Child Psychiatry & Human Development

, Volume 49, Issue 1, pp 9–19 | Cite as

An Initial Case Series of Intensive Cognitive–Behavioral Therapy for Obsessive–Compulsive Disorder in Adolescents with Autism Spectrum Disorder

  • Marina Iniesta-SepúlvedaEmail author
  • Joshua M. Nadeau
  • Amaya Ramos
  • Brian Kay
  • Bradley C. Riemann
  • Eric A. Storch
Original Article


Obsessive–compulsive disorder (OCD) is prevalent among youth with autism spectrum disorder (ASD). Cognitive–behavioral therapy (CBT) with ASD-specific modifications has support for treating OCD in this population; however, use of intensive CBT in youth with ASD and severe OCD has not been tested. The current study examined the preliminary effectiveness of an individualized intensive CBT protocol for OCD in adolescents with ASD. Nine adolescents (aged 11–17 years) completed a regimen of intensive CBT (range 24–80 daily sessions) incorporating exposure with response prevention (ERP). Treatment materials, language and techniques were modified in accordance with evidence-based findings for this population. Seven of nine participants (78%) were treatment responders, and large treatment effects (d = 1.35–2.58) were obtained on primary outcomes (e.g., obsessive–compulsive symptom severity). Preliminary findings suggest that an intensive CBT approach for OCD is effective among adolescents with ASD.


Obsessive–compulsive disorder Autism spectrum disorders Cognitive–behavioral therapy Intensive treatment Adolescents 



The Funding for preparation this manuscript was provided to the first author by Ministry of Education, Culture and Sports of Spanish Government in the “José Castillejo” Program, Grant CAS15/00381. Ministry of Education, Culture and Sports had no role in the study, or the decision to submit the paper for publication.


  1. 1.
    American Psychiatric Association (2013) Diagnostic and statistical manual of mental disorders, 5th edn. American Psychiatric Publishing, Washington DCCrossRefGoogle Scholar
  2. 2.
    Centers for Disease Control and Prevention. (2014) Prevalence of autism spectrum disorder among children aged 8 years: autism and developmental disabilities monitoring network. MMWR Surveill Summ 63:1–21Google Scholar
  3. 3.
    Dean M, Kasari C, Shih W, Frankel F, Whitney R, Landa R et al (2014) The peer relationships of girls with ASD at school: comparison to boys and girls with and without ASD. J Child Psychol Psychiatry 55:1218–1225CrossRefPubMedGoogle Scholar
  4. 4.
    Smith LE, Greenberg JS, Mailick MR (2014) The family context of autism spectrum disorders: influence on the behavioral phenotype and quality of life. Child Adolesc Psychiatr Clin N Am 23:143–155CrossRefPubMedGoogle Scholar
  5. 5.
    Joshi G, Petty C, Wozniak J, Henin A, Fried R, Galdo M et al (2010) The heavy burden of psychiatric comorbidity in youth with autism spectrum disorders: a large comparative study of a psychiatrically referred population. J Autism Dev Disord 40:1361–1370CrossRefPubMedGoogle Scholar
  6. 6.
    Posserud M, Hysing M, Helland W, Gillberg C, Lundervold AJ (2016) Autism traits: the importance of “co-morbid” problems for impairment and contact with services. Data from the Bergen Child Study. Res Dev Disabil. doi: 10.1016/j.ridd.2016.01.002 PubMedGoogle Scholar
  7. 7.
    Leyfer OT, Folstein SE, Bacalman S, Davis NO, Dinh E, Morgan J et al (2006) Comorbid psychiatric disorders in children with autism: interview development and rates of disorders. J Autism Dev Disord 36:849–861CrossRefPubMedGoogle Scholar
  8. 8.
    Bellini S (2004) Social skill deficits and anxiety in high-functioning adolescents with autism spectrum disorders. Focus Autism Other Dev Disabl 19:78–86CrossRefGoogle Scholar
  9. 9.
    Lewin AB, Wood JJ, Gunderson S, Murphy TK, Storch EA (2011) Phenomenology of comorbid autism spectrum and obsessive–compulsive disorders among children. J Dev Phys Disabil 23:543–553CrossRefGoogle Scholar
  10. 10.
    McGuire JF, Piacentini J, Lewin AB, Brennan EA, Murphy TK, Storch EA (2015) A meta-analysis of cognitive behavior therapy and medication for child obsessive–compulsive disorder: moderators of treatment effectiveness, response, and remission. Depress Anxiety 32:580–593CrossRefPubMedPubMedCentralGoogle Scholar
  11. 11.
    Sánchez-Meca J, Rosa-Alcázar AI, Iniesta-Sepúlveda M, Rosa-Alcázar Á (2014) Differential efficacy of cognitive–behavioral therapy and pharmacological treatments for pediatric obsessive–compulsive disorder: a meta-analysis. J Anxiety Disord 28:31–44CrossRefPubMedGoogle Scholar
  12. 12.
    Geller DA, Biederman J, Stewart SE, Mullin B, Farrell C, Wagner KD (2003) Impact of comorbidity on treatment response to paroxetine in pediatric obsessive–compulsive disorder: is the use of exclusion criteria empirically supported in randomized clinical trials? J Child Adolesc Psychopharmacol 13:19–29CrossRefGoogle Scholar
  13. 13.
    Storch EA, Merlo LJ, Larson MJ, Geffken GR, Lehmkuhl HD, Jacob ML (2008) Impact of comorbidity on cognitive–behavioral therapy response in pediatric obsessive–compulsive disorder. J Am Acad Child Adolesc Psychiatry 47:583–592CrossRefPubMedGoogle Scholar
  14. 14.
    Storch EA, Björgvinsson T, Riemann B, Lewin AB, Morales MJ, Murphy TK (2010) Factors associated with poor response in cognitive–behavioral therapy for pediatric obsessive–compulsive disorder. Bull Menninger Clin 74:167CrossRefPubMedGoogle Scholar
  15. 15.
    Ung D, Selles R, Small BJ, Storch EA (2015) A systematic review and meta-analysis of cognitive–behavioral therapy for anxiety in youth with high-functioning autism spectrum disorders. Child Psychiatry Hum Dev 46:533–547CrossRefPubMedGoogle Scholar
  16. 16.
    Sofronoff K, Attwood T, Hinton S (2005) A randomized controlled trial of a CBT intervention for anxiety in children with Asperger syndrome. J Child Psychol Psychiatry 46:1152–1160CrossRefPubMedGoogle Scholar
  17. 17.
    Reaven JA, Blakeley-Smith A, Nichols S, Dasari M, Flanigan E, Hepburn S (2009) Cognitive–behavioral group treatment for anxiety symptoms in children with high-functioning autism spectrum disorders a pilot study. Focus Autism Other Dev Disabl 24:27–37CrossRefGoogle Scholar
  18. 18.
    White SW, Albano AM, Johnson CR, Kasari C, Ollendick T, Klin A (2010) Development of a cognitive–behavioral intervention program to treat anxiety and social deficits in teens with high-functioning autism. Clin Child Fam Psychol Rev 13:77–90CrossRefPubMedPubMedCentralGoogle Scholar
  19. 19.
    Storch EA, Lewin AB, Collier AB, Arnold E, De Nadai AS, Dane BF (2014) A randomized controlled trial of cognitive–behavioral therapy versus treatment as usual for adolescents with autism spectrum disorders and comorbid anxiety. ‎Depress Anxiety 32:174–181CrossRefPubMedPubMedCentralGoogle Scholar
  20. 20.
    Sze KM, Wood JJ (2007) Cognitive behavioral treatment of comorbid anxiety disorders and social difficulties in children with high-functioning autism: a case report. J Contemp Psychother 37:133–143CrossRefGoogle Scholar
  21. 21.
    Wood JJ, Drahota A, Sze K, Har K, Chiu A, Langer DA (2009) Cognitive behavioral therapy for anxiety in children with autism spectrum disorders: a randomized, controlled trial. J Child Psychol Psychiatry 50:224–234CrossRefPubMedPubMedCentralGoogle Scholar
  22. 22.
    Wood JJ, Ehrenreich-May J, Alessandri M, Fujii C, Renno P, Laugeson E (2015) Cognitive behavioral therapy for early adolescents with autism spectrum disorders and clinical anxiety: a randomized, controlled trial. Behav Ther 46:7–19CrossRefPubMedGoogle Scholar
  23. 23.
    White SW, Ollendick T, Albano AM, Oswald D, Johnson C, Southam-Gerow MA (2013) Randomized controlled trial: multimodal anxiety and social skill intervention for adolescents with autism spectrum disorder. ‎J Autism Dev Disord 43:382–394CrossRefPubMedPubMedCentralGoogle Scholar
  24. 24.
    El-Ghoroury NH, Krackow E (2011) A developmental–behavioral approach to outpatient psychotherapy with children with autism spectrum disorders. J Contemp Psychother 41:11–17CrossRefGoogle Scholar
  25. 25.
    Elliott SJ, Fitzsimons L (2014) Modified CBT for treatment of OCD in a 7-year-old boy with ASD—a case report. J Child Adolesc Psychiatr Nurs 27:156–159CrossRefPubMedGoogle Scholar
  26. 26.
    Lehmkuhl HD, Storch EA, Bodfish JW, Geffken GR (2008) Brief report: exposure and response prevention for obsessive compulsive disorder in a 12-year-old with autism. J Autism Dev Disord 38:977–981CrossRefPubMedPubMedCentralGoogle Scholar
  27. 27.
    Nadeau JM, Arnold EB, Storch EA, Lewin AB (2014) Family cognitive–behavioral treatment for a child with autism and comorbid obsessive compulsive disorder. ‎Clin Case Stud 13:22–36CrossRefGoogle Scholar
  28. 28.
    Reaven J, Hepburn S (2003) Cognitive–behavioral treatment of obsessive–compulsive disorder in a child with asperger syndrome:a case report. Autism 7:145–164CrossRefPubMedGoogle Scholar
  29. 29.
    Rooney M, Alfano CA, Walsh KS, Parr AF (2011) Differential diagnosis and treatment of obsessive–compulsive, inattentive, and sleep symptoms in a 7-year-old with PDD-NOS. Clin Case Stud 10:133–146CrossRefGoogle Scholar
  30. 30.
    Murray K, Jassi A, Mataix-Cols D, Barrow F, Krebs G (2015) Outcomes of cognitive behaviour therapy for obsessive–compulsive disorder in young people with and without autism spectrum disorders: a case controlled study. Psychiatry Res 228:8–13CrossRefPubMedGoogle Scholar
  31. 31.
    Russell AJ, Mataix-Cols D, Anson MAW, Murphy DGM (2009) Psychological treatment for obsessive–compulsive disorder in people with autism spectrum disorders–a pilot study. Psychother Psychosom 78:59–61CrossRefPubMedGoogle Scholar
  32. 32.
    Russell AJ, Jassi A, Fullana MA, Mack H, Johnston K, Heyman I, Mataix-Cols D (2013) Cognitive behavior therapy for comorbid obsessive–compulsive disorder in high-functioning autism spectrum disorders: a randomized controlled trial. Depress Anxiety 30:697–708CrossRefPubMedGoogle Scholar
  33. 33.
    Vause T, Neil N, Jaksic H, Jackiewicz G, Feldman M (2015) Preliminary randomized trial of function-based cognitive–behavioral therapy to treat obsessive compulsive behavior in children with autism spectrum disorder. Focus Autism Other Dev Disabl. doi: 10.1177/1088357615588517 Google Scholar
  34. 34.
    Scahill L, Riddle MA, McSwiggin-Hardin M, Ort SI, King RA, Goodman WK (1997) Children’s Yale-Brown obsessive compulsive scale: reliability and validity. J Am Acad Child Adolesc Psychiatry 36:844–852CrossRefPubMedGoogle Scholar
  35. 35.
    AACAP (2012) Practice parameter for the assessment and treatment of children and adolescents with obsessive–compulsive disorder. J Am Acad Child Adolesc Psychiatry 51:98–113CrossRefGoogle Scholar
  36. 36.
    Storch EA, Bagner DM, Geffken GR, Adkins JW, Murphy TK, Goodman WK (2007) Sequential cognitive–behavioral therapy for children with obsessive–compulsive disorder with an inadequate medication response: a case series of five patients. Depress Anxiety 24:375–381CrossRefPubMedGoogle Scholar
  37. 37.
    Goodwin R, Koenen KC, Hellman F, Guardino M, Struening E (2002) Helpseeking and access to mental health treatment for obsessive–compulsive disorder. Acta Psychiatr Scand 106:143–149CrossRefPubMedGoogle Scholar
  38. 38.
    Kessler RC, Avenevoli S, Costello EJ, Georgiades K, Green JG, Gruber MJ et al (2012) Prevalence, persistence, and sociodemographic correlates of DSM-IV disorders in the National Comorbidity Survey Replication Adolescent Supplement. Arch Gen Psychiatry 69:372–380CrossRefPubMedGoogle Scholar
  39. 39.
    Kessler RC, Berglund P, Demler O, Jin R, Merikangas KR, Walters EE (2005) Lifetime prevalence and age-of-onset distributions of DSM-IV disorders in the National Comorbidity Survey Replication. Arch Gen Psychiatry 62:593–602CrossRefPubMedGoogle Scholar
  40. 40.
    Oswald TM, Winter-Messiers MA, Gibson B, Schmidt AM, Herr CM, Solomon M (2016) Sex differences in internalizing problems during adolescence in autism spectrum disorder. J Autism Dev Disord 46:624–636CrossRefPubMedGoogle Scholar
  41. 41.
    Rosa-Alcázar AI, Sánchez-Meca J, Rosa-Alcázar Á, Iniesta-Sepúlveda M, Olivares-Rodríguez J, Parada-Navas JL (2015) Psychological treatment of obsessive–compulsive disorder in children and adolescents: a meta-analysis. Span J Psychol 18:e20CrossRefPubMedGoogle Scholar
  42. 42.
    Leckman JF, Sholomskas D, Thompson D, Belanger A, Weissman MM (1982) Best estimate of lifetime psychiatric diagnosis: a methodological study. Arch Gen Psychiatry 39:879CrossRefPubMedGoogle Scholar
  43. 43.
    Iniesta-Sepúlveda M, Rosa-Alcázar AI, Rosa-Alcázar Á, Storch EA (2014) Evidence-based assessment in children and adolescents with obsessive–compulsive disorder. J Child Fam Stud 23:1455–1470CrossRefGoogle Scholar
  44. 44.
    Storch EA, Murphy TK, Geffken GR, Soto O, Sajid M, Allen P et al (2004) Psychometric evaluation of the Children’s Yale–Brown obsessive–Compulsive Scale. Psychiatry Res 129:91–98CrossRefPubMedGoogle Scholar
  45. 45.
    Wu MS, McGuire J, Arnold E, Lewin A, Murphy T, Storch EA (2014) Psychometric properties of the Children’s Yale-Brown Obsessive Compulsive Scale in Youth with Autism Spectrum Disorders and obsessive–Compulsive Symptoms. Child Psychiatry Hum Dev 45:201–211CrossRefPubMedGoogle Scholar
  46. 46.
    Bird HR, Andrews H, Schwab-Stone M, Goodman S, Dulcan M, Richters J et al (1996) Global measures of impairment for epidemiologic and clinical use with children and adolescents. Int J Methods Psychiatr Res 6:295–307CrossRefGoogle Scholar
  47. 47.
    Endicott J, Nee J, Yang R, Wohlberg C (2006) Pediatric quality of life enjoyment and satisfaction questionnaire (PQ-LES-Q): reliability and validity. J Am Acad Child Adolesc Psychiatry 45:401–407CrossRefPubMedGoogle Scholar
  48. 48.
    Birmaher B, Khetarpal S, Brent D, Cully M, Balach L, Kaufman J, Neer SM (1997) The screen for child anxiety related emotional disorders (SCARED): scale construction and psychometric characteristics. J Am Acad Child Adolesc Psychiatry 36:545–553CrossRefPubMedGoogle Scholar
  49. 49.
    Stern JA, Gadgil MS, Blakeley-Smith A, Reaven JA, Hepburn SL (2014) Psychometric properties of the SCARED in youth with autism spectrum disorder. Res Autism Spectr Disord 8:1225–1234CrossRefPubMedPubMedCentralGoogle Scholar
  50. 50.
    Irwin DE, Stucky B, Langer MM, Thissen D, DeWitt EM, Lai JS et al (2010) An item response analysis of the pediatric PROMIS anxiety and depressive symptoms scales. Qual Life Res 19:595–607CrossRefPubMedPubMedCentralGoogle Scholar
  51. 51.
    NIMH (1985) Rating scales and assessment instruments for use in pediatric psychopharmacology research. Psychopharmacol Bull 21:839–843Google Scholar
  52. 52.
    Lewin AB, Piacentini J (2010) Evidence-based assessment of child obsessive compulsive disorder: recommendations for clinical practice and treatment research. Child Youth Care Forum 39:73–89CrossRefPubMedPubMedCentralGoogle Scholar
  53. 53.
    Pituch KA, Green VA, Didden R, Lang R, O’Reilly MF, Lancioni GE, Sigafoos J (2011). Parent reported treatment priorities for children with autism spectrum disorders. Res Autism Spectr Disord 5:135–143CrossRefGoogle Scholar
  54. 54.
    Storch EA, Lewin AB, De Nadai AS, Murphy TK (2010) Defining treatment response and remission in obsessive–compulsive disorder: a signal detection analysis of the Children’s Yale-Brown Obsessive Compulsive Scale. J Am Acad Child Adolesc Psychiatry 49:708–717PubMedGoogle Scholar
  55. 55.
    Storch EA, Arnold EB, Lewin AB, Nadeau JM, Jones AM, De Nadai AS et al (2013) The effect of cognitive–behavioral therapy versus treatment as usual for anxiety in children with autism spectrum disorders: a randomized, controlled trial. J Am Acad Child Adolesc Psychiatry 52:132–142CrossRefPubMedGoogle Scholar
  56. 56.
    Conelea CA, Freeman JB (2015) What do therapists and clients do during exposures for OCD? Introduction to the special issue on theory-based exposure process. J Obsessive Compuls Relat Disord 6:144–146CrossRefGoogle Scholar
  57. 57.
    Taboas WR, McKay D, Whiteside SP, Storch EA (2015) Parental involvement in youth anxiety treatment: conceptual bases, controversies, and recommendations for intervention. J Anxiety Disord 30:16–18CrossRefPubMedGoogle Scholar
  58. 58.
    Whiteside SP, McKay D, De Nadai AS, Tiede MS, Ale CM, Storch EA (2014) A baseline controlled examination of a 5-day intensive treatment for pediatric obsessive–compulsive disorder. Psychiatry Res 220:441–446CrossRefPubMedGoogle Scholar
  59. 59.
    Storch EA, Lehmkuhl HD, Ricketts E, Geffken GR, Marien W, Murphy TK (2010) An open trial of intensive family based cognitive–behavioral therapy in youth with obsessive–compulsive disorder who are medication partial responders or nonresponders. J Clin Child Adolesc Psychol 39:260–268CrossRefPubMedGoogle Scholar
  60. 60.
    Kerns CM, Kendall PC, Berry L, Souders MC, Franklin ME, Schultz RT et al (2014) Traditional and atypical presentations of anxiety in youth with autism spectrum disorder. J Autism Dev Disord 44:2851–2861CrossRefPubMedPubMedCentralGoogle Scholar

Copyright information

© Springer Science+Business Media New York 2017

Authors and Affiliations

  1. 1.Department of PsychologyCatholic University of MurciaMurciaSpain
  2. 2.Department of EducationCatholic University of MurciaGuadalupeSpain
  3. 3.Department of PediatricsUniversity of South FloridaSt. PetersburgUSA
  4. 4.Rogers Memorial HospitalOconomowocUSA
  5. 5.Department of Health Policy and ManagementUniversity of South FloridaTampaUSA
  6. 6.Department of Psychiatry and Behavioral NeurosciencesUniversity of South FloridaSt. PetersburgUSA
  7. 7.Department of PsychologyUniversity of South FloridaSt. PetersburgUSA
  8. 8.All Children’s Hospital – Johns Hopkins MedicineSt. PetersburgUSA

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