session
	Lily throw out a paper that Lily had made a mark on	In-session
	Lily throw out a paper that she drew something on	In-session
	Lily throw out a paper with her name on it	In-session
	Lily throw out a paper with a loving message to her mother on it	In-session
	Lily throw out dog pee pads	At home
	Lily watching leaves float down the canal	At home
	Lily put hair from hairbrush outside for bird nests	In-session
	Dad emptying bathroom trashcan	At home
	Lily not collecting at recess or art class	At home
	Lily throw out empty water bottles	In-session
	Lily watch mom make dinner	At-home
	Lily and mom donate old toys that she did not play with	At home
	Lily throw out hair from hairbrush in the trash	At home
	Lily throw out old notes from backpack	At home
High	Lily get haircut without bringing hair home	At home

Maintenance phase

After 4 months of acute treatment and substantial progress, Lily was encouraged to generalize her skills in new environments (e.g., school, restaurants, vacation) and sessions were tapered to every other week and then monthly. During this time, treatment focused on problem-solving difficulties encountered discarding items and setting goals. Lily had been carrying multiple backpacks to school with papers and books that were not needed on a daily basis and was encouraged to reduce this load into a single backpack. She set goals of making her favorite meal for dinner with her mother’s help and of having a friend over to play now that her bedroom was less cluttered. Lily’s mother expressed a desire to donate old clothing that no longer fit Lily. Lily was resistant to this plan and said that she had a plan to sell them on eBay or make them into doll clothes. Lily’s mother responded by setting deadlines for when those plans would have to be completed by and donated the clothes when Lily had not taken steps toward her plan. These types of parental boundaries were helpful to Lily’s maintenance of treatment gains and demonstrated Lily’s mother’s progress reducing family accommodation.

8 Complicating Factors

Lily’s treatment presented some unique complications that required flexible treatment implementation. While it was positive that Lily did not want to collect paper by taking monitoring forms, this made it difficult to assess target behaviors and progress when the family did not remember events from the previous week. Electronic tracking of exposures may be a good alternative as applications for tracking exposures become available for smart phones and tablet computers (e.g., Whiteside, 2013). Similarly, the family’s unwillingness to have the therapist communicate with Lily’s school made it difficult to monitor her progress and implement treatment strategies at school.

It was also difficult to accurately predict the level of difficulty of exposure tasks before beginning each task due to Lily’s poor insight into her emotional state and lack of reported anxiety. Pence, Sulkowski, Jordan, and Storch (2010) discuss accidental flooding as a common difficulty when clients have poor insight into the difficulty of exposure tasks. They suggest that the therapist should try to remain calm and confident despite probable personal anxiety in this situation and to help the client to continue the exposure without engaging in compulsions or delaying the compulsions.

Finally, throughout the maintenance phase, Lily had many creative plans for items that her mother felt should be discarded, as is common in people with compulsive hoarding (Hartl & Frost, 1999). She was given a fixed period of time to complete those plans and then the item was discarded when she had not used the items. It was important for parents to follow through with the planned reward system for Lily to continue engaging in exposures and working toward her goals.

9 Access and Barriers to Care

In this case, it was important to be able to extend the duration of some initial exposure sessions so that Lily did not escape from demands of the exposure by exhibiting disruptive behavior. The family was billed accordingly when sessions ran over and were motivated in future sessions to stay on-task and begin exposure tasks promptly. Lily’s mother had chosen not to submit charges to insurance and paid out of pocket for treatment. Extended sessions may pose problems, however, for insurance reimbursement or a therapist’s schedule, creating a potential barrier to implementing treatment effectively in a community setting.

10 Follow-Up

Lily and her mother were asked to complete the following measures at the end of active treatment and primary measures are presented in Figure 1. Previously reported measures will not be redescribed. They also provided pictures of Lily’s bedroom that were taken before treatment and after treatment (see Figure 2) to demonstrate the amount of items she had discarded and changes in her quality of life.

Figure 1.

Pre- and posttreatment scores for primary assessment measures.

Figure 2.

Pre- and posttreatment clutter in Lily’s bedroom.

MASC-P

Following treatment, Lily’s mother filled out another MASC-P (March, 1998). Identical to the initial visit, the only subscale that approached clinical significance was the Separation Anxiety subscale (T-score = 68). All of the other subscales remained relatively stable except the Social Anxiety subscale which decreased from a T-score of 50 to 41. Lily’s mother continued to deny impairment related to Separation Anxiety and declined formal interventions to address these fears.

CSI

Lily’s mother’s ratings on the CSI-P (Storch et al., 2011) reflected substantial drops in the total score and all subscale scores. The highest subscale at post, Discarding, reduced from a score of 22 to 4. The other subscales dropped by more than half (Clutter = 4, Acquire = 1, Distress/Impairment = 6). Collectively, these reductions lowered the total score to 11.

The MASC

Lily reported substantial reductions on all of the MASC (March et al., 1997) subscales including the total score which decreased from a T-score of 69 to 34. Following treatment, Lily’s overall MASC-C score suggested anxiety symptom lower than other children Lily’s age.

OCI-CV

Following treatment, Lily reported no obsessive-compulsive symptoms on the OCI-CV. Overall, the total score reduced from a z-score of −.38 to −1.34. At the initial visit, Lily’s OCI-CV score was consistent with a sample of youth with OCD. At the follow-up, Lily’s score provides evidence for OC symptom presence and frequency below the levels of other youth with OCD. Although there is no definitive way to rule out clinical significance, the reduction represents a definite improvement. Furthermore, the Doubting/Checking, Obsessing, Hoarding, and Ordering subscales, which were substantially higher than the comparison sample, were within the normal range of the sample. Although minimal, the Washing and Neutralizing subscales did increase. Finally, in comparing the changes from pre- to post-, Lily’s exhibited a change in score that was one standard deviation above the average change for the comparison sample. Therefore, Lily’s improvement was higher than expected in treatment.

CY-BOCS

Overall, Lily’s score decreased from a clinically significant score of 28 to a subclinical score of 8 (Obsession subscale = 8, Compulsion subscale = 0). Lily’s mother reported an absence of the previously endorsed aggressive symptoms (fear harm will come to self and fear of acting on unwanted impulses). In addition, she reported that Lily’s fear of hurting objects and her need to know or remember things had diminished. Although Lily’s difficulty throwing things away was still present, it had mitigated in severity so much so that she was experiencing no interference or distress due to compulsive behavior. Given this impressive reduction in CY-BOCS score, it is important to note that Lily still had difficulty with resisting and controlling obsessive thoughts.

ROARS

The ROARS score at the follow-up also presented a substantial drop. Lily’s mother indicated that Lily had experienced no rage outbursts the week prior to the assessment. Lily’s overall ROARS score dropped from 7 to 0.

11 Treatment Implications of the Case

This case highlights the importance of flexibly implementing treatment components to meet diagnostic and individual needs. Treatment differed from CBT protocols for OCD (e.g., POTS Study Team, 2004) in three important ways: (a) incorporating exposures to acquiring cues as well as discarding, (b) central involvement of family members to address accommodation, and (c) inclusion of parent management training to address disruptive behaviors. In addition, flexibility in implementing treatment components helped to continue exposures when barriers presented. Specifically, Lily’s unreliable report of her distress made it very difficult to develop a hierarchy and progress in a linear fashion. By attempting to gauge Lily’s distress based on her mother’s report and not allowing her to escape from the demands of each task, she was able to learn that disruptive behavior was not a way to escape and that distress decreased over time.

In addition, this case demonstrates the importance of parental involvement in treatment. Parents are often very involved in helping the child save items and, as was prominent in this case, may be changing their own routines to avoid the child’s distress. Without having parents present to practice skills in session, it would likely have been very difficult to make large changes in Lily’s home environment. Through the use of rewards and differential attention, Lily’s parents were able to decrease her rage episodes and motivate her to engage in exposure tasks.

12 Recommendations to Clinicians and Students

This case illustrates the importance of incorporating multiple treatment components concurrently with complex behavior in a family setting. Parental involvement in treatment sessions may be very important to help families understand the function of the behaviors (e.g., negative reinforcement), to allow the therapist to model treatment techniques (e.g., differential attention), and to allow parents to practice their skills. As therapists are often asking parents to become experts very quickly to aid in therapy homework, in-session participation may be very critical.

Footnotes

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

Author Biographies

Chelsea M. Ale, PhD, is a postdoctoral fellow in clinical child psychology at Mayo Clinic in Rochester, MN. Her research and clinical interests include early childhood anxiety, parenting, and treatment of comorbid anxiety, and disruptive behavior.

Elysse B. Arnold, BA, is a research assistant at the Rothman Center for Pediatric Neuropsychiatry and will be starting the doctoral program in clinical psychology at the University of South Florida.

Stephen P. H. Whiteside, PhD, ABPP, is an associate professor of psychology at Mayo Clinic in Rochester, MN. He specializes in the assessment and treatment of child and adolescent anxiety disorders, developing electronic tools to enhance behavior therapy, and developing more efficient and effective treatments of childhood anxiety disorder.

Eric A. Storch, PhD, is a professor of clinical psychology in the Departments of Pediatrics, Psychiatry and Behavioral Neurosciences, and Psychology at the University of South Florida. He holds the All Children’s Hospital Guild Endowed Chair in child neurodevelopment. He specializes in the cognitive behavioral treatment of adult and childhood obsessive compulsive disorder (OCD), as well as other obsessive-compulsive spectrum disorders (e.g., trichotillomania, tic disorders, body dysmorphic disorder, skinpicking) and anxiety disorders.

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