cbt family therapy case study

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Cognitive-Behavioral Therapy for a 9-Year-Old Girl With Disruptive Mood Dysregulation Disorder

Megan e. tudor.

1 Yale School of Medicine, New Haven, CT, USA

Karim Ibrahim

Emilie bertschinger, justyna piasecka, denis g. sukhodolsky.

Disruptive mood dysregulation disorder (DMDD) is a relatively new diagnosis in the field of childhood onset disorders. Characterized by both behavior and mood disruption, DMDD is a purportedly unique clinical presentation with few relevant treatment studies to date. The current case study presents the application of cognitive-behavioral therapy (CBT) for anger and aggression in a 9-year-old girl with DMDD, co-occurring attention deficit hyperactivity disorder (ADHD), and a history of unspecified anxiety disorder. At the time of intake evaluation, she demonstrated three to four temper outbursts and two to three episodes of aggressive behavior per week, in addition to prolonged displays of non-episodic irritability lasting hours or days at a time. A total of 12 CBT sessions were conducted over 12 weeks and 5 follow-up booster sessions were completed over a subsequent 3-month period. Irritability-related material was specially designed to target the DMDD clinical presentation. Post-treatment and 3-month follow-up assessments, including independent evaluation, demonstrated significant decreases in the target symptoms of anger, aggression, and irritability. Although the complexities of diagnosing and treating DMDD warrant extensive research inquiry, the current case study suggests CBT for anger and aggression as a viable treatment for affected youth.

1 Theoretical and Research Basis for Treatment

Anger, aggression, and irritability in youth are associated with various clinical diagnoses, including attention deficit hyperactivity disorder (ADHD), oppositional defiant disorder (ODD), and depression ( G. A. Carlson, Danzig, Dougherty, Bufferd, & Klein, 2016 ; Stringaris, 2011 ; Sukhodolsky, Smith, McCauley, Ibrahim, & Piasecka, 2016 ). A more recent diagnostic category now exists that also captures these symptoms: disruptive mood dysregulation disorder (DMDD; American Psychiatric Association [APA], 2013 ). DMDD is a childhood onset disorder characterized by at least three severe temper outbursts per week with distress that is disproportionate to emotional triggers. Furthermore, mood between these outbursts is disrupted, with children presenting as irritable or angry at least 50% of their waking hours. To meet criteria for the diagnosis, irritability symptoms should be present for at least 12 months without symptom-free intervals longer than 3 months. DMDD has significant overlap with symptoms of both disruptive behavior and mood disorders ( Dougherty et al., 2014 ; Mayes, Waxmonsky, Calhoun, & Bixler, 2016 ), leading to contention as to whether or not DMDD is truly a distinct diagnostic category ( Noller, 2016 ; Runions et al., 2016 ; Wakefield, 2013 ). Nevertheless, the Diagnostic and Statistical Manual of Mental Disorders (5th ed.; DSM-5 ; APA, 2013 ) includes DMDD as such ( APA, 2013 ; Roy, Lopes, & Klein, 2014 ), thus warranting further research on related assessment and treatment.

Children and adolescents with DMDD may benefit from behavioral interventions for anger and aggression. A large evidence base exists for cognitive-behavioral therapy (CBT) as a treatment for anger and aggression ( Sukhodolsky, Kassinove, & Gorman, 2004 ). Because anger outbursts, angry mood, and aggression are the core symptoms of DMDD, CBT may also be useful for children who meet diagnostic criteria for this newly characterized disorder.

Treatment studies related to DMDD are rare, despite converging evidence that DMDD may be common among clinic-referred youth ( Freeman, Youngstrom, Youngstrom, & Findling, 2016 ) and stable throughout childhood development ( Mayes et al., 2015 ). Two studies have demonstrated some effectiveness of treating concurrent ADHD and disruptive mood symptoms in children ( Baweja et al., 2016 ; Blader et al., 2016 ). One randomized controlled trial (RCT) to date has examined psychotherapeutic treatment effectiveness, specifically for youth with psychostimulant-medicated ADHD and an earlier diagnostic iteration of DMDD, known as severe mood dysregulation (SMD; Waxmonsky et al., 2015 ). The treatment program, ADHD plus Impairments in Mood (AIM), drew from extant CBT, behavioral parent training (BPT), and problem-solving models to target children’s awareness of and responses to mood dysregulation. Irritability symptoms were measured by the three items (temper loss, angry or sad mood, and hyperarousal) on two clinical parent interviews that focus on disruptive behaviors in children: the Washington University of St. Louis Kiddie Schedule for Affective Disorders and Schizophrenia (WASH-U-KSADS; Geller et al., 2001 ) and the Disruptive Behavior Disorders Structured Parent Interview (DBD-I; Hartung, McCarthy, Milich, & Martin, 2005 ). Disruptive behaviors were shown to significantly decrease in the experimental treatment versus an active control, whereas effects on the measured mood symptoms were not significant. Temper outbursts decreased during the course of treatment but were reported to substantially increase during treatment follow-up phase. Overall, the study indicates that behavioral interventions built from CBT and parent management training (PMT) principles may be helpful in youth with DMDD, though time-limited booster sessions may be warranted to maintain treatment benefits.

Many questions regarding the treatment of DMDD in children remain, especially in an individual therapy format. The present case study allows for an initial exploration of specially tailored CBT for anger and aggression ( Sukhodolsky & Scahill, 2012 ) as a viable treatment for a child with DMDD.

2 Case Introduction

“Bella” was a 9-year-old Hispanic girl whose mother enrolled her in our RCT for youth with anger and aggression ( Sukhodolsky, Vander Wyk et al., 2016 ). This ongoing RCT subscribes to a Research Domain Criteria (RDoC) approach by identifying dimensions of behavior and related neural markers that are not confined to specific diagnostic categories ( Cuthbert, 2014 ). Thus, Bella’s presentation of multiple diagnoses (explained below) complemented a trans-diagnostic approach to treating a broader spectrum of irritable behavior. Following assessment protocol, Bella was randomly assigned to CBT treatment (as opposed to supportive psychotherapy).

3 Presenting Complaints

Bella’s mother sought treatment due to increasing disruptive behaviors over the past year, including non-compliance at home and at school, physical aggression toward peers, and frequent behavioral meltdowns which resembled the temper tantrums of a much younger child. Tantrums included screaming, yelling, slamming doors, and crying. Triggers could include being asked to take her daily medication or feeling that someone was standing too close to her. Bella and her mother both noted that it was difficult for Bella to “move on” when something angered her. She also noted that Bella had an underlying irritable mood, manifesting as Bella appearing “cranky” the majority of the time and the family feeling they needed to “walk on eggshells” to avoid upset. Bella was at risk for suspension from her sports teams due to recurrent unprovoked aggression toward her teammates. At school, at least one phone call home per week was being placed due to Bella’s refusal to comply or sometimes to even speak to her teacher for days at a time. Bella and her mother noted that Bella was generally well liked by peers and teachers, given that she was hardworking and funny, yet her current disruptive behaviors were causing significant interference in making new friends and meeting academic goals.

Bella lived with her mother, stepfather, and three older siblings. She visited with her father who lived nearby approximately once per month. Bella’s mother denied any pre- or perinatal complications and stated that Bella met developmental milestones on time. Behavioral difficulties reportedly began around age 3, where Bella’s mother noted that she was extremely active and markedly stubborn. These concerns were exacerbated in the school setting and, by age 6, Bella participated in a pediatric evaluation that yielded a diagnosis of ADHD-Combined presentation due to ongoing difficulties with inattention and hyperactivity that were impeding her academic performance. Bella’s history was further complicated by persistent difficulties with math and related anxiety about math performance. These combinations of symptoms led to the provision of a school 504 plan that afforded Bella intensive math support, extra time on tests, and classroom breaks, as needed. At the time of intake, Bella was attending fourth grade in mainstream classes and described herself as doing well in school, save for assignments in math assignments which remained her least favored subject.

Bella had not participated in any form of psychological treatment prior to participating in our treatment study. Bella was prescribed Stratera (18 mg/day) at age 7 by her pediatrician, which was maintained at the time of our intake interview and throughout treatment. In our study, we include participants with either no medication or stable medication regimens, though medication management is not provided. Stratera is a brand name version of atomoxetine, a selective norepinephrine reuptake inhibitor. Although psychostimulant medication is generally recommended as the first-line treatment for ADHD in children ( Blader et al., 2016 ), there are sometimes reasons for prescribing alternative medications such as atomoxetine ( Pliszka, 2007 ). According to Bella’s mother, at age 7, Bella presented with mild anxiety, particularly related to school performance. Comorbid anxiety has been observed in 25% to 35% of children diagnosed with ADHD, and atomoxetine is accepted as effective with this dual diagnosis ( Hammerness, McCarthy, Mancuso, Gendron, & Geller, 2009 ). Overall, this relatively low dose of medication had reportedly proven useful in addressing both anxiety and ADHD symptoms for Bella and, according to our team’s psychiatry consultants, was appropriate for progressing with therapy without psychiatric re-evaluation.

Our study does not provide medication management or consultation regarding medication that children are receiving in the community. Children are eligible to participate if medication has been stable without plans for change for the 4-month study period. We generally only recommend psychiatric evaluation or re-evaluation for ADHD symptoms if these symptoms are clearly an underlying factor in the participant’s anger and aggression, or if symptoms grossly affect the participant’s ability to understand the material or engage in treatment. Neither of these descriptions applied to Bella, who met criteria for ADHD diagnosis based on clinical interview and was in the borderline clinical range on parent report measures ( T = 68 on the Attention Deficit/Hyperactivity subscale of the Child Behavior Checklist [CBCL]; Achenbach & Rescorla, 2001 ), but whose symptoms appeared relatively non-impairing at the time of intake.

5 Assessment

As part of the study, Bella and her mother were administered comprehensive assessments of irritability and associated psychopathology, including clinical interviews and parent report measures. With Bella’s assessment, we maintained adherence to the study protocol, which only required participation of one parent. However, we would have been happy to obtain information from Bella’s father or engage him in the study process if it had been requested by the family. In addition, Bella and her mother stated that behavior presentation was largely similar across the two households.

Diagnostic Interview

DSM-5 diagnoses were assigned based on the structured interview conducted by an experienced clinical psychologist (last author). The Kiddie Schedule for Affective Disorder and Schizophrenia for School-Age Children, Present and Lifetime (K-SADS-PL; Kaufman et al., 1997 ) is a diagnostic interview that assesses psychopathology in children based on child and parent report. Interview questions are presented to both children and parents separately, followed by integration of both informants’ report. DMDD symptoms were evaluated by the K-SADS addendum ( Leibenluft, 2011 ). DMDD symptoms are coded as “Not present,” “Sub-threshold,” or “Threshold” for DSM-5 diagnostic criteria. At the time of the interview, Bella’s prior diagnosis of ADHD-Combined presentation was confirmed due to impairing symptoms of inattention, distractibility, and hyperactivity, though these symptoms were reportedly significantly decreased and minimally impairing since medication prescription at age 7. Her preexisting community diagnosis of unspecified anxiety disorder was not confirmed with K-SADS; both Bella and her mother reported occasional bouts of worry about school performance but not to the frequency or intensity that warrants clinical diagnosis.

Per the K-SADS, Bella and her mother shared that Bella typically presented with out-of-control 30-min temper outbursts approximately 3 to 5 times per week. Outbursts consistently appeared out of proportion to the situation at hand and reportedly resembled that of a much younger child, around 3 to 4 years old. Outbursts consisted of screaming, crying, insulting others, and general non-compliance occurring at home and, less often, in the community (e.g., in the grocery store, at the sidelines of a soccer match). In between outbursts, Bella’s mood was described as generally “cranky” and her mother described feeling that she was “walking on eggshells” around Bella. Bella’s mother shared that this irritability occurred approximately 75% of the time, with Bella appearing neutral or cheerful the remaining 25% of each day. Bella’s persistently angry and irritable presentation was not only endorsed by her mother but also her elder siblings, teacher, and soccer coach. Opposition and defiance were noted since age 3; however, the outbursts and irritability described here had manifested for approximately 2 years preceding assessment (since age 7). The longest symptom-free period was as a few days, and such bouts were reportedly rare. Overall, symptoms were described as causing impairment for Bella in her family relationships, friendships, and school performance. The obtained symptom profile, in addition to the absence of past or current mania, warranted a diagnosis of DMDD. Of note, Bella also met criteria for ODD; however, a diagnosis of DMDD contraindicates ODD diagnosis ( APA, 2013 ).

Of note, we do not collect teacher ratings as part of study assessment procedure, although sometimes families bring copies of past assessments that include teacher ratings. However, in clinical settings, it is advisable to collect teacher ratings of ADHD as well as symptoms of other behavioral and mood disorders. For example, clinicians could seek out teacher report versions of the parent report measures described below, to then be integrated into the clinical assessment. Further information gathering can include discussion of core DMDD symptoms with teachers or other school professionals in order to better understand presentation of these symptoms across multiple settings.

Parent Report Measures

Bella’s mother filled out a battery of parent report measures. Scores on the measures of anger/irritability and aggression are presented in Table 1 . The 18-item CBCL–Aggressive Behavior subscale ( Achenbach & Rescorla, 2001 ) was completed as a “gold standard” measure of aggressive behavior and yielded a clinically elevated score for Bella. The Affective Reactivity Index (ARI; Stringaris et al., 2012 ) consists of seven items, six of which are averaged as an index of irritability. Youth with SMD were reported to have an average score of 7 on this measure. As such, Bella’s score of 10 reflected clinical elevation. The Disruptive Behavior Rating Scale (DBRS; Barkley, 1997 ) is an eight-item measure keyed to the DSM symptoms of ODD. A mean DBRS score of 12 and above indicates clinically significant symptoms, and Bella’s score of 13 was above this clinical threshold. Parent ratings of depression and anxiety conducted per the Child Depression Inventory ( Kovacs, 2011 ) and the Multidimensional Anxiety Scale for Children ( March, 2012 ) indicated that Bella was experiencing normative levels of internalizing symptoms. Together, these parent ratings indicated that Bella’s particular presentation of DMDD was characterized by externalizing behaviors and irritability, rather than depressive mood.

Pre-Treatment, Post-Treatment, and Follow-Up Assessments.

Note . MOAS = Modified Overt Aggression Scale; CGI-I = Clinical Global Impression–Improvement score (as compared with baseline functioning); CBCL = Child Behavior Checklist ( t scores); ARI = Affective Reactivity Index; DBRS = Disruptive Behavior Rating Scale.

Aggressive behavior was measured using the Modified Overt Aggression Scale (MOAS; Silver & Yudofsky, 1991 ; Yudofsky, Silver, Jackson, Endicott, & Williams, 1986 ) tailored to the assessment of aggression in clinical trials ( Blader, Schooler, Jensen, Pliszka, & Kafantaris, 2009 ). The MOAS was administered as an interview with the parent and child (separately) by an independent evaluator (licensed clinical social worker) who was not involved in treatment and was unaware of the treatment that Bella was receiving. The MOAS is used as a primary outcome measure in the relevant clinical trial ( Sukhodolsky, Vander Wyk et al., 2016 ) and consists of 16 items related to the aggressive behavior over the past week. Items are weighted based on potential harm and create four aggression subscales, including Verbal Aggression, Aggression Against Objects, Self-Directed Aggression, and Aggression Against Others. Bella evidenced significant levels of aggressive behaviors in all subscales excepting for self-directed aggression, resulting in an overall score of 32. For example, Bella was reported as presenting with three aggressive incidents (e.g., punching) toward non-relative peers in the week preceding evaluation.

Target Symptoms

In addition to the MOAS, the independent evaluator also elicited the two most pressing concerns in the area of anger and aggression and described these concerns, which are referred to as “target symptoms.” Target symptoms are coded in terms of frequency, duration, severity, and impact on adaptive functioning across all contexts ( McGuire et al., 2014 ). Bella’s target symptoms were (a) anger outbursts and meltdowns, characterized by verbal aggression and subsequent “shutting down,” with refusal to comply or communicate, and (b) physical aggression, such as hitting, punching, and shoving which most commonly occurred toward sports teammates, classmates, and her older brother.

Intellectual Functioning

Per study protocol, Bella completed the Wechsler Abbreviated Scale of Intelligence (WASI), indicating a verbal IQ of 93, a performance IQ of 99, and a full-scale IQ of 96. Overall, this intellectual functioning screener suggested that Bella’s intelligence was uniform across abilities and fell in the Average range of functioning. These results indicated that Bella would be a good candidate for the CBT content and activities ( Lickel, MacLean, Blakeley-Smith, & Hepburn, 2012 ).

6 Case Conceptualization

Bella, like many youth with ADHD, exhibited disruptive behavior concurrent with inattention and hyperactivity symptoms ( C. L. Carlson, Tamm, & Gaub, 1997 ). Although pharmacological treatment significantly decreased Bella’s school difficulties by age 7, anger and aggression persisted. Evidence suggests that children like Bella may possess an inherent predisposition for irritability, including impaired functioning in the amygdala and frontal lobe ( Vidal-Ribas, Brotman, Valdivieso, Leibenluft, & Stringaris, 2016 ). Her early onset of irritable behavior and aggression may have resulted in teachers and family members responding in an inadvertently reinforcing manner, for example, separating Bella from other children versus problem solving. Thus, Bella’s clinical profile reflected both a predisposition to disruptive behavior and an interaction with her environment that resulted in interference with developmental maturation of emotion regulation or social skills that were expected for her age. In addition to disruptive behaviors, Bella has also experienced some academic difficulties, particularly in the area of math. Academic performance became a source of anxiety which further compounded non-compliance with homework and behavioral problems at school. As such, Bella had learned from a young age to primarily communicate her negative emotions through avoidance, physical aggression, and tantrums, which were reinforced by Bella’s attainment of desired goals (e.g., a child going away or obeying her demands, family offering her several hours of personal space). Alone, these behaviors would have warranted a diagnosis of ODD. For Bella, however, her prolonged instances of angry and irritable mood in between temper outbursts indicated a diagnosis of DMDD. It is also important to note that early onset of ADHD and co-occurring symptoms of anxiety are also consistent with the diagnosis of DMDD ( Dougherty et al., 2014 ; Mulraney et al., 2015 ; Uran & Kılıç, 2015 ).

Although Bella demonstrated many strengths, such as athletic ability and sense of humor, many of her social experiences became overshadowed by negative interactions, which were interfering with her enjoyment of home and school life. As such, our treatment goal was to replace Bella’s maladaptive anger outbursts and aggressive behaviors with age-appropriate skills of managing frustration and communicating with others. Simultaneously, Bella’s mother was taught parenting tools for supporting Bella’s progress in learning of new emotion regulation and problem-solving skills.

7 Course of Treatment and Assessment of Progress

Bella and her mother were seen by a post-doctoral clinical psychologist (first author) for 12 weekly 60-min CBT sessions. Then, she participated in five booster sessions over the subsequent 3 months. Our program typically offers three booster sessions; however, additional booster sessions were requested by the family to maintain treatment gains. We agreed to provide extra boosters because in a recently published study of behavioral intervention for children with SMD, immediate irritability-related treatment gains were not maintained at 6-week follow-up ( Waxmonsky et al., 2015 ). Manualized CBT for anger and aggression in youth was administered using a structured treatment manual ( Sukhodolsky & Scahill, 2012 ). The treatment is organized into three modules: emotion regulation, social problem solving, and social skills.

After each session, children received a therapeutic homework, which is referred to as “anger management practice” with the child to avoid using the word homework . As part of this practice, children are asked to fill out an anger management log, different for each session, which asks for specific examples of using each skill discussed in the last session in the context of an angry or aggressive outburst, whether anger management strategies were implemented successfully or unsuccessfully. Completion of anger logs is rewarded at the next session with enthusiastic praise from the therapist and small prizes when developmentally appropriate. Parenting skills are also integrated into treatment and coached during additional parenting sessions.

The manual includes built-in flexibility features that allow the child and the therapist to select therapeutic techniques and activities that match the child’s developmental level and target symptoms. Additional material was integrated that focused on DMDD-specific symptoms (described further below). Progress was assessed through the battery of interview and parent report measures described previously, which were conducted before and after treatment, and following a 3-month “booster” phase. Treatment progress was also discussed at weekly check-ins with Bella’s mother about the form, frequency, duration, and intensity of Bella’s target symptoms (i.e., temper outbursts, physical aggression).

Emotion Regulation and Anger Management

Sessions 1 to 3 involved an introduction to therapy, psychoeducation, identification of anger triggers, and the development of strategies to prevent anger episodes, such as scripting verbal reminders and relaxation training. Bella responded well to this phase of treatment and was particularly impressed that there were alternative approaches to handling angry behaviors. She stated that she was unaware that anger could be changed. Bella’s anger triggers typically included the perception that peers or family members had wronged her and the desire to “teach them” it was not okay through yelling or aggression. For example, immediately preceding the first session, Bella had punched a basketball teammate for “putting her hands on” her. Bella’s mother confirmed that the girl had simply brushed against Bella while walking by her. Bella took to silently singing a popular song lyric, “Stop! Wait a minute!” in her mind when recognizing an anger cue or early signs of anger escalation (e.g., a 1 or a 2 on her 5-point anger thermometer), and then engaging in deep breathing or reciting verbal reminders to guide her behaviors, such as, “You are going to get in trouble” or “Maybe this isn’t something to get worked up over.” Each week, Bella earned small prizes (e.g., shopkins) for completing anger management practice logs that described her handling of an anger-provoking episode.

Social Problem Solving

Sessions 4 to 6 covered social problem-solving skills including problem identification, generating different solutions, and evaluating the possible consequences to reduce conflict. Identifying the differences between responses that are passive, assertive , or aggressive was especially useful in enhancing Bella’s ability to generating solutions to conflicts. The therapist helped Bella and her mother to collaborate on developing behavioral contracts to prevent specific conflicts at home. For instance, Bella initially presented with a 5- to 10-min anger outbursts approximately 5 times per week when asked to take her medication. This occurred despite the fact that Bella’s mother did not alter the request and, ultimately, Bella took her medication successfully each time. In treatment, Bella agreed to calmly and immediately take her medication each night and her mother agreed to take her to get doughnuts every Saturday based on that behavior. Subsequently, Bella’s tantrums regarding medication decreased to 0 within 2 weeks and maintained for the several subsequent months of treatment.

Bella also excelled at decreasing her hostile attribution bias by reframing her previously negative perceptions of others’ intentions. She recognized that many past incidents where she believed that people were attempting to bother or assault her were misunderstood. Bella showed pride in her new ways of handling these situations, making statements like, “People want to be my friend more now. They used to think I was cool but kind of crazy. Now they just think I am cool.”

Social Skills

Sessions 7 to 9 addressed social skills for preventing and resolving conflicts or anger-provoking situations with siblings, peers, teachers, and family. Potential solutions to conflicts were role-played in session, for example, acting out how to calmly handle disagreements with friends about what to play or how to politely ask her brother to stop teasing her. For example, when playing with others, Bella practiced asking for the opinions of her friends, like, “Would you all like to play it this way?” rather than insisting that they play her way at the beginning of a play session (e.g., “I’m in charge, I don’t care if you don’t like it”). These skills were practiced in session with her therapist playing the part of other children who may disagree, which was effective in escalating anger and allowing for practice of positive interactions. Monitoring of voice tone and facial expression was exercised through the use of video recording, thereby helping Bella monitor and modify her outward expression of anger. Bella agreed that these skills contributed to more positive play time and more fun with her friends, which she noted as a more important goal than getting her way.

Importantly, Bella practiced simply stating, “I need help” or “I need a break” when feeling upset, rather than using harsh words or physical aggression. Her teacher and family reinforced this effective communication by calmly and briefly discussing the situation at hand, problem solving, and allowing Bella some alone time, as needed. These communication skills were integral in decreasing aggression, as Bella felt that she had a new tool for resolving social problems that did not put her at risk for getting in trouble (unlike punching others).

Parent Training

Parents are an integral component in CBT for anger and aggression ( Sukhodolsky & Scahill, 2012 ). Three separate 60-min sessions were conducted with Bella’s mother to address family conflict and provide strategies for encouraging positive behaviors such as giving praise, attention, and privileges. This duration of sessions was sufficient with Bella’s treatment, although more flexibility may be required in other cases. The treatment manual suggests conducting parent sessions in conjunction with the first, middle, and final CBT sessions, though flexible administration is often required due to family scheduling needs and to ensure that parent training coincides effectively with CBT sessions. Treatment progress and skills covered in each CBT session were also reviewed with the parent at each visit so that parents could track and reward application of new anger management skills at home. These parenting skills were especially important to Bella’s progress, given that she was growing up in a household with multiple siblings and expected behaviors often went unnoticed, whereas misbehavior resulted in one-on-one attention. In parenting sessions, the converse response was practiced with Bella’s mother, wherein “shut down mode” or yelling received no attention, whereas Bella’s problem solving and use of other coping strategies received praise and encouragement.

School Consultation

To maximize treatment gains in the school setting, Bella’s therapist had intermittent phone conversations with Bella’s fourth-grade schoolteacher. Target behaviors (e.g., decreasing aggression, increasing compliance) and related strategies (e.g., Bella’s recognition of anger cues, practicing effective communication in place of aggression) were relayed to Bella’s teacher, who was eager to encourage Bella’s progress in the school setting through prompting and praise. Bella’s teacher provided invaluable insight into behavioral progress, including report that Bella’s decrease in irritable behaviors made her more amenable to math tutoring. Subsequently, Bella arrived to several sessions sharing about success with math during the previous week.

Adapting Treatment for DMDD

Although much of the extant CBT treatment manual was appropriate for addressing Bella’s target behaviors of aggression and tantrums, some specialized material was integrated into Bella’s care to target the prolonged periods of irritability she demonstrated at home, school, and, sometimes, in the therapy session. These adaptations included (a) extending psychoeducation, (b) emphasizing on behavioral activation, (c) building an emotion regulation template for reducing duration of irritable mood periods, and (d) including extra booster sessions during the 3-month booster period (five instead of the usual three sessions). Psychoeducation included characteristics of prolonged irritable episodes, such as specific triggers, the common feeling of being “stuck” in that mood, and creating a creative metaphor for the irritable mood. Bella described her prolonged irritable episodes as “shut down mode” wherein her brain withdrew and could only react “in a snappy way” toward others. This allowed Bella to quickly identify irritability and remind herself that it was possible to coach her brain to “reverse shut down mode” where she could enjoy herself and interactions with others.

Behavioral activation was used to reduce prolonged periods of negative mood (e.g., Pass, Whitney, & Reynolds, 2016 ). Specifically, Bella maintained a list of enjoyable activities she could do in any setting to help herself keep active and busy, which, in turn, reduced the intensity of her “shut down mode” and increased her chances of being happy. For example, she would read, watch television, or ask family members to play with her during these instances. Prior to treatment, when in “shut down mode,” she was most likely to retreat to her room and dwell on the situation that triggered her anger.

Last, although decreasing irritability was an important goal, it was also recognized that some occasional irritable mood is typical, especially after a child is particularly disappointed or frustrated. As such, Bella and her mother collaborated with the therapist to identify a goal for the form and duration of irritable behavior. Specifically, Bella decided that 20 min of alone time, which she would request of her family calmly, would be sufficient to take part in a fun activity and help her “move on,” to which her mother agreed. These skills were especially relevant during the booster sessions of therapy, likely because tantrums and aggression had significantly decreased and “shut down mode” became a more pressing behavioral concern.

Post-Treatment Assessments

All outcome data are presented in Table 1 . Bella’s improvement was assessed following 12 sessions of CBT (and also at follow-up, presented in the “Follow-Up” section below). All post-treatment measures indicated a significant decrease in anger/irritability and aggression and fell within the normative range of functioning.

MOAS score reduced from 32 to 2, demonstrating that Bella had exhibited zero instances of verbal or physical aggression in the past week, and only one instance involving property damage: slamming a door when asked to clean her room before watching a movie. At that time, her mother noted that “shutting down” occurred once during the past week and was disruptive to family activities. As such, this behavior was targeted in later booster sessions.

The independent evaluator assigned a Clinical Global Impression-Improvement (CGI-I) score as a primary categorical outcome measure in the present research study ( Arnold et al., 2003 ). This score indicates the level of behavioral change from baseline rated on a 7-point scale (1 = very much improved ; 7 = very much worse ). Bella’s target symptoms of decreasing meltdowns and decreasing physical aggression were rated as 1 “ very much improved .”

8 Complicating Factors

Bella’s irritability served as a mildly complicating factor in two treatment sessions (Session 5 and a booster session). Specifically, irritability and opposition presented to a degree that limited Bella’s engagement in session material. In both occurrences, Bella was angered by something that occurred prior to session and initially refused to speak to her therapist. Although these instances were challenging in terms of completing planned session material, they were recognized as inherent to Bella’s target symptoms and, ultimately, helpful in exercising in-vivo practice of emotion regulation skills. Fortunately, Bella and her therapist were always able to end these sessions on a positive and meaningful note by offering validation and clear contingencies that both modeled and rewarded behavior activation (e.g., “I’m sorry to see you are having a rough day, Bella. When you are ready to talk, let me know. I want to ask you one question about the past week and then I have a very funny video to show you!”). These potentially complicating factors are especially important for the consideration of students and professionals, and are addressed further in “Recommendations to Clinicians and Students” section.

9 Access and Barriers to Care

It is important to note that the current treatment was conducted as part of a research study and, thus, may not reflect the typical clinic environment. As part of the study, the family received free clinical services, monetary compensation for their time, and flexible scheduling options. These characteristics of the study likely lessened the burden of participation for the family, who did not report any significant difficulties with completing all study visits. A family of a child referred to an outpatient clinic for a similar treatment would be responsible for the treatment cost, without compensation for time dedicated to assessment and treatment, which could limit some families’ ability to access and complete treatment.

10 Follow-Up

Bella participated in five booster sessions over the course of 3 months, immediately following the completion of the standard 12 CBT sessions offered as part of our research study. These sessions were designed to review and reinforce the content of the therapy program and to identify ongoing areas of need. These sessions are administered once per month on average, although in Bella’s case, we added two additional sessions to address DMDD symptoms. In Bella’s case, these boosters were useful for check-ins regarding irritability and behavioral activation skills, which were relevant to the remaining behavioral goals at that time. Our study typically offers three booster sessions for families but, given past evidence that suggests the utility of follow-up sessions for youth with DMDD ( Waxmonsky et al., 2015 ), two additional sessions appeared appropriate. Bella and her mother noted that these sessions were helpful at maintaining progress and continuing to target irritability goals. This report was supported by the follow-up data that were consistent with data collected post treatment (see Table 1 ). During the week preceding follow-up assessment, she was reported to have slammed a door three times when frustrated by homework assignments related to math. No instances of “shut down” were reported.

Following study completion, the family was encouraged to seek out consultation from the team should any concerns arise regarding Bella’s behavior management. No such requests have been made (4 months post study at the time of manuscript preparation).

11 Treatment Implications of the Case

The current case demonstrates the feasibility of CBT for anger and aggression in children with DMDD. No existing studies have examined individually administered CBT for anger and aggression in youth with DMDD, though the need thereof is increasingly important as this new diagnosis gains clinical attention ( Leibenluft, 2011 ; Roy et al., 2014 ). Our current case study shows how a child with DMDD can be effectively treated with a structured CBT for anger and aggression treatment ( Sukhodolsky & Scahill, 2012 ) enhanced with psychoeducation and behavioral activation strategies ( Hopko, Lejuez, Ruggiero, & Eifert, 2003 ). The enhancements to the CBT program may have been especially important to Bella’s excellent response to treatment. The five booster sessions allowed for a more gradual transition out of therapy and focused on decreasing non-episodic irritability, which may have been key to her long-term progress. These results are in contrast to previous findings that treatment gains were not maintained 3 months after group therapy for SMD ( Waxmonsky et al., 2015 ).

Notably, Bella was a participant in our ongoing randomized controlled study that tests the utility of CBT for irritability in children across diagnostic categories. This study is based on the RDoC initiative ( National Institutes of Mental Health, 2016 ) that aims to explore the core dimensions of psychopathology based on neurobiology and behavior, as opposed to the traditional categorical approach to diagnosis. Ultimately, RDoC attempts to integrate findings in genetics, neurology, molecular biology, cognitive science, and other disciplines to better inform our diagnostic classification system. The Negative Valence System, one of the five RDoC domains, encapsulates anger and aggression—the variables targeted in Bella’s treatment. Applying a treatment for a core symptom area (anger and aggression) rather than a specific diagnosis may have been ideal in treating Bella. Given DMDD’s high co-morbidity with other DSM diagnoses, including ADHD, and its significant overlap with ODD and depression, treatment of a specific categorical diagnosis would be challenging and likely misguided. In addition, almost all childhood psychiatric diagnoses are associated with increased risk of aggression ( Jensen et al., 2007 ). If a treatment such as CBT for anger and aggression can be implemented successfully across diagnostic categories, it may decrease the need for diagnostic precision in an imperfect system such as the DSM-5 . The current case study indicates that this singular treatment may be applied and/or modified to effectively treat a core symptom area in children that meets criteria for various DSM-5 disorders. It will be especially useful to identify other treatment packages that may be applied trans-diagnostically, especially for commonly co-occurring disorders in youth.

A benefit of the current treatment may be the ease of implementation across professionals. Bella’s provider possessed a PhD in clinical psychology, whereas other clinicians in our current study are psychology graduate students and child and adolescent psychiatry fellows. This flexibility in implementation may be particularly relevant for treatment of children with DMDD who may present with psychiatry referrals. Potential psychopharmacologic treatments for DMDD that have been suggested might include antidepressants, mood stabilizers, stimulants, and antipsychotics ( Tourian et al., 2015 ); however, medication alone may not be ideal. Medications, of course, are not without side effects, many of them significant and/or requiring regular monitoring over the course of treatment, including with blood work. In addition, given that there are two distinct symptoms clusters being treated in DMDD—irritable or depressed mood and angry outbursts—it is reasonable to conclude that in many cases, more than one medication might be required to treat symptoms. Our CBT program with some modification appears to be effective in treating DMDD over a short period of time with minimal modifications and, as such, may be ideal for first-line treatment for youth DMDD, particularly those who present with irritable mood in between outbursts.

Bella’s presentation did not reflect the symptom profile of some other youth DMDD. Namely, while she experienced significant and impairing irritability, she did not experience depressive symptoms such as withdrawal, anhedonia, or suicidal ideation. Therefore, the treatment implications of the current case are cautioned in terms of application to youth experiencing depressive mood between anger outbursts, wherein additional or different modifications would likely be warranted for treatment results and, above all, patient safety. It is of interest to note that behavioral but not mood symptom changes were an outcome of group therapy for SMD ( Waxmonsky et al., 2015 ), which further speaks to the complex nature of treating the co-occurring symptoms captured by DMDD. Furthermore, the same must be stated in reference to anxiety symptoms, which commonly co-occur with DMDD but were not endorsed for Bella. Youth with DMDD and significant anxiety may benefit from additional anxiety-focused behavioral interventions (i.e., exposure and response prevention).

Another caution toward the current results is the fact that Bella was receiving medication for ADHD and mild anxiety. The medication was stable during the study, and it is unknown what effect the treatment would have had in a child with the same diagnostic profile without medication. Lastly, the fact that the current case study focuses on a female is not to be overlooked. Like all disruptive behavioral disorders, early evidence suggests that females may be less likely to be given a diagnosis of DMDD ( Dougherty et al., 2014 ; Tufan et al., 2016 ). We are glad to provide evidence of treatment utility with a female patient, given that they may be less likely to be featured in this area of child psychology, though further study of treatment implications as they differ (or do not differ) across the sexes is warranted.

12 Recommendations to Clinicians and Students

Although we have previously stated that CBT for anger and aggression can be delivered by a range of clinicians, it is important that clinicians feel familiar and competent with delivering the complete manual prior to starting treatment. The modules reflect a variety of themes and strategies that may be useful to children; however, a high degree of flexibility is recommended ( Kendall & Beidas, 2007 ). For example, it can be useful to improvise and incorporate material from later sessions if that material is pertinent to a child’s presenting complaint on a given day. Furthermore, some children may dislike particular strategies (e.g., deep breathing), and it is significantly more important to maintain a strong therapeutic alliance by collaborating on goals and strategies than it is to achieve 100% fidelity for every session. In fact, as part of our current research study, an 80% fidelity rating is encouraged.

In addition, children with DMDD can be difficult to engage with due to both their baseline anger and irritability, as well as recurrent temper outbursts or meltdowns. It is likely that the clinician will experience at least one disruptive behavior episode (or many more) during session. These incidents are par for the course and, perhaps in a counterintuitive manner, are extremely beneficial to the child’s progress in treatment. Specifically, therapists are able to demonstrate appropriate behavioral contingencies and extinction schedules that will be useful for parents to observe. Bella, for example, once came to session angry at her sister and refused to speak to her therapist. The therapist use the opportunity to remind Bella of the skills she could apply to “turn it around” and checked in with Bella’s mother until Bella was observed putting effort into that goal (i.e., taking deep breaths, attempting to join the conversation), at which time she was praised and given a choice of a fun activity. Thus, Bella’s mother was able to observe selective attention, which can be a particularly difficult parenting skill for parents of children with disruptive behavior, and Bella was able to practice skills with the direct support of her clinician. We encourage clinicians and students not to dread disruptive behavior in session, but rather to welcome it as a unique and effective learning opportunity. However, clinicians must, of course, have a sound understanding of behavioral intervention to successfully respond to such incidents.

As with any type of behavioral modification, progress can be quite gradual. It may take several sessions before the child “buys in” to the treatment. It can be helpful to frame the treatment in terms of tangible benefits for the child; there is often a noticeable switch where the child recognizes that decreasing anger and aggression leads to specific and appreciable outcomes. For example, most children will recognize that hitting a peer will make that peer less likely to play with them in the future, even if they feel that the peer “deserves it,” or that insulting a teacher will lead to them getting detention even if they feel it is “unfair.” It is important to remember that these children often have a long history of feeling that they are “bad,” and an integral component of treatment is to counter this belief. A strong rapport can be built in the first session, simply by validating the child’s point of view and listening to recent difficulties without criticism. It is often helpful to alert the children that nothing shared in session will get them into trouble and, in fact, that the goal of therapy is to help them get in trouble less and enjoy their day-to-day life more. Ultimately, it is ideal for the child to recognize how their behavioral change will benefit them in their day-to-day life, which usually leads to them feeling proud about their efforts and accomplishments.

The parent check-ins at the end of each session are crucial to the success of the therapy. As outlined in the manual, be sure to stress to the parents during the first session how important it is to consistently praise positive behavior and to “catch the child being good.” At each parent check-in, the parent should provide a concrete example to the clinician of the child engaging in a positive behavior or attempting to apply skills and tools learned during the previous CBT session. Due to the “review” nature of these check-ins, a notable risk is present that the parent and/or child will attempt to use the time to simply list complaints about the past week, which is counterproductive to long-term progress. As such, clinicians should troubleshoot specific concerns and integrate them into session material (e.g., problem solving) but should also assertively request “highlights” of the past week. In addition, it can be helpful to supplement the three parent sessions and parent check-ins with concepts and tools from Parent Management Training, including structured behavior plans for the home. The clinician should also remind parents that the goal of treatment is not 100% remission. Occasional outbursts are a normal part of development and are not always pathological. It is best to frame the child’s success in terms of a decrease in the frequency and intensity of the target symptoms that were defined at the beginning of the treatment.

It is also important to point out to clinicians and students that the study of treatment for DMDD is new. Here, we present the results of an extant treatment that was adapted for a child with DMDD. It would be remiss for us to imply that this may be the only viable treatment for youth with DMDD, though it is difficult to expound upon treatment alternatives. Nevertheless, as mentioned previously, DMDD overlaps with other diagnostic categories that have long-standing evidence for the utility of cognitive (e.g., Boxer & Butkus, 2005 ), behavioral (e.g., Folino, Ducharme, & Conn, 2008 ; Rote & Dunstan, 2011 ), and combined (e.g., Pass et al., 2016 ) approaches to treatment. We are not currently aware of an evidence-based psychotherapeutic approach that would be definitively distinct from the CBT treatment presented here.

Last, as shown in the current case, these youth are likely to present with a complex history and multiple diagnoses, including ADHD and internalizing disorders. Thus, it is important for clinicians and students working with these youth to be well versed in a variety of clinical presentations, as well as related behavioral and pharmacological treatments. Furthermore, in the age of RDoC, clinical training will likely benefit from integrating behavioral treatments for core symptoms—such as anger and aggression. Such a training priority may help to serve a larger population of youth, including those with more complex clinical presentations such as DMDD.

Acknowledgments

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This study is supported by National Institute of Mental Health (Grant/Award Number “R01 MH101514” to Drs. Denis Sukhodolsky and Kevin Pelphrey).

Biographies

Megan E. Tudor , PhD, is a postdoctoral associate at the Yale Child Study Center where she conducts clinical research, including diagnostic assessment and therapy for research participants. Her research interests relate to imporoving clinical services for youth with a variety of neurodevelopmental and behavioral disorders, as well as their family members.

Karim Ibrahim , MS, is a former trainee of the Yale Child Study Center where his focus was on behavioral interventions for autism and disruptive behavior disorders. He is a doctoral candidate in clinical psychology at the University of Hartford.

Emilie Bertschinger , BA, is a post-graduate associate at the Yale Child Study Center. She completed her bachelor’s in psychology at Boston University in 2015. She coordinates the clinical research study described in the current case study.

Justyna Pasecka , MD, is a fellow in the Solnit Integrated Training Program in Adult and Child Psychiatry at the Yale Child Study Center. She will complete her training in 2017 and will continue providing clinical services with children and adolescents.

Denis G. Sukhodolsky , PhD, is an associate professor and director of the Evidence-Based Practice Unit at the Yale Child Study Center. His lab conducts research on the efficacy and mechanisms of behavioral treatmetns for children with neurodevelopmental disorders such as autism spectrum disorder, Tourette syndrome, OCD, anxiety, and disruptive behavior disorder.

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.

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How to Write a Case Conceptualization: 10 Examples (+ PDF)

Such understanding can be developed by reading relevant records, meeting with clients face to face, and using assessments such as a mental status examination.

As you proceed, you are forming a guiding concept of who this client is, how they became who they are, and where their personal journey might be heading.

Such a guiding concept, which will shape any needed interventions, is called a case conceptualization, and we will examine various examples in this article.

Before you continue, we thought you might like to download our three Positive CBT Exercises for free . These science-based exercises will provide you with detailed insight into positive Cognitive-Behavioral Therapy (CBT) and give you the tools to apply it in your therapy or coaching.

This Article Contains:

What is a case conceptualization or formulation, 4 things to include in your case formulation, a helpful example & model, 3 samples of case formulations, 6 templates and worksheets for counselors, relevant resources from positivepsychology.com, a take-home message.

In psychology and related fields, a case conceptualization summarizes the key facts and findings from an evaluation to provide guidance for recommendations.

This is typically the evaluation of an individual, although you can extend the concept of case conceptualization to summarizing findings about a group or organization.

Based on the case conceptualization, recommendations can be made to improve a client’s self-care , mental status, job performance, etc (Sperry & Sperry, 2020).

• Summary of the client’s identifying information, referral questions, and timeline of important events or factors in their life . A timeline can be especially helpful in understanding how the client’s strengths and limitations have evolved.
• Statement of the client’s core strengths . Identifying core strengths in the client’s life should help guide any recommendations, including how strengths might be used to offset limitations.
• Statement concerning a client’s limitations or weaknesses . This will also help guide any recommendations. If a weakness is worth mentioning in a case conceptualization, it is worth writing a recommendation about it.

Note: As with mental status examinations , observations in this context concerning weaknesses are not value judgments, about whether the client is a good person, etc. The observations are clinical judgments meant to guide recommendations.

• A summary of how the strengths, limitations, and other key information about a client inform diagnosis and prognosis .

You should briefly clarify how you arrived at a given diagnosis. For example, why do you believe a personality disorder is primary, rather than a major depressive disorder?

Many clinicians provide diagnoses in formal psychiatric terms, per the International Classification of Diseases (ICD-10) or Diagnostic and Statistical Manual of Mental Disorders (DSM-5). Some clinicians will state a diagnosis in less formal terms that do not coincide exactly with ICD-10 or DSM-5 codes. What is arguably more important is that a diagnostic impression, formal or not, gives a clear sense of who the person is and the support they need to reach their goals.

Prognosis is a forecast about whether the client’s condition can be expected to improve, worsen, or remain stable. Prognosis can be difficult, as it often depends on unforeseeable factors. However, this should not keep you from offering a conservative opinion on a client’s expected course, provided treatment recommendations are followed.

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Based on the pointers for writing a case conceptualization above, an example for summarizing an adolescent case (in this instance, a counseling case for relieving depression and improving social skills) might read as follows.

Background and referral information

This is a 15-year-old Haitian–American youth, referred by his mother for concerns about self-isolation, depression, and poor social skills. He reportedly moved with his mother to the United States three years ago.

He reportedly misses his life and friends in Haiti. The mother states he has had difficulty adjusting socially in the United States, especially with peers. He has become increasingly self-isolating, appears sad and irritable, and has started to refuse to go to school.

His mother is very supportive and aware of his emotional–behavioral needs. The youth has been enrolled in a social skills group at school and has attended three sessions, with some reported benefit. He is agreeable to start individual counseling. He reportedly does well in school academically when he applies himself.

Limitations

Behavioral form completed by his mother shows elevated depression scale (T score = 80). There is a milder elevation on the inattention scale (T score = 60), which suggests depression is more acute than inattention and might drive it.

He is also elevated on a scale measuring social skills and involvement (T score = 65). Here too, it is reasonable to assume that depression is driving social isolation and difficulty relating to peers, especially since while living in Haiti, he was reportedly quite social with peers.

Diagnostic impressions, treatment guidance, prognosis

This youth’s history, presentation on interview, and results of emotional–behavioral forms suggest some difficulty with depression, likely contributing to social isolation. As he has no prior reported history of depression, this is most likely a reaction to missing his former home and difficulty adjusting to his new school and peers.

Treatments should include individual counseling with an evidence-based approach such as Cognitive-Behavioral Therapy (CBT). His counselor should consider emotional processing and social skills building as well.

Prognosis is favorable, with anticipated benefit apparent within 12 sessions of CBT.

How to write a case conceptualization: An outline

The following outline is necessarily general. It can be modified as needed, with points excluded or added, depending on the case.

• Client’s gender, age, level of education, vocational status, marital status
• Referred by whom, why, and for what type of service (e.g., testing, counseling, coaching)
• In the spirit of strengths-based assessment, consider listing the client’s strengths first, before any limitations.
• Consider the full range of positive factors supporting the client.
• Physical health
• Family support
• Financial resources
• Capacity to work
• Resilience or other positive personality traits
• Emotional stability
• Cognitive strengths, per history and testing
• The client’s limitations or relative weaknesses should be described in a way that highlights those most needing attention or treatment.
• Medical conditions affecting daily functioning
• Lack of family or other social support
• Limited financial resources
• Inability to find or hold suitable employment
• Substance abuse or dependence
• Proneness to interpersonal conflict
• Emotional–behavioral problems, including anxious or depressive symptoms
• Cognitive deficits, per history and testing
• Diagnoses that are warranted can be given in either DSM-5 or ICD-10 terms.
• There can be more than one diagnosis given. If that’s the case, consider describing these in terms of primary diagnosis, secondary diagnosis, etc.
• The primary diagnosis should best encompass the client’s key symptoms or traits, best explain their behavior, or most need treatment.
• Take care to avoid over-assigning multiple and potentially overlapping diagnoses.

When writing a case conceptualization, always keep in mind the timeline of significant events or factors in the examinee’s life.

• Decide which events or factors are significant enough to include in a case conceptualization.
• When these points are placed in a timeline, they help you understand how the person has evolved to become who they are now.
• A good timeline can also help you understand which factors in a person’s life might be causative for others. For example, if a person has suffered a frontal head injury in the past year, this might help explain their changeable moods, presence of depressive disorder, etc.

Sample #1: Conceptualization for CBT case

This is a 35-year-old Caucasian man referred by his physician for treatment of generalized anxiety.

Strengths/supports in his case include willingness to engage in treatment, high average intelligence per recent cognitive testing, supportive family, and regular physical exercise (running).

Limiting factors include relatively low stress coping skills, frequent migraines (likely stress related), and relative social isolation (partly due to some anxiety about social skills).

The client’s presentation on interview and review of medical/psychiatric records show a history of chronic worry, including frequent worries about his wife’s health and his finances. He meets criteria for DSM-5 generalized anxiety disorder. He has also described occasional panic-type episodes, which do not currently meet full criteria for panic disorder but could develop into such without preventive therapy.

Treatments should include CBT for generalized anxiety, including keeping a worry journal; regular assessment of anxiety levels with Penn State Worry Questionnaire and/or Beck Anxiety Inventory; cognitive restructuring around negative beliefs that reinforce anxiety; and practice of relaxation techniques, such as progressive muscle relaxation and diaphragmatic breathing .

Prognosis is good, given the evidence for efficacy of CBT for anxiety disorders generally (Hofmann, Asnaani, Vonk, Sawyer, & Fang, 2012).

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Sample #2: Conceptualization for DBT case

This 51-year-old Haitian–American woman is self-referred for depressive symptoms, including reported moods of “rage,” “sadness,” and “emptiness.” She says that many of her difficulties involve family, friends, and coworkers who regularly “disrespect” her and “plot against her behind her back.”

Her current psychiatrist has diagnosed her with personality disorder with borderline features, but she doubts the accuracy of this diagnosis.

Strengths/supports include a willingness to engage in treatment, highly developed and marketable computer programming skills, and engagement in leisure activities such as playing backgammon with friends.

Limiting factors include low stress coping skills, mild difficulties with attention and recent memory (likely due in part to depressive affect), and a tendency to self-medicate with alcohol when feeling depressed.

The client’s presentation on interview, review of medical/psychiatric records, and results of MMPI-2 personality inventory corroborate her psychiatrist’s diagnosis of borderline personality disorder.

The diagnosis is supported by a longstanding history of unstable identity, volatile personal relationships with fear of being abandoned, feelings of emptiness, reactive depressive disorder with suicidal gestures, and lack of insight into interpersonal difficulties that have resulted in her often stressed and depressive state.

Treatments should emphasize a DBT group that her psychiatrist has encouraged her to attend but to which she has not yet gone. There should also be regular individual counseling emphasizing DBT skills including mindfulness or present moment focus, building interpersonal skills, emotional regulation, and distress tolerance. There should be a counseling element for limiting alcohol use. Cognitive exercises are also recommended.

Of note, DBT is the only evidence-based treatment for borderline personality disorder (May, Richardi, & Barth, 2016). Prognosis is guardedly optimistic, provided she engages in both group and individual DBT treatments on a weekly basis, and these treatments continue without interruption for at least three months, with refresher sessions as needed.

Sample #3: Conceptualization in a family therapy case

This 45-year-old African-American woman was initially referred for individual therapy for “rapid mood swings” and a tendency to become embroiled in family conflicts. Several sessions of family therapy also appear indicated, and her psychiatrist concurs.

The client’s husband (50 years old) and son (25 years old, living with parents) were interviewed separately and together. When interviewed separately, her husband and son each indicated the client’s alcohol intake was “out of control,” and that she was consuming about six alcoholic beverages throughout the day, sometimes more.

Her husband and son each said the client was often too tired for household duties by the evening and often had rapid shifts in mood from happy to angry to “crying in her room.”

On individual interview, the client stated that her husband and son were each drinking about as much as she, that neither ever offered to help her with household duties, and that her son appeared unable to keep a job, which left him home most of the day, making demands on her for meals, etc.

On interview with the three family members, each acknowledged that the instances above were occurring at home, although father and son tended to blame most of the problems, including son’s difficulty maintaining employment, on the client and her drinking.

Strengths/supports in the family include a willingness of each member to engage in family sessions, awareness of supportive resources such as assistance for son’s job search, and a willingness by all to examine and reduce alcohol use by all family members as needed.

Limiting factors in this case include apparent tendency of all household members to drink to some excess, lack of insight by one or more family members as to how alcohol consumption is contributing to communication and other problems in the household, and a tendency by husband and son to make this client the family scapegoat.

The family dynamic can be conceptualized in this case through a DBT lens.

From this perspective, problems develop within the family when the environment is experienced by one or more members as invalidating and unsupportive. DBT skills with a nonjudgmental focus, active listening to others, reflecting each other’s feelings, and tolerance of distress in the moment should help to develop an environment that supports all family members and facilitates effective communication.

It appears that all family members in this case would benefit from engaging in the above DBT skills, to support and communicate with one another.

Prognosis is guardedly optimistic if family will engage in therapy with DBT elements for at least six sessions (with refresher sessions as needed).

Introduction to case conceptualization – Thomas Field

The following worksheets can be used for case conceptualization and planning.

• Case Conceptualization Worksheet: Individual Counseling helps counselors develop a case conceptualization for individual clients.
• Case Conceptualization Worksheet: Couples Counseling helps counselors develop a case conceptualization for couples.
• Case Conceptualization Worksheet: Family Counseling helps counselors develop a case conceptualization for families.
• Case Conceptualization and Action Plan: Individual Counseling helps clients facilitate conceptualization of their own case, at approximately six weeks into counseling and thereafter at appropriate intervals.
• Case Conceptualization and Action Plan: Couples Counseling helps couples facilitate conceptualization of their own case, at approximately six weeks into counseling and thereafter at appropriate intervals.
• Case Conceptualization and Action Plan: Family Counseling helps families facilitate conceptualization of their own case, at approximately six weeks into counseling and thereafter at appropriate intervals.

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The following resources can be found in the Positive Psychology Toolkit© , and their full versions can be accessed by a subscription.

Analyzing Strengths Use in Different Life Domains can help clients understand their notable strengths and which strengths can be used to more advantage in new contexts.

Family Strength Spotting is another relevant resource. Each family member fills out a worksheet detailing notable strengths of other family members. In reviewing all worksheets, each family member can gain a greater appreciation for other members’ strengths, note common or unique strengths, and determine how best to use these combined strengths to achieve family goals.

Four Front Assessment is another resource designed to help counselors conceptualize a case based on a client’s personal and environmental strengths and weaknesses. The idea behind this tool is that environmental factors in the broad sense, such as a supportive/unsupportive family, are too often overlooked in conceptualizing a case.

If you’re looking for more science-based ways to help others through CBT, check out this collection of 17 validated positive CBT tools for practitioners. Use them to help others overcome unhelpful thoughts and feelings and develop more positive behaviors.

In helping professions, success in working with clients depends first and foremost on how well you understand them.

This understanding is crystallized in a case conceptualization.

Case conceptualization helps answer key questions. Who is this client? How did they become who they are? What supports do they need to reach their goals?

The conceptualization itself depends on gathering all pertinent data on a given case, through record review, interview, behavioral observation, questionnaires completed by the client, etc.

Once the data is assembled, the counselor, coach, or other involved professional can focus on enumerating the client’s strengths, weaknesses, and limitations.

It is also often helpful to put the client’s strengths and limitations in a timeline so you can see how they have evolved and which factors might have contributed to the emergence of others.

Based on this in-depth understanding of the client, you can then tailor specific recommendations for enhancing their strengths, overcoming their weaknesses, and reaching their particular goals.

We hope you have enjoyed this discussion of how to conceptualize cases in the helping professions and that you will find some tools for doing so useful.

We hope you enjoyed reading this article. For more information, don’t forget to download our three Positive CBT Exercises for free .

• Hofmann, S. G., Asnaani, A., Vonk, I. J., Sawyer, A. T., & Fang, A. (2012). The efficacy of cognitive behavioral therapy: A review of meta-analyses. Cognitive Therapy and Research , 36 (5), 427–440.
• May, J. M., Richardi, T. M., & Barth, K. S. (2016). Dialectical behavior therapy as treatment for borderline personality disorder. The Mental Health Clinician , 6 (2), 62–67.
• Sperry, L., & Sperry, J. (2020).  Case conceptualization: Mastering this competency with ease and confidence . Routledge.

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Cognitive–Behavioral Family Therapy

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• Contributor bios
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When applied to families, the cognitive–behavioral therapeutic approach examines the interactional dynamics of family members and how they contribute to family functioning and dysfunction. In Cognitive–Behavioral Family Therapy , Dr. Frank M. Dattilio demonstrates a single-session intervention with a single mother and her three sons, identifying some of the automatic thoughts and schemas that exist among these family members.

This DVD depicts the manner in which a cognitive–behavioral approach can be addressed within a family structure, with the therapist engaging the family and highlighting issues that involve emotions, beliefs, and behavioral exchange.

Cognitive–behavioral family therapy is an approach that is conducted against the backdrop of systems theory and includes the premise that members of a family simultaneously influence and are influenced by each other.

The focus of this approach is placed on thoughts and behaviors and how the behavior of one family member leads to behaviors, cognitions, and emotions with other family members. This, in turn, elicits cognitions, behaviors, and emotions in reciprocal response.  As this cycle continues, the volatility of the family dynamics escalates, rendering family members vulnerable to a negative spiral of conflict.

Cognitive behavior therapy places a heavy emphasis on schema or what is otherwise known as "core beliefs." The primary aim of the approach is to help family members recognize distortions in their thinking based on erroneous information and restructure their thinking and modify their behavior in order to improve their interactional patterns.

The role of emotions is also important in this approach and is addressed through the use of cognitive appraisal, which plays a significant part in the interrelationships that exist. With this approach, restructuring distorted beliefs has a pivotal impact on regulating emotions and behaviors and vice versa.

Frank M. Dattilio, PhD, ABPP , is one of the leading figures in the world in cognitive behavior therapy. He maintains faculty appointments in the Department of Psychiatry at Harvard Medical School in Cambridge, Massachusetts, and the University of Pennsylvania School of Medicine in Philadelphia.

He is a licensed psychologist in the states of Pennsylvania, New Jersey, New York, and Delaware and is listed in the National Register of Health Service Providers in Psychology. He is also a clinical member of the American Association for Marriage and Family Therapy.

Dr. Dattilio is board certified in both clinical psychology and behavioral psychology through the American Board of Professional Psychology and received a certificate of training in forensic psychology through the Department of Psychiatry at the University of Pennsylvania School of Medicine, Philadelphia. He is also a founding fellow of the Academy of Cognitive Therapy. Dr. Dattilio has been a visiting faculty member at many major universities and medical schools throughout the world.

He is the recipient of numerous awards, including the award for Distinguished Psychologist by the APA's Division 29 (Psychotherapy) and the award for Distinguished Contributions to the Science and Profession of Psychology by the Pennsylvania Psychological Association. Dr. Dattilio has also been inducted into the prestigious College of Physicians of Philadelphia for his many contributions to medicine and science, and he is the recipient of the 2005 Association for Behavioral and Cognitive Therapies award for "Outstanding Contribution by an Individual for Clinical Activities." Dr. Dattilio also received the 2007 award for Distinguished Contributions to Psychology and Humankind by the Philadelphia Society of Clinical Psychology. He most recently received the Marriage and Family Therapist of the Year award for 2010 from the Pennsylvania Association of Marriage and Family Therapy.

Dr. Dattilio's active areas of research involve topics in cognitive behavior therapy, clinical and forensic psychology, and case-based investigations. He is featured in "Harvard Science."

Dr. Dattilio has over 250 professional publications and 18 books in the areas of anxiety disorders, forensic and clinical psychology, and marital and family discord. He has also presented extensively throughout the United States, Canada, Africa, Europe, South America, Asia, Australia, New Zealand, Mexico, Cuba, and the West Indies on both cognitive behavior therapy and forensic psychology. To date, his works have been translated into 28 languages and are used in 80 countries throughout the world.

Among his many publications, Dr. Dattilio is the author of Cognitive–Behavior Therapy with Couples and Families: A Comprehensive Guide for Clinicians (2010). He is also co-author of Crime and Mental Illness (2008); Practical Approaches to Forensic Mental Health Testimony (2007); Mental Health Experts: Roles and Qualifications for Court (1st ed., 2002; 2nd ed., 2007); Cognitive Therapy with Couples (1990); Panic Disorder: Assessment & Treatment Through a Wide Angle Lens (2000); The Family Psychotherapy Treatment Planner (2000; 2nd ed., 2010), and The Family Therapy Homework Planner (2000; 2nd ed., 2010); co-editor of Comprehensive Casebook of Cognitive Therapy (1992); Cognitive–Behavioral Strategies in Crisis Intervention (1994; 2nd ed., 2000; 3rd ed., 2007); Cognitive Therapy with Children and Adolescents: A Casebook for Clinical Practice (1995; 2nd ed., 2003); and Comparative Treatments for Couple Dysfunction (2000); and editor of Case Studies in Couples and Family Therapy: Systemic and Cognitive Perspectives (1998).

He has also filmed several professional videotapes and audiotapes including the popular series "Five Approaches to Linda" (Lehigh University Media, 1996) and remains on the editorial board of a number of national and international refereed journals, including the New England Journal of Medicine .

Dr. Dattilio's areas of expertise are in couple and family problems, forensic psychological evaluations, as well as the treatment of anxiety and behavior disorders.

• Dattilio, F. M. (Ed.). (1998). Case studies in couple and family therapy: Systemic and cognitive perspectives . New York, NY: The Guilford Press.
• Dattilio, F. M., & Beck, A. T. (2010). Cognitive–behavioral therapy with couples and families: A comprehensive guide for clinicians . New York, NY: The Guilford Press.
• Dattilio, F. M., & Freeman, A. (Eds.). (2010). Cognitive–behavioral strategies in crisis intervention (3rd ed.). New York, NY: The Guilford Press.
• Dattilio, F. M., & Padesky, C. A. (1990). Cognitive therapy with couples . Sarasota, FL: Professional Resource Exchange, Inc.
• Reinecke, M. A., Dattilio, F. M., & Freeman, A. (Eds.). (2006). Cognitive therapy with children and adolescents, second edition: A casebook for clinical practice . New York, NY: The Guilford Press.
• Cognitive–Behavioral Couples Therapy Arthur Freeman
• Cognitive–Behavioral Therapy for Clients With Multiple Problems Gayle Y. Iwamasa
• Cognitive–Behavioral Therapy for Perfectionism Over Time Martin M. Antony
• Cognitive–Behavioral Therapy Strategies Keith S. Dobson
• Cognitive–Behavioral Therapy With Donald Meichenbaum Donald Meichenbaum
• Cognitive Therapy Judith S. Beck
• Enhanced Cognitive–Behavioral Couple Therapy Donald H. Baucom
• Functional Family Therapy for High-Risk Adolescents James F. Alexander
• Stepfamily Therapy in Practice Scott Browning
• Cognitive Therapy Keith S. Dobson
• Enhanced Cognitive–Behavioral Therapy for Couples: A Contextual Approach Norman B. Epstein and Donald H. Baucom
• Family Therapy William J. Doherty and Susan H. McDaniel

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Cognitive Behaviour Therapy Case Studies

• Mike Thomas - University of Chester, UK
• Mandy Drake - University of Chester, UK
• Description

This distinctive practical format is ideal in showing how to put the principles of CBT and stepped care into effect. As well as echoing postgraduate level training, it provides an insight into the experiences the trainee will encounter in real-world practice. Each chapter addresses a specific client condition and covers initial referral, presentation and assessment, case formulation, treatment interventions, evaluation of CBT strategies and discharge planning. Specific presenting problems covered include:

- First onset and chronic Depression

- Social Phobia

- Obsessive-Compulsive Disorder

- Generalised Anxiety Disorder (GAD)

- Chronic Bulimia Nervosa and Anorexia nervosa

- Alcohol Addiction

- Personality Disorder

'This text is more than a cook book representation of CBT - it shows how some real-world creative work can be done'. - Michael Worrell, Consultant Clinical Psychologist & Programme Director CBT Training Programmes, CNWL Foundation Trust and Royal Holloway University of London

The contributors describe therapy experiences with people with problems ranging from depression and specific anxiety problems to personality disorder, and offer reflections on progress, as well as learning exercises and tips for clinical practice. 

Great resource for use in skills sessions. Provides more in-depth case studies that we can use across a number of courses.

This book helped my studetns explore real case and debate real solutions.

Excellent case studies for teaching, diverse range of clients and issues.

This is a good book for students to be aware of, when looking at the interventions for working with people with mental health problems.

This is an excellent text book, it gives a step by step guide for lecturers and students alike and is a must for every CBT practitioner.

Great text with well illustrated case examples for a range of different disorders.

As a lecturer I have found it's material useful in case discussions, formulations and role plays for students.

This is a good book. Being a researcher myself in the writings of case studies according to the CBT framework, I find this book essential for my students for they will be able to grasp not only the basics of how to write a CBT case study, but also to comprehend the elements which such research is constituted by

This is an excellent resource. Professor Thomas' in-depth knowledge of CBT enables him to present realistic case-studies. The introductory chapters provide a contemporary view of CBT before we are provided with detailed and varied case histories. I particularly liked the addition of a critique of each case study.

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Family Involvement in Cognitive-Behavioral Therapy for Children’s Anxiety Disorders

Cognitive-behavioral therapy (CBT) for children with anxiety disorders may be especially effective when the family is included in treatment.

July 2006, Vol. XXIII, No. 8

Cognitive-Behavioral Therapy for Adolescent Depression

Developing an Effective Treatment Protocol

Family Therapy in the Treatment of Depression

NAMI Programs Educate Families of Mentally Ill

From Prevention to Preemption: A Paradigm Shift in Psychiatry

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Cognitive-behavioral therapy (CBT) for children with anxiety disorders may be especially effective when the family is included in treatment. 1-3 Family CBT (FCBT) has consistently yielded a high proportion of treatment responders (more than 70%) and in some studies has outperformed CBT programs with little family involvement. 3 This article presents the rationale supporting FCBT, provides a case study illustrating FCBT techniques, and summarizes the findings of a recent clinical trial.

RATIONALE SUPPORTING FCBT

FCBT for children’s anxiety disorders draws on effective cognitive-behavioral techniques 4 and supplements these with targeted family interventions . A good description of fundamental CBT techniques was published in 2003. 5 CBT for children’s anxiety disorders consists of 2 phases: skills training, and application and practice. During the skills training phase, children are taught techniques for reappraisal of feared situations, relaxation, and self-reward. In the application and practice phase, a hierarchy is created in which feared situations are ordered from least to most distressing. Children work their way up the hierarchy and are rewarded as they attempt increasingly fearful activities.

Seven studies have compared versions of FCBT with versions of child-focused CBT (CCBT) with little family involvement for children presenting with anxiety disorders . 3 Five of the studies have reported some outcome measures favoring FCBT over CCBT at the posttreatment assessment, whereas no outcome measures have favored CCBT over FCBT. In contrast, there were no differences found between the FCBT and CCBT programs studied, 6,7 and some longer-term outcome studies have suggested that differences between FCBT and CCBT lessen over the course of time. Nonetheless, the extant evidence suggests that there may be some advantage of the FCBT paradigm, particularly with regard to immediate effects.

Most FCBT programs have not focused on the specific parenting practices that are hypothesized to contribute to the development and maintenance of anxiety in children. In comparison, the FCBT program Building Confidence (J.J. Wood et al, unpublished manual, 2006) was developed by drawing on basic research in parent-child interaction patterns in families of children with anxiety disorders, 8,9 with the goal of enhancing treatment effectiveness. These studies suggest that high levels of parental intrusiveness and a lack of parent-granted autonomy are linked with anxiety disorders in children.

Parents who act intrusively tend to take over tasks that children are (or could be) doing independently and impose an immature level of functioning on their children. Among schoolaged children, parental intrusiveness can manifest in at least 3 domains: unnecessary assistance with children’s daily routines (eg, dressing), infantilizing behavior (eg, using baby words, excessive physical affection), and invasions of privacy (eg, parents opening doors without knocking). 10 Parents who act intrusively are posited to interfere with the process of habituation (fear reduction) by preventing children from actually confronting feared but benign stimuli. 9,11 Conversely, parents who grant appropriate levels of autonomy may enhance children’s feelings of mastery and self-efficacy, 12 and thus contribute to the regulation of anxiety.

The Building Confidence FCBT manual goes beyond previous CBT programs by directly intervening with parental intrusiveness and parentgranted autonomy. 10 The Building Confidence program includes individual sessions with the child and complementary parent-training sessions. These parent-training sessions emphasize:

• Giving choices when children are indecisive (rather than making choices for them).
• Allowing children to struggle and learn by trial and error rather than taking over tasks for them.
• Labeling and accepting children’s emotional responses (rather than criticizing them).
• Promoting children’s acquisition of novel self-help skills.

An incentive system is also taught to parents to encourage their children’s courageous behavior. A typical FCBT session begins with a 20-minute individual meeting with the child to conduct skills training or application/practice. Skills are reviewed less thoroughly with the child than in CCBT, permitting time for parent-training (20 minutes) and conjoint parent-child meetings (10 minutes). The following case describes a child with separation anxiety, but the issues it raises are also applicable to other types of anxiety disorders.

Ben is an 11-year-old boy living with his single mother in a semirural area of California. They share a small apartment with another single mother and her school-aged son. Ben’s mother works from home and their income is below the poverty line.

Ben is a slender boy with a friendly smile who is extremely nervous about being away from his mother, a behavior that meets the criteria for separation anxiety disorder. He has missed 20 days of school in the 2 months before intake because of reluctance to be away from home, has left school early 5 times because he felt “sick,” and frequently goes to the nurse’s office in school. His pediatrician has found no medical problem that would explain these difficulties.

Ben sleeps in his mother’s bed every night. He is distressed by worries about his mother being in a car accident while he is away from her, a concern not based on previous experience. Ben has avoided playdates, team sports, and afterschool activities because of separation anxiety, causing his mother to worry about his social development. Ben is exceptionally well-behaved and polite, and he has a precocious sense of humor. He noticeably perked up when interacting with male clinicians, flopping around the therapy room in mock slapstick routines or rushing to initiate conversation about topics he thought would be of interest.

There are numerous signs of intrusive parenting: Ben’s mother encourages his sleeping with her; she showers with him and washes his hair (an atypical scenario for an 11- year-old), she dresses and undresses him, and grooms his hair (which tangles easily and is difficult to manage) on a daily basis. Despite receiving assistance from his mother during these routines, Ben is actually capable of self-care in each of these areas. Ben also often sits on his mother’s lap, both he and his mother assert that all of these interactions help him feel less anxious.

FCBT USING THE BUILDING CONFIDENCE PROGRAM

The case study illustrates a typical pre-sentation of a child with separation anxiety disorder. 10 Commonly, as in Ben’s case, sexual abuse is screened for and ruled out; nonetheless, the intrusive interactions in question are developmentally inappropriate. In Ben’s case, the interactions appeared to be unintentionally reinforcing to his mother, since she indicated that she enjoyed being able to “be there for him and comfort him.”

Paradoxically, such comforting seems to support Ben’s separation anxiety rather than eradicate it. He feels dependent on his mother’s comforting for the regulation of his anxiety, and when he is away from her he finds it challenging to cope with the anxiety he experiences. Child psychiatrists and psychologists do not always screen for these kinds of intrusive parenting behaviors and, therefore, may be unaware of the role such behaviors play in the maintenance of anxiety disorders in children.

Skills training and focus on autonomy-granting

The first 4 sessions of FCBT focus on teaching core CBT skills, such as positive self-talk, and core parenting skills that can facilitate a child’s independence and self-confidence. Ben was exceptionally motivated, thrived on praise from his therapist, and made rapid progress in learning CBT skills. Coping skills that were emphasized included challenging Ben’s worries about his mother’s safety (eg, “My mom has never been in a car accident before, how likely would it be?”). However, Ben’s separation anxiety symptoms were slow to remit early in treatment. A major focus of parent training was increasing parentgranted autonomy and reducing intrusiveness. In talking with Ben’s mother, it was noted that children feel more confident when they do things for themselves that others have previously done for them and that this confidence can lead to courageous behavior.

Like many parents, Ben’s mother seemed to be caught between agreement (“He is very clingy,” she would acknowledge) and doubt (“He is only 11; can’t he still be a little boy?”). She emphasized that Ben’s clingy behaviors were not burdensome to her. To address her ambivalence, several techniques were employed:

• Empathizing with her desire to keep Ben close to her.
• Warning her that without him becoming a bit more independent, Ben’s maladaptive anxiety-related behaviors were likely to get worse.
• Offering a plan of action that emphasized gradual changes in parent-child interaction.

Parent communication skills, such as giving choices, as described above, were taught to Ben’s mother to support his development of autonomous behaviors. (Note that all parent-training activities in FCBT are directly related to 1 of 2 goals: altering the targeted parent-child interaction patterns or enhancing the child’s application/practice of CBT skills.)

Initial steps in increasing autonomygranting and reducing intrusiveness were selected by Ben, who noted that showering on his own and dressing himself would not be a problem as long as his mother was somewhere in the house. In a family meeting, Ben presented this to his mother and a plan was made to try it out. At the following session, Ben was praised for his followthrough. The therapist assessed the progress of these independent skills during each session, and Ben would flash an enormous smile, proudly affirming his mastery of the self-help tasks. Hair-brushing was added to the list, and when his mother could not tolerate his “lack of skill,” she simply gave him a shorter haircut that was largely maintenance- free-an excellent solution that supported Ben’s autonomy.

Ben’s mother-while not undermining these changes-did express sadness about his emerging independence. This reaction was normalized by the therapist (“All parents feel this way as their children become more mature”). Frequent reminders of the treatment rationale, and particularly the important role parents play in children’s anxiety reduction (by supporting their autonomy), were helpful in maintaining the mother-therapist alliance, as well as the changes in family routines that had been achieved.

Skills application and practice with parent support

A key tenet of FCBT is that early increases in parent-granted autonomy and independent child behaviors in sessions 1 through 4 pave the way for (a) increased self-confidence in the child, which facilitates the child’s engagement in facing feared situations in sessions 5 through 16 and (b) parental adoption of communication techniques (eg, giving choices) that enhance the effectiveness of the application and practice phase of CBT.

Ben’s first task in the application/practice phase was returning to school, and the timing of this coincided closely with his upsurge in self-confidence following the independent behavior sessions. Typical CBT techniques for addressing school refusal were employed, 13 and Ben stayed at school for longer and longer periods each day. Though predictably nervous, he tried his hardest, focused on challenging his fearful thoughts about his mother’s safety, and successfully ignored his anxious feelings (which were labeled “false alarms”). Incentives offered by his mother (eg, earning television time) also helped promote his adherence to the school-return plan.

Ben returned to school full time by session 10, evidencing habituation and a humorous “blas” attitude about his success. It is worth additional emphasis that the rapidity and ease with which full school return was accomplished was facilitated by Ben’s early self-confidence in the independent skills exercises and by his mother’s use of parenting skills to support his autonomy, both of which are FCBT-specific strategies.

Reducing cosleeping-a key goal in separation anxiety treatment-proved to be a formidable challenge. Ben agreed in principle by session 8 to sleep in his own bed on a nightly basis, but his mother was noncommittal. Ben’s anxiety was moderately high about sleeping independently even after the many successes he had achieved by midtreatment. Without his complete investment in this task, and with his mother’s reticence about changing their routine, treatment progress plateaued for several sessions (Ben’s mother said they had simply forgotten to have him sleep by himself).

Two shifts in the therapist’s approach proved critical. First, to increase the mother’s motivation, it was noted to her that full remission of separation anxiety rarely occurs unless children sleep on their own (which is true, in our clinical experience) and that excessive anxiety could ultimately interfere with Ben’s social and intellectual development. Second, to increase Ben’s motivation, a checklist was made of a number of highly feared tasks that when completed would lead to what he considered a large reward (a video his mother agreed to purchase for him). This checklist included Ben sleeping independently for 4 weeks in a row, inviting children from school over at least 4 times, and joining an after-school activity (choices were given).

Of course, Ben was given help in applying CBT skills in preparation for these activities. It was thought that by appealing to both Ben and his mother, chances for success would be doubled compared with relying on the solitary (and wavering) motivation of either of them alone.

This multifaceted approach proved effective. Ben’s mother was sufficiently persuaded by the therapist’s logic to permit a trial of the sleeping plan, while Ben was quite invested in his checklist incentive program and began sleeping independently. Within 2 weeks, Ben’s ratings on a 0-to-10 anxiety scale indicated that he felt no anxiety when sleeping by himself (again, reflecting habituation to a feared-but benign- situation). Simultaneously, he initiated playdates with a neighborhood boy that soon became reciprocal, and joined an after-school music program that he enjoyed. Ben’s mother was pleased with these accomplishments and began to praise the therapy program, including its emphasis on Ben’s independence. She voiced no further reservations about the new sleeping arrangements.

While still exhibiting a shy, eagerto- please disposition, Ben had no core anxiety disorder symptoms by session 16 when he was interviewed by an independent evaluator (using a structured diagnostic interview). Treatment gains were maintained at a 1-year follow-up interview

FINDINGS FROM A RECENT CLINICAL TRIAL

In a recent clinical trial, the Building Confidence FCBT program was compared with traditional CCBT with minimal family involvement. 3 Forty children with anxiety disorders (aged 6 through 13 years) were randomly assigned to FCBT or CCBT. Anxiety disorders (separation anxiety disorder, social phobia, and/or generalized anxiety disorder) were confirmed by an independent evaluator using a structured diagnostic interview. The 2 treatment conditions were matched for therapist contact time (12 to16 therapy sessions lasting 60 to 80 minutes each). Outcome measures included independent evaluators’ diagnoses, severity ratings for each diagnosis on the Clinician’s Rating Scale, 14 and improvement ratings on the Clinical Global Impressions (CGI) scale; child-reports on the Multidimensional Anxiety Scale for Children (MASC) 15 ; and parent reports on the MASC.

Overall, results favored FCBT over CCBT, highlights included:

• 79% of children in FCBT met CGI criteria for good treatment response, compared with only 26% of children in CCBT.
• Children in FCBT had greater improvement on independent evaluators’ ratings on the Clinician’s Rating Scale than children in CCBT.
• Parent reports of child anxiety on the MASC-but not children’s selfreports- were lower in FCBT than CCBT at posttreatment.

Although both treatment groups showed statistically significant improvement on all outcome measures, FCBT provided additional benefit over and above CCBT on most indices of improvement.

It should be noted that FCBT appears to be equally effective for children with primary diagnoses of separation anxiety disorder, social phobia, and generalized anxiety disorder. Although the case study presented above illustrates how FCBT can address separation anxiety, parental involvement is also beneficial for the treatment of the other 2 primary child anxiety disorder diagnoses. For example, parental intrusiveness is often seen in cases of children with social anxiety. Parents may offer excessive comfort when children are fearful in social situations and take over social tasks (eg, by speaking for their children) that children could handle independently. Variations of the FCBT techniques described above have proved helpful in addressing such family interaction patterns.

FCBT involves a complex interplay of cognitive-behavioral techniques and family restructuring, drawing on the combined (and sometimes complementary) resources and motivations of children and their parents. While CCBT is quite effective by itself, FCBT can lead to even greater improvements in anxiety, at least in the short term. 3 Therefore, it may be beneficial for clinicians to assess for parental intrusive-ness and autonomy-granting in cases of school-aged children with anxiety disorder and consider the use of a structured FCBT protocol that explicitly addresses such family dynamics when they are present.

Disclosures:

Dr Wood is an assistant professor of psychological studies in education in the department of education at the University of California, Los Angeles. His research focuses on the psychopathology of childhood anxiety, with an emphasis on randomized, controlled trials of cognitive- behavioral therapy interventions. The writing of this paper was supported, in part, by a grant from NIMH awarded to Dr Wood (MH075806). He reports that he has no conflicts of interest with the subject matter of this article.

References:

1. Barrett PM, Dadds MR, Rapee RM. Family treatment of childhood anxiety: a controlled trial. J Consult Clin Psychol. 1996;64:333-342. 2. Cobham VE, Dadds MR, Spence SH. The role of parental anxiety in the treatment of childhood anxiety. J Consut Clin Psychol. 1998;66:893-905. 3. Wood JJ, Piacentini JC, Southam-Gerow M, et al. Family cognitive behavioral therapy for child anxiety disorders. J Am Acad Child Acolesc Psychiatry. 2006; 45:314-321. 4. Kendall PC. Treating anxiety disorders in children: results of a randomized clinical trial. J Consult Clin Psychol. 1994;62:100-110. 5. Silverman WK. Using CBT in the treatment of social phobia, separation anxiety and GAD. Psychiatr Times. September 2003; Vol 20. 6. Nauta MH, Scholing A, Emmelkamp PM, Minderaa RB. Cognitive-behavioral therapy for children with anxiety disorders in a clinical setting: no additional effect of a cognitive parent training. J Am Acad Child Adolesc Psychiatry. 2003;42:1270-1278. 7. Spence SH, Donovan C, Brechman-Toussaint M. The treatment of childhood social phobia: the effectiveness of a social skills training-based, cognitivebehavioural intervention, with and without parental involvement. J Child Psychol Psychiatry. 2000;41: 713-726. 8. Hudson JL, Rapee RM. Parent-child interactions and anxiety disorders: an observational study. Behav Res Ther. 2001;39:1411-1427. 9. Rapee RM. The development of generalized anxiety. In:Vasey MW, Dadds MR, eds. The Developmental Psychopathology of Anxiety. New York: Oxford University Press; 2001. 10. Wood JJ. Parental intrusiveness and children’s separation anxiety in a clinical sample. Child Psychiatry Hum Dev. In press. 11. Fox NA, Henderson HA, Marshall PJ, et al. Behavioral inhibition: linking biology and behavior within a developmental framework. Annu Rev Psychol. 2005;56:235-262. 12. Chorpita BF, Barlow DH. The development of anxiety: the role of control in the early environment. Psychol Bull. 1998;124:3-21. 13. Kearney CA, Hugelshofer DS. Systemic and clinical strategies for preventing school refusal behavior in youth. J Cog Psychother. 2000;14:51-65. 14. Silverman WK, Albano AM. The Anxiety Disorders Interview Schedule for DSM-IV: Child and Parent Versions. San Antonio, TX: Graywind; 1996. 15. March JS, Parker JD, Sullivan K, et al. The Multidimensional Anxiety Scale for Children (MASC): factor structure, reliability, and validity. J Am Acad Child Adolesc Psychiatry. 1997;36:554-565.

Evidence-based References

Barrett PM, Dadds MR, Rapee RM. Family treatment of childhood anxiety: a controlled trial. J Consult Clin Psychol. 1996;64:333-342. Wood JJ, Piacentini JC, Southam-Gerow M, et al. Family cognitive behavioral therapy for child anxiety disorders. J Am Acad Child Acolesc Psychiatry. 2006;45:314-321

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Family-based cognitive behavioural therapy versus family-based relaxation therapy for obsessive-compulsive disorder in children and adolescents: protocol for a randomised clinical trial (the TECTO trial)

• Anne Katrine Pagsberg   ORCID: orcid.org/0000-0003-0818-8338 1 , 2 ,
• Camilla Uhre 1 , 2 ,
• Valdemar Uhre 1 , 2 , 3 ,
• Linea Pretzmann 1 , 2 ,
• Sofie Heidenheim Christensen 1 ,
• Christine Thoustrup 1 , 2 ,
• Iben Clemmesen 1 ,
• Amanda Aaen Gudmandsen 1 ,
• Nicoline Løcke Jepsen Korsbjerg 1 ,
• Anna-Rosa Cecilie Mora-Jensen 1 , 2 ,
• Melanie Ritter 1 ,
• Emilie D. Thorsen 1 ,
• Klara Sofie Vangstrup Halberg 1 ,
• Birgitte Bugge 1 ,
• Nina Staal 1 ,
• Helga Kristensen Ingstrup 1 ,
• Birgitte Borgbjerg Moltke 1 ,
• Anne Murphy Kloster 1 ,
• Pernille Juul Zoega 1 ,
• Marie Sommer Mikkelsen 1 ,
• Gitte Sommer Harboe 1 ,
• Katrin Frimann Larsen 1   na1 ,
• Line Katrine Harder Clemmensen 4 ,
• Jane Lindschou 5 ,
• Janus Christian Jakobsen 5 , 6 ,
• Janus Engstrøm 5 ,
• Christian Gluud 5 , 6 ,
• Hartwig Roman Siebner 2 , 3 , 7 ,
• Per Hove Thomsen 8 ,
• Katja Hybel 8 ,
• Frank Verhulst 1 ,
• Pia Jeppesen 1 , 2 , 9 ,
• Jens Richardt Møllegaard Jepsen 1 , 10 ,
• Signe Vangkilde 1 , 11 ,
• Markus Harboe Olsen 5 , 12 ,
• Julie Hagstrøm 1 ,
• Nicole Nadine Lønfeldt 1 &
• Kerstin Jessica Plessen 1 , 13  

BMC Psychiatry volume  22 , Article number:  204 ( 2022 ) Cite this article

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Cognitive behavioural therapy (CBT) is the recommended first-line treatment for children and adolescents with obsessive-compulsive disorder (OCD), but evidence concerning treatment-specific benefits and harms compared with other interventions is limited. Furthermore, high risk-of-bias in most trials prevent firm conclusions regarding the efficacy of CBT. We investigate the benefits and harms of family-based CBT (FCBT) versus family-based psychoeducation and relaxation training (FPRT) in youth with OCD in a trial designed to reduce risk-of-bias.

This is an investigator-initiated, independently funded, single-centre, parallel group superiority randomised clinical trial (RCT). Outcome assessors, data managers, statisticians, and conclusion drawers are blinded. From child and adolescent mental health services we include patients aged 8–17 years with a primary OCD diagnosis and an entry score of ≥16 on the Children’s Yale-Brown Obsessive-Compulsive Scale (CY-BOCS). We exclude patients with comorbid illness contraindicating trial participation; intelligence quotient < 70; or treatment with CBT, PRT, antidepressant or antipsychotic medication within the last 6 months prior to trial entry. Participants are randomised 1:1 to the experimental intervention (FCBT) versus the control intervention (FPRT) each consisting of 14 75-min sessions. All therapists deliver both interventions. Follow-up assessments occur in week 4, 8 and 16 (end-of-treatment). The primary outcome is OCD symptom severity assessed with CY-BOCS at end-of-trial. Secondary outcomes are quality-of-life and adverse events. Based on sample size estimation, a minimum of 128 participants (64 in each intervention group) are included.

In our trial design we aim to reduce risk-of-bias, enhance generalisability, and broaden the outcome measures by: 1) conducting an investigator-initiated, independently funded RCT; 2) blinding investigators; 3) investigating a representative sample of OCD patients; 3) using an active control intervention (FPRT) to tease apart general and specific therapy effects; 4) using equal dosing of interventions and therapist supervision in both intervention groups; 5) having therapists perform both interventions decided by randomisation; 6) rating fidelity of both interventions; 7) assessing a broad range of benefits and harms with repeated measures.

The primary study limitations are the risk of missing data and the inability to blind participants and therapists to the intervention.

Trial registration

ClinicalTrials.gov : NCT03595098, registered July 23, 2018.

Peer Review reports

Obsessive-compulsive disorder (OCD) affects 0.5 to 3% of children and adolescents in the population [ 1 ] and is associated with reduced quality of life and significant social and occupational impairment [ 2 ]. In Denmark, a recent study showed that the cumulative incidence rate of OCD in children (< age 18 years) was higher for girls, 0.96% [95% CI, 0.92–1.00%], than for boys 0.63%, [95% CI, 0.56–0.72%] [ 3 ]. OCD is characterised by persistent intrusive thoughts, urges, or images that cause anxiety (obsessions), and/or by repetitive behaviours (compulsions) that are performed in an attempt to reduce anxiety or discomfort [ 4 ]. Early detection and intervention is important to ensure a good prognosis, as the disorder often persists into adulthood and can become chronic if left untreated [ 5 , 6 ].

The recommended first-line treatment for youth with OCD (age < 18 years) is behavioural therapy or cognitive behavioural therapy (CBT) either alone or in combination with antidepressant medication in more severely affected cases [ 7 , 8 , 9 ]. Yet, more than 40% of patients do not or only partially benefit from CBT. The cornerstone of CBT for OCD is exposure and response prevention (ERP), in which patients are gradually exposed to anxiety provoking situations that trigger obsessions and then encouraged to refrain from compulsive behaviour. Our recent systematic review showed that CBT may be an effective treatment for OCD in youths, but the included trials were at high risk-of-bias and the certainty of the evidence was low [ 10 ]. Also, information about effects on outcomes other than symptom severity was limited [ 10 ]. While symptom reduction represents an important outcome, outcomes such as adverse events, quality of life, and daily life functioning are equally relevant [ 10 ].

The efficacy of CBT for children and adolescents with OCD has been compared with credible control interventions such as relaxation training (RT) or psychoeducation and relaxation training (PRT) in three randomised clinical trials (RCTs), all pointing to the superiority of CBT [ 11 , 12 , 13 ]. Response rates in the three trials were 50 to 72% for CBT versus 20 to 41% for PRT with an effect size of 0.3 reported in one of the studies [ 12 ]. However, these trials were at risk-of-bias due to unclear randomisation process, missing outcome data and, for one trial, deviations from the intended treatment [ 14 ]. Also, although one study found higher response rates and a faster decline in OCD severity with CBT compared to PRT, symptom reduction at end of treatment was comparable in the two groups [ 13 ].

While drop-out rates from CBT of up to 26% implies some degree of unacceptability of the treatment [ 15 ], adverse events or reactions are not systematically monitored or reported in psychotherapy trials [ 16 ]. One study reported that psychotherapists within child- and adolescent psychiatric services in Sweden were unfamiliar with the concept of adverse events in psychotherapy [ 17 ]. Current estimates of how frequently adverse events occur in psychotherapy are based on surveys that ask either therapists or patients to evaluate negative therapy outcomes in retrospect. For example, 5.2% of patients reported lasting harmful effects from psychotherapy in a British survey [ 18 ].

To improve our understanding of the treatment effects of CBT in children and adolescents with OCD there is a need for a carefully designed RCT at low risk-of-bias, which specifically addresses the broader treatment effects as well as tolerability.

The TECTO trial aims to compare the benefits and harms of family-based CBT (FCBT) versus family-based psychoeducation and relaxation training (FPRT) in children and adolescents with OCD to guide future clinical practice and research. We include an active intervention as comparison to tease apart general and specific therapy effects and allow us to investigate possible predictors, moderators, and mediators of CBT.

The null hypothesis of this superiority trial is that both interventions have similar therapeutic effects for the outcomes of interest. The alternative hypothesis is that FCBT will be superior to FPRT in alleviating OCD symptoms and improving health-related quality of life, and the co-primary alternative hypothesis is that FCBT will be associated with more adverse events than FPRT due to the ERP component of the FCBT.

The TECTO trial is an investigator-initiated, independently funded, single-centre, parallel group, randomised superiority clinical trial in a hospital setting comparing 16 weeks of FCBT versus FPRT in children and adolescents with OCD aged 8 to 17 years (both inclusive). This design allows us to test how CBT-specific factors (e.g. the ERP component) contribute to the observed treatment effects. A follow-up assessment is conducted 6 months after end of treatment to investigate the stability of treatment outcomes. The TECTO trial protocol follows the SPIRIT recommendations [ 19 ] and has been registered at clinicaltrials.gov (NCT03595098, 23 July 2018, final update is protocol version 13.0, 11 June 2021). Figure  1 shows the TECTO flow diagram and the populated SPIRIT checklist is provided in Supplementary file  1 .

TECTO flow diagram

Sub-studies

We combine the TECTO RCT with longitudinal case-control sub-studies to elucidate how neurobiological, cognitive, emotional, and neuroendocrine factors may predict, moderate and mediate CBT responses. The sub-studies involve neuroimaging of brain structure and function, evaluation of therapy factors (such as patient and parent treatment confidence, motivation, alliance, and compliance, and therapist fidelity to manuals), as well as tests of neurocognitive functions across domains, emotion regulation, and salivary oxytocin levels. Analysis of the TECTO trial data will be conducted in three steps. Step 1 is the main analysis of the RCT presented here, in which we test the efficacy of FCBT versus FPRT. In Step 2, we test sub-study-specific hypotheses and extract features for Step 3. In Step 3, we integrate data using machine learning techniques (see e.g. [ 20 ]) to investigate which multivariate combinations of features (e.g. brain activity patterns; clinical, therapeutic and family factors; cognitive and emotion regulation measures; and oxytocin levels) best predict treatment outcomes and differentiate between patients and healthy controls, and between treatment responders and non-responders among patients. Finally, we conduct a separate sub-study involving both quantitative and qualitative methods to examine which and how adverse events are related to psychotherapy for youth with OCD.

The sub-studies as well as the six-month follow-up study will not be presented in further detail in the present paper (but they are detailed including plans for collection, laboratory evaluation, and storage of biological specimens in NCT03595098 on clinicaltrials.gov ).

The TECTO trial is conducted at the Child and Adolescent Mental Health Center (CAMHC), Copenhagen University Hospital – Mental Health Services CPH, Denmark. CAMHC is a free-of-charge public healthcare provider for children and adolescents below age 18 years. 1.8 million people live in the Capital Region of Denmark of whom around 200,000 are in the target age group of the TECTO trial. The sample will be representative of the clinical population of youth with moderate to severe OCD, as only a limited capacity of non-hospital mental health services exists in Denmark. All individuals with suspected OCD aged 8 to 17 years are directly referred by the Central Visitation Unit to our OCD team, which is established to promote clinical expertise and research in the management of OCD at CAMHC. In addition, we facilitate referral of patients with suspected OCD from 1) the Tourette Clinic at the Department of Pediatric and Adolescent Medicine, Herlev Hospital, Capital Region; 2) Pedagogical Psychological Services in the 29 municipalities of the Capital Region; and 3) general practitioners and physicians from non-hospital child and adolescent psychiatric clinics in the Capital Region. The TECTO trial organization is shown in supplementary file  2 .

Participants

Inclusion and exclusion criteria.

Inclusion criteria

OCD as primary diagnosis, meeting the criteria for ICD-10 F42 [ 4 ], based on a semi-structured psychopathological interview using the Kiddie-Schedule for Affective Disorders and Schizophrenia - Present and Lifetime Version (K-SADS-PL) [ 21 ].

Children’s Yale-Brown Obsessive-Compulsive Scale (CY-BOCS) [ 22 ] entry score ≥ 16, a cut-off score used in previous studies [ 13 , 23 ].

Ages 8 through 17 years (both inclusive).

Signed informed consent.

Exclusion criteria

Comorbid illness that contraindicates trial participation: pervasive developmental disorder excluding Asperger’s syndrome (ICD-10 F84.0–84.4 + F84.8–84.9); schizophrenia/paranoid psychosis (ICD-10 F20–25 + F28–29); mania or bipolar disorder (ICD-10 F30 and F31); depressive psychotic disorders (F32.3 + F33.3); substance dependence syndrome (ICD-10 F1x.2) [ 4 ].

Intelligence quotient < 70 measured with the full scale Wechsler Intelligence Scales (either WISC-V [ 24 ] for children ages 8 to 16 years or WAIS-IV [ 25 ] for adolescents aged 17 years).

Treatment with CBT, PRT, antidepressant or antipsychotic medication within the last 6 months prior to trial entry.

Recruitment procedure, eligibility screening, and baseline assessment

Based on the standard clinical assessment, our specialised OCD team evaluates whether a patient is eligible for participation in the trial. All diagnostic evaluations are based on the structured psychopathological interview (K-SADS-PL) and confirmed by a consultant or a specialised psychologist in child and adolescent psychiatry. If the patient meets the criteria, the family members receive age-appropriate verbal and written information about the trial (for details, please see supplementary file  3 and 4 ).

If the parents or legal caretaker gives informed consent to study participation, we collect baseline data. In addition to patient medical history, clinical and diagnostic evaluation, and somatic examination, the assessment includes the CY-BOCS, a semi-structured interview assessing the severity of OCD symptomatology [ 22 ]; the Wechsler Intelligence Scales (WISC-V or WAIS-IV depending on the age of the participant [ 24 , 25 ]); and the Social Responsiveness Scale (SRS) (a parent and/or teacher rating scale assessing the presence and extent of social and communicative impairment) [ 26 ]. If the period between screening and start of treatment exceeds 1 week, we perform a new baseline CY-BOCS before randomisation.

Trial participants are compensated with a DKK 250 gift card per test day for engaging in research activities that go beyond the standard assessment and treatment programme.

Withdrawal/discontinuation from trial

Participants who no longer wish to participate in the trial can withdraw their informed consent at any time without explaining the reason and with no consequences for the participant’s further treatment. We discontinue participants from the intervention if the participant experiences intolerable adverse reactions, shows symptoms contraindicating further trial participation, is diagnosed with any disorder that is defined as an exclusion criterion during the intervention period, or experiences a significant worsening of their clinical state during the course of the trial (i.e. increases of 30% or more from baseline on the CY-BOCS total score). In all cases of discontinuation, the investigator and/or therapist will encourage the participant to continue with follow-up assessment and collected data will be used in analyses. Reasons for withdrawal or discontinuation are systematically documented.

Risks and benefits for participants

We are not aware of any major risks or safety issues associated with participation in the trial. We expect most patients to benefit from both interventions. We hypothesise that some patients in both intervention groups may experience anxiety symptoms or lack of improvement. All procedures of the trial have been designed with careful consideration of our participants being vulnerable children and adolescents. We believe that any potential inconvenience caused by trial participation can be justified by the potential scientific value of our results, leading to improved treatment options for youth with OCD. CAMHC provides care for participants who need more treatment after receiving psychotherapy in the TECTO trial.

Parental participation

Parents or caretakers of children with OCD are often involved in the child’s symptoms which may negatively affect the functional level of the family [ 27 ]. Thus, parental training is important to increase the effectiveness of psychotherapy [ 28 ]. Therefore, we include parents as participants. The parents are involved in the clinical assessments and treatment of their child. We observe and score parent-child interactions in clinically relevant situations (e.g. in the presence of a feared stimulus, and in an emotion regulation task) [ 29 , 30 ]. If the parents do not give informed consent to be trial participants, the child can still be included.

Trial conduct

The trial is conducted in compliance with the study protocol, the Helsinki Declaration [ 31 ], and the applicable regulatory requirements (The Ethics Committee of Capital Region of Denmark approval number: H-18010607, and The Knowledge Centre on Data Protection Compliance in The Capital Region of Denmark: VD-2018-263, I-Suite no.: 6502). We act in accordance with the Danish personal and health data regulations when collecting information from patients’ medical records (The Danish Act on Processing of Personal Data, and Danish Health Act, Section 43, Subsection 1). Recruitment of participants started after regulatory approvals was obtained. Recruitment and randomisation of the first participant took place on September 4, 2018, and randomisation of the last participant is expected to take place by the end of 2021. Final follow-up of the last participant (at six-month follow-up) is scheduled for the end of 2022.

Protocol amendments are implemented only after re-approvals from the ethics committee and important protocol modifications (e.g. changes to eligibility criteria, outcomes, analyses) are communicated directly and in collaboration with Copenhagen Trial Unit to relevant parties (e.g. investigators, clinical departments, trial participants, trial registries, steering committee, advisory board).

Ethics approval and consent to participate

The Ethics Committee of Capital Region of Denmark approved the protocol (H-18010607). Patients who are deemed eligible to participate in the trial according to the in- and exclusion criteria receive verbal (all ages) and written (adolescents aged at least 15 years and all parents/legal guardians) information about the trial and are informed of their rights to withdraw from the trial at any point without it affecting future treatment. All participants and their guardians are given verbal information about the trial by a health care professional in the outpatient clinic, OCD-team, and are asked permission to be contacted by the research team. Initial information about the trial is provided in an age-appropriate manner and during regular clinic visits at the CAMHS in the presence of a guardian and in the privacy of an examination room. Guardians are explained their right to have an assessor (e.g. friend or family member) present and in case the guardian should want that, a new appointment will be made for the information meeting. Written information brochures approved by the ethical committee explaining the study background, procedures and aims are handed out to all potential participants and their guardians. Potential participants then have a minimum of 24 h to consider participation before being contacted by the doctor, psychologist, or the trial manager involved in the trial. If potential participants and their guardians approve to participate, both guardians sign informed consent at the first contact. Guardians have the possibility of signing a power of attorney to the other guardian. Guardians are informed that use of this form is voluntary and can be withdrawn at any time. Furthermore, if a participant turns 18 years old before the end of the trial, the participant is be asked to sign an informed consent at trial start. Each guardian receives their own participant information (verbal and written) and informed consent form regarding parental participation (for details, please see supplementary file  3 and 4 ).

Randomisation

Participants are randomised at the allocation ratio 1:1. Randomisation is handled centrally at an external unit, the Copenhagen Trial Unit, using a computer-generated allocation sequence with varying block sizes concealed from the investigators. The allocation sequence is stratified by age (8 to 12 years and 13 to 17 years) and CY-BOCS total score at baseline (16 to 23 points (moderate severity) and 24 to 40 points (severe to extreme severity)). Participants are enrolled and assigned to the intervention groups using a web-based system developed by the Copenhagen Trial Unit.

We employ blinding to the intervention whenever possible. It is not possible to fully blind the participants, their parents, and the therapists due to the explicit nature of the intervention. However, the name and the specific content of the assigned intervention is not disclosed to participants and their parents. Outcome assessment is performed by blinded investigators. Data managers, statisticians, and conclusion drawers are fully blinded as well. Before the follow-up assessment sessions are conducted during the trial, unblinded trial personnel instruct the child/families to avoid giving any information concerning the therapy to the blinded outcome assessor. We will follow the rule that statistical analyses are conducted with the intervention groups coded as e.g. ‘Intervention A’ and ‘Intervention B’. We will write two abstracts while the blinding is intact: one assuming the experimental intervention group is A and the control intervention group is B, and one assuming the opposite. After this, the code will be broken.

Investigators doing qualitative interviews will be unblinded and do no further assessment of the participant after the interview. Participants leaving the trial can be unblinded if they wish to. Unblinding for the entire trial cohort will be performed confidentially via the data manager to the steering committee after the two conclusions have been drawn.

Participant timeline

Both intervention groups involve therapy delivered over 16 weeks. Participants undergo assessments at baseline (week 0–1), at week 4, week 8, and at end-of-treatment (week 16). A long-term follow-up takes place at week 40. Table  1 shows the participant timeline and outcome assessments.

The primary outcome is OCD symptom severity assessed with the CY-BOCS at the end of intervention. Secondary outcomes are 1) health-related quality of life assessed with the Health-related Quality of Life Screening Instrument for Children and Adolescents (KIDSCREEN-52) [ 32 ] at the end of intervention; and 2) adverse events during the intervention, assessed with the Negative Effects Questionnaire (NEQ), which measures six factors; symptoms, quality, dependency, stigma, hopelessness, and failure.

Exploratory outcomes are: serious adverse events (SAE) (assessed until week 40); Child Obsessive-Compulsive Impact Scale (COIS) [ 33 ]; Clinical Global Impression – Severity and Improvement (CGI-S and CGI-I) [ 34 ]; Children’s Global Assessment Scale (C-GAS) [ 35 ]; diagnostic status and proportion of patients in remission (no longer meeting the diagnostic criteria for OCD (ICD-10 F.42)), assessed with K-SADS-PL [ 21 ] at the end of the intervention; response defined as a reduction on the CY-BOCS at end-of-treatment of at least 30% in intraindividual comparison with the score at baseline; Toronto Obsessive-Compulsive Rating Scale (TOCS) [ 36 ]; suicidality (K-SADS-PL suicidality items sum-score); the Family Accommodation Scale (FAS) [ 37 ], a parent-reported measure that examines parental accommodation to children’s obsessions and compulsions; and the Parental Stress Scale (PSS) [ 38 ], a measure of perceived stress pertaining to the parenting role. Finally, we will assess social and environmental characteristics of families with the Family Environment Scale (FES) [ 39 ].

Therapy factors, such as confidence in treatment (on a 7-point Likert scale), motivation for treatment (on a 7-point Likert scale), the Therapeutic Alliance Scale for Children–revised (TASC-R) [ 40 , 41 ], and compliance (see below) will be assessed in exploratory analyses as covariates for outcome.

In the 16-week trial, all outcomes are measured at baseline and week 16. In addition, several outcomes are measured repeatedly: clinical state measures (CY-BOCS, KIDSCREEN, COIS and CGI-I/S) along with family factors (PSS and FAS) and adverse events (NEQ) are also assessed at week 4 and week 8. Moreover, treatment compliance is measured at every session and motivation for treatment and therapeutic alliance is assessed at week 4 and week 8.

Assessment team

Trained clinicians blind to intervention group (PhD students or psychologists/MDs, and for selected assessments trained and supervised psychology or medical students) perform the assessments. Participating patients and parents fill out the self-administrated questionnaires.

We use the generic definition of adverse events as defined by the International Conference on Harmonization of Technical Requirements for Registration of Pharmaceuticals for Human Use – Guidelines for Good Clinical Practice [ 42 ] (see supplementary file  5 ). All SAE’s will be reported to The Ethics Committee of Capital Region of Denmark.

Quality assurance and quality control

Representatives from the Copenhagen Trial Unit monitor activities in accordance with Good Clinical Practices [ 42 ] as far as applicable for a non-pharmacological trial. Activities are monitored via on-site visits combined with central (remote) monitoring. In general, a risk-based approach will be taken by defining the intensity of monitoring required and central monitoring and central review of monitoring reports.

Interventions

The experimental intervention is a manualised form of exposure-based FCBT for OCD [ 43 ]. The key components are ERP, family involvement, psychoeducation, and homework assignments. The active control condition is manualised FPRT [ 13 ]. The key components are relaxation training (activation and relaxation of individual muscles and muscle groups, breathing exercises), family involvement, psychoeducation, and homework assignments.

Both interventions include 14 sessions each of 75 min, delivered over 16 weeks (weekly sessions at week 1 to 12, and a session at week 14 and one at week 16, with the possibility of a flexible planning of the two session-free weeks). Elements common to both interventions include: the therapeutic approach of externalising OCD; setting an agenda at each session; assigning and reviewing homework; monitoring and ranking symptoms; providing treatment rationale; involving parents; using positive reinforcement (rewards); building a collaborative working alliance; and providing psychoeducation about OCD and the connection between thoughts, emotions, bodily sensations, and behaviours (the cognitive diamond). Parents may assume a supportive role for the child or as a co-therapist. In five of the 14 sessions (sessions 1, 2, 7, 11, and 14) the parents join their child for the entire session. In the remaining sessions, the child is treated individually for 45 min, followed by parent-sessions for an additional 30 min with or without the child present. To be classified as a family-based intervention, at least one parent or legal caretaker must participate in at least three sessions. The participants will be offered a booster session within the first 6 months after the 16-week intervention. Table  2 illustrates similarities and differences between FCBT and FPRT.

Experimental intervention – family based cognitive behavioural therapy

The FCBT manual was published in Danish in 2015 [ 43 ], and was used in the The Nordic long-term OCD treatment study (NordLOTS), a large, multicentre, open study covering three Scandinavian countries [ 23 ]. It is based on the treatment manuals by March and Mulle [ 44 ] as well as an adapted version by Piacentini [ 13 ], adding more family-based intervention. Addressing family factors that may influence the treatment response in paediatric OCD is a potential target for optimising exposure-based CBT. In particular, family accommodation (i.e. family members of the patient with OCD participate in rituals and/or modification of routines) appears to constitute a barrier to treatment because it reinforces avoidance behaviours and undermines exposure-based exercises [ 13 , 28 ]. The key components in FCBT are in-session and at home ERP practice [ 45 ].

Control intervention – Psychoeducation/relaxation training

The active control intervention is manualised FPRT based on the relaxation manual by Cautela and Groden [ 46 ], adapted by Piacentini for use in a previous trial [ 13 ] and translated into Danish and adapted for use in the TECTO trial. The sessions consist of psychoeducation, muscle relaxation, attention training, breathing exercises, and visualisation techniques. Proscribed interventions include ERP, discouraging compulsive behaviour, discouraging family accommodation, replacing compulsions with relaxation techniques, and positively reinforcing refraining from performing compulsions.

Concomitant interventions

Concomitant treatment with any other psychotherapy, antidepressant and antipsychotic medication is not permitted. All other types of concomitant treatments, such as counselling, parent support, network management or in-patient care are allowed provided both intervention groups have equal access.

Criteria for modification of interventions for a given trial participant

We strive to perform all 14 sessions of treatment within 16 weeks (maximal duration 18 weeks). For an individual treatment course to be defined as complete, 10 out of the total 14 sessions should be delivered. Breaks in treatment are minimised and reasons for breaks are registered. In the case of adverse events or significant worsening of clinical state, the patient may be discontinued from the intervention by the investigator and continue in treatment as usual in the clinic.

Assessment of participant compliance

During the treatment period (weeks 1 to 16), we assess the participants’ and parents’ compliance to therapy on a weekly basis. Compliance is assessed by the therapist and includes measures of patient and parent attendance and homework compliance.

Each therapist conducts both interventions. To avoid potential ‘treatment-by-therapist-confounding’, we balance the assignment of the clinical therapists over time as part of the randomisation process. Both interventions are carried out by master’s level clinical therapists who are either psychologists or child and adolescent consultant psychiatrists with comprehensive post-graduate clinical training in cognitive therapeutic techniques. Each therapist receives education and bi-weekly supervision in both interventions by a certified (FCBT) or specially trained (FPRT) supervisor. Before treating any trial participant, therapists are required to treat at least one non-trial patient with FCBT and one with FPRT under live or video recorded observation.

Treatment fidelity

All treatment sessions are video recorded if the participant consents to this. To investigate fidelity to the treatment manuals, approximately 15% of all FCBT sessions and FPRT sessions, distributed evenly across the 14 treatment sessions, are randomly selected for adherence and quality review. Fidelity for FCBT is evaluated using the NordLots Treatment Integrity Scale [ 23 , 45 ] and for FPRT by a corresponding manual developed by the TECTO research team (supplementary file  6 ). We evaluate both interventions concerning therapeutic alliance, psychoeducation, exposure, relaxation training, and family involvement on three categories of treatment fidelity: 1) manual adherence, 2) treatment differentiation, and 3) therapist competence.

Statistical analysis

Data management.

Data management is handled by an external and independent party at the Copenhagen Trial Unit. Data is collected in OpenClinica, an electronic data capture system for clinical trials. All entries are logged in OpenClinica and data validation checks are conducted to obtain a high quality of data. The electronic data capture system and all associated databases follow the regulations set by The Knowledge Centre on Data Protection Compliance in The Capital Region of Denmark and adheres to the General Data Protection Regulation.

Sample size estimation and feasibility of recruitment

The sample size is based on the primary outcome, the CY-BOCS score (continuous variable) measuring severity of OCD symptoms on 10 items which can be rated 0 to 4 points (total score range 0 to 40). Using a power of 80%, a two-sided alpha of 5%, and expecting a SD of 8 on the CY-BOCS total score based on reports in similar patient groups [ 13 ], the required sample size necessary to detect or reject a minimal relevant difference of at least 4 points on CY-BOCS total score was estimated to be 64 participants in each intervention group, a total of 128 [ 13 , 47 ]. Power calculations for secondary outcomes (KIDSCREEN-52 and NEQ) will follow in a detailed statistical analysis plan (see below).

To estimate the expected recruitment potential of OCD patients in CAMHC we drew on the available hospital statistics in the planning phase of the trial before initiation in 2018. In the year 2016, 108 patients aged 8–17 years were referred to and treated in CAMHC for OCD. We therefore estimated that around 324 patients would be eligible for participation in the TECTO trial within our recruitment period of 3 years (ultimo 2018 to ultimo 2021). With a target sample size of 128, we considered it feasible to recruit 40% of all referred patients. Randomised clinical trials with psychiatric patients are prone to drop-outs and missing data [ 48 ]. Thus, we aim to include and randomise up to 20 extra participants, i.e. up to 148 participants in total (74 in each group), which will increase our power for our primary outcome to 85.7%.

Statistical analysis plan

We will analyse all continuous outcomes with linear regression, dichotomous outcomes with logistic regression, and count data with the van Elteren test [ 49 ]. In the primary analysis, we will include the intention-to-treat population, and the analysis will be adjusted for the stratification variables used in the randomisation. A detailed statistical analysis plan will be developed and published before any analyses are carried out. The analysis plan will include subgroup analysis and handling of missing data.

The TECTO trial is designed to systematically investigate beneficial and adverse effects of FCBT versus FPRT in the treatment of children and adolescents with OCD with as minimised risk-of-bias as we found operational. The main and intended difference between the two treatment approaches is the absence of the ERP component in the FPRT arm of the trial, which is deemed the most effective treatment element for OCD [ 50 , 51 ]. Several treatment elements of the active control intervention FPRT are specifically designed to mimic traditional FCBT for OCD, thereby providing rigorous control for the non-ERP aspects. In addition to conducting a trial at risk-of-bias with a credible control intervention, the TECTO trial strives to meet the need for systematic and repeated assessment of adverse events and of additional outcomes pertaining to treatment effects beyond symptom reduction.

The American Academy of Child and Adolescent Psychiatry (AACAP) practice parameter recommends CBT as first-line treatment for youth with OCD, emphasizing that families are involved in the treatment of especially younger children with OCD, for whom parents control many aspects of daily activity [ 9 , 52 ]. Our recent systematic review updated the evidence base for CBT for paediatric OCD and indicated that CBT appears superior to no intervention/placebo and has effects comparable with sertraline [ 10 ]. However, the included studies had a high risk-of-bias. Risk-of-bias is an inherent feature of psychotherapeutic interventions which renders the blinding of participants and therapists impossible. In addition, some of the included studies did not conceal allocation, did not blind outcome assessors, or reported incomplete outcome data. These shortcomings resulted in low or very low certainty of the evidence (GRADE) across the evaluated outcomes.

Similar intervention groups as those used in the TECTO trial – CBT versus PRT – with varying degrees of parent involvement have been investigated in three previous RCTs [ 11 , 12 , 13 ]. The first trial was published in 2008 and investigated FCBT versus family-based RT (FRT) in 42 young children with OCD aged 5 to 8 years [ 11 ]. The intention-to-treat analysis showed a non-significant moderate treatment effect of FCBT, while complete case analysis showed a larger and significant effect. These findings led to a second trial published in 2014 which included 127 participants. This larger trial showed a superiority of FCBT relative to FRT for both primary outcomes: (1) responder status defined as an independent, evaluator-rated CGI-I score of 1 (very much improved) or 2 (much improved) and (2) change in independent evaluator-rated CY-BOCS total score [ 12 ]. This trial had a pre-specified sample size, manualised interventions, supervision of therapists, and fidelity ratings in both intervention groups. Furthermore, most comorbidities (except pervasive developmental disorders and Paediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcal Infections (PANDAS)) were included, strengthening the generalisability to clinical samples. The trial was, however, limited by (1) allowing antidepressant medication at inclusion and during the trial, which may have affected effect sizes; (2) including only outpatients without acute suicidality, which limits generalisability; and (3) not assessing negative effects of treatment (only SAEs were reported).

The third trial was published in 2011 and examined the efficacy of FCBT versus PRT in children and adolescents aged 8 to 17 years with OCD [ 13 ]. The 71 patients were randomized 7:3 to 12 sessions of manualized FCBT or PRT. The participants were largely medication-free (8.5% medicated but not with antidepressants) and included OCD patients with comorbidities (except for disorders contraindicating trial participation, including psychosis, pervasive developmental disorders, mania, or substance dependence). Suicidal patients were excluded. FCBT led to significantly higher response rates than PRT in intention-to-treat (57% vs. 27%) and completer analyses (68% vs. 35%). The participants receiving FCBT showed a faster decline in OCD severity during the trial, as compared with those receiving PRT, however, the magnitude of symptom reduction was comparable in the two groups at end point. The trial had careful quality adherence procedures, therapist assignment balanced across conditions, and weekly group supervisions and case reviews for therapists. Therapy sessions were videotaped, and 10% of FCBT sessions were selected and reviewed by experienced CBT therapists and found satisfactory regarding adherence/quality. The trial also had several limitations. No adherence/quality procedure was implemented for the PRT group. Although the trial was well-powered with a randomised design, the somewhat small sample of PRT participants ( n  = 22) combined with quite large effects of PRT may still question whether ERP really is the ‘active ingredient’ in successful OCD treatment. Even though parents attended some full sessions and parts of sessions in the PRT group, there was less parental involvement in PRT than FCBT, and negative effects of treatment were not assessed or reported. Regarding potential conflicts of interest, several of the authors disclosed receiving royalties for the manuals used in the study from Oxford University Press.

We believe to have improved the trial design in TECTO compared to the previous RCTs by planning a sufficiently powered trial with a well-balanced and concealed allocation (1:1). We use repeated measures by assessing several outcomes not only at baseline and end-of-treatment (week 16) but also at week 4 and week 8. Moreover, as part of broadening the spectrum of treatment outcomes TECTO is the first RCT to assess remission for pediatric OCD at end-of treatment according to diagnostic criteria. Another important strength of our trial is the systematic assessment of negative treatment effects throughout the trial.

We further balance the trial groups by providing equal dosing of therapy sessions, parent participation, therapist education and supervision, and fidelity ratings of both interventions. Each therapist will conduct both interventions and we strive to avoid potential ‘treatment-by-therapist-confounding’ by balancing the assignment of the clinical therapists over time. We monitor motivation for treatment and therapeutic alliance repeatedly.

To enhance generalizability, we include patients with a broad range of comorbidities, only excluding patients with conditions contraindicating study participation. Our RCT is the first to include patients with suicidality. Suicidality appears relatively common in paediatric OCD where one small study with 54 patients found 13% with clinically significant suicidal ideation [ 53 ]. In adults with OCD, 16 to 63% experience suicidal ideation, with as many as 25% reporting at least one prior suicide attempt [ 54 , 55 , 56 ]. To avoid risks of confounding effects, we do not allow concomitant treatment with antidepressant medication.

Both interventions in the TECTO trial are fully manualised. The manual used for FCBT stems from the NordLOTS study, in which the first part of this stepped care study was an uncontrolled clinical trial including 269 participants with OCD aged 7 to 17 years. The study successfully applied an intervention consisting in 14 weekly sessions of FCBT in community mental health clinics, and the response rate among completers was 73% [ 45 ]. Patients receiving the therapy had a substantial mean symptom reduction of 53% measured with CY-BOCS, and about half of the participants were in remission at end of treatment. In the TECTO trial, we match our control intervention, FPRT, as closely as possible to the FCBT intervention. The manual used for FPRT stems from Cautela and Groden [ 46 ] and is modified by Piacentini, in which patients treated with PRT experienced reduced OCD symptoms, but to a lesser degree than those treated with FCBT [ 13 ]. In the trial by Piacentini, participant- and parent-rated confidence in the efficacy of treatment did not differ between PRT and FCBT, further emphasizing that PRT is a credible control treatment [ 13 ].

We aim to further minimise risk-of-bias by blinding of outcome assessors, using a random allocation sequence generation through an external unit and performing the trial as an investigator-initiated, independently funded trial. However, we were unable to come up with pragmatic solutions on how to blind the participants, parents and caregivers to the two interventions. The primary trial limitations are the implicit lack of participant and therapist blinding, and the risk of missing data from follow-up assessments.

To conclude, the TECTO trial in an investigator-initiated, independently funded trial using an RCT design with blinded outcome assessment addressing the limitations of former studies of the effects of CBT, which is the recommended first-line treatment for children and adolescents with OCD. We investigate the benefits and harms of FCBT versus FPRT in an optimal trial design including a trial size based on sample size estimation. We aim to minimise risk-of-bias, enhance generalisability, and broaden the outcome measures, several assessed repeatedly. We investigate a representative sample of youth with OCD including suicidal patients, use equal dosing of interventions and equal dosing of therapist supervision in both interventions, have therapists perform both interventions decided by randomisation, perform fidelity ratings of both interventions, and systematically assess both benefits and harms of treatment.

For future perspectives, the TECTO sub-studies, involving specific neurobiological and neurocognitive targets combined with the RCT design presented here, makes it possible to further tease apart CBT-specific and general treatment mechanisms in OCD therapy by including a wide range of neurocognitive and neurobiological outcomes that may predict, moderate or mediate successful treatment. The data from the TECTO RCT forms the basis for our analysis plan for the sub-studies involving testing specific sub-study hypotheses and extraction of features for data integration using machine learning techniques to investigate which multivariate combinations of features best differentiate patients versus healthy controls and treatment responders versus non-responders, and best predict treatment outcomes. The TECTO trial therefore has the potential to document the absolute effect of CBT and suggest concrete mechanisms of change. Finally, the in-depth mixed-method sub-study of adverse events can help inform safer psychotherapy practices, develop instruments and guidelines for monitoring adverse events, and improve patient and parent information regarding expectations and potential risks in psychotherapeutic treatment.

Availability of data and materials

After the results have been published, we aim to make a depersonalised dataset publically available on, e.g. clinicaltrials.gov , and/or the EU ZENODO database. The final choice will reflect which platform(s) that are compliant with current legislation at that time.

Change history

29 july 2022.

A Correction to this paper has been published: https://doi.org/10.1186/s12888-022-04142-4

Abbreviations

American Academy of Child and Adolescent Psychiatry

Child and Adolescent Mental Health Centre

Cognitive Behavioural Therapy

Children’s Global Assessment Scale

Clinical Global Impression-Improvement

Clinical Global Impression-Severity

Child Obsessive-Compulsive Impact Scale

Children’s Yale-Brown Obsessive-Compulsive Scale

Exposure and Response Prevention

Family Accommodation Scale

Family-based Cognitive Behavioural Therapy

Family Environment Scale

Family-based Psychoeducation/Relaxation Training

International Classification of Diseases-10

Kiddie-Schedule for Affective Disorders and Schizophrenia for school-aged children, Present and Lifetime version

Negative Effects Questionnaire

Obsessive-Compulsive Disorder

Psychoeducation/Relaxation Training

Parental Stress Scale

• Randomised clinical trial

Serious Adverse Event

Standard deviation

Social Responsiveness Scale

Therapeutic Alliance Scale for Children – Revised

Treatment Effects of Family Based Cognitive Therapy in Children and Adolescents with Obsessive Compulsive Disorder

Toronto Obsessive-Compulsive Scale

Wechsler Adult Intelligence Scale, IV

Wechsler Intelligence Scale for Children, V

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Acknowledgments

We acknowledge Trial Managers Merete Lindahl and Katrine Holmegaard Sørensen for their help coordinating the trial and the pilot study.

The trial has received internal and external funding. Several of the foundations (Lundbeckfonden, Region Hovedstadens forskningspulje/forskningsfond) use peer review.

The TECTO trial has obtained the following external funding:

•Lundbeckfonden: DKK 1,575,000. Grant number: R191-2015-922.

•Region Hovedstadens Forskningspulje: DKK 1,659,000.

•Region Hovedstadens Forskningsfond: DKK 1,475,000.

•Gangstedfonden: DKK 216,000. Grant number: R433-A29811.

•Lundbeckfonden: DKK 390,000. Grant number: R211-2015-3990.

•Psykiatrisk Forskningsfond af 1967: DKK 50,000.

•Holms Mindelegat: DKK 86,533. Grant number: 20006-1951.

•Læge Sofus Carl Emil Friis og Hustru Olga Friis’ legat: DKK 507,736.

•Netværk for Forskning og Kvalitetssikring i Psykoterapi: DKK 10,000.

Sponsor, steering group, and investigators have no conflicts of interest with funding bodies. Funding bodies will not be involved in any part of the design, conduct, analysis, interpretation, and reporting of this trial. The Steering Committee has the overall responsibility for the planning, conducting and reporting of the trial. Decisions relevant for day-to-day management will be handled by the Executive Committee.

Hartwig R. Siebner holds a 5-year professorship in precision medicine at the Faculty of Health Sciences and Medicine, University of Copenhagen which is sponsored by the Lundbeck Foundation (Grant Nr. R186–2015-2138).

Author information

Katrin Frimann Larsen passed away prior to publication of the article.

Authors and Affiliations

Child and Adolescent Mental Health Center, Copenhagen University Hospital – Mental Health Services CPH, Gentofte Hospitalsvej 3A, 1. sal, 2900 Hellerup, Copenhagen, Denmark

Anne Katrine Pagsberg, Camilla Uhre, Valdemar Uhre, Linea Pretzmann, Sofie Heidenheim Christensen, Christine Thoustrup, Iben Clemmesen, Amanda Aaen Gudmandsen, Nicoline Løcke Jepsen Korsbjerg, Anna-Rosa Cecilie Mora-Jensen, Melanie Ritter, Emilie D. Thorsen, Klara Sofie Vangstrup Halberg, Birgitte Bugge, Nina Staal, Helga Kristensen Ingstrup, Birgitte Borgbjerg Moltke, Anne Murphy Kloster, Pernille Juul Zoega, Marie Sommer Mikkelsen, Gitte Sommer Harboe, Katrin Frimann Larsen, Frank Verhulst, Pia Jeppesen, Jens Richardt Møllegaard Jepsen, Signe Vangkilde, Julie Hagstrøm, Nicole Nadine Lønfeldt & Kerstin Jessica Plessen

Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark

Anne Katrine Pagsberg, Camilla Uhre, Valdemar Uhre, Linea Pretzmann, Christine Thoustrup, Anna-Rosa Cecilie Mora-Jensen, Hartwig Roman Siebner & Pia Jeppesen

Danish Research Centre for Magnetic Resonance, Centre for Functional and Diagnostic Imaging and Research, Copenhagen University Hospital - Amager and Hvidovre, Copenhagen, Denmark

Valdemar Uhre & Hartwig Roman Siebner

Applied Mathematics and Computer Science, Technical University of Denmark, Kgs Lyngby, Denmark

Line Katrine Harder Clemmensen

Copenhagen Trial Unit, Centre for Clinical Intervention Research, Capital Region of Denmark, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark

Jane Lindschou, Janus Christian Jakobsen, Janus Engstrøm, Christian Gluud & Markus Harboe Olsen

Department of Regional Health Research, Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark

Janus Christian Jakobsen & Christian Gluud

Department of Neurology, Copenhagen University Hospital Bispebjerg and Fredriksberg, Copenhagen, Denmark

Hartwig Roman Siebner

Department of Child and Adolescent Psychiatry, Aarhus University Hospital, Psychiatry, Copenhagen, Denmark

Per Hove Thomsen & Katja Hybel

Child and Adolescent Psychiatric Department, Region Zealand Psychiatry, Research Unit, Roskilde, Denmark

Pia Jeppesen

Center for Clinical Intervention and Neuropsychiatric Schizophrenia Research (CINS), Mental Health Center Glostrup, Copenhagen University Hospital, Glostrup, Denmark

Jens Richardt Møllegaard Jepsen

Department of Psychology, Faculty Social Sciences, University of Copenhagen, Copenhagen, Denmark

Signe Vangkilde

Department of Neuroanaesthesiology, The Neuroscience Centre, The Neuroscience Centre, Copenhagen University Hospital – Rigshospitalet, Copenhagen, Denmark

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The trial is conducted in compliance with the study protocol, the Helsinki Declaration [ 31 ], and the applicable regulatory requirements (The Ethics Committee of Capital Region of Denmark approval number: H-18010607, and The Knowledge Centre on Data Protection Compliance in The Capital Region of Denmark: VD-2018-263, I-Suite no.: 6502). We act in accordance with the Danish personal and health data regulations when collecting information from patients’ medical records (The Danish Act on Processing of Personal Data, and Danish Health Act, Section 43, Subsection 1). Recruitment of participants started after regulatory approvals had been obtained.

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Hartwig R. Siebner has received honoraria as speaker from Sanofi Genzyme, Denmark and Novartis, Denmark, as consultant from Sanofi Genzyme, Denmark, Lophora, Denmark, and Lundbeck AS, Denmark, and as editor-in-chief (Neuroimage Clinical) and senior editor (NeuroImage) from Elsevier Publishers, Amsterdam, The Netherlands. He has received royalties as book editor from Springer Publishers, Stuttgart, Germany and from Gyldendal Publishers, Copenhagen, Denmark.

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Pagsberg, A.K., Uhre, C., Uhre, V. et al. Family-based cognitive behavioural therapy versus family-based relaxation therapy for obsessive-compulsive disorder in children and adolescents: protocol for a randomised clinical trial (the TECTO trial). BMC Psychiatry 22 , 204 (2022). https://doi.org/10.1186/s12888-021-03669-2

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Cognitive-Behavioral Family Therapy

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Name of Model

Cognitive-Behavioral Family Therapy (CBFT)

Behavioral family therapy (BFT)

Introduction

Cognitive-behavioral family therapy (CBFT) was born as the family therapy correlate to cognitive-behavioral therapy. That is, it integrates behaviorism and cognitive approaches and applies them to family systems. Because of its flexibility and continued evolution, CBFT is able to focus on a variety of problems, from promoting changes within individuals in families to altering family interaction styles. Furthermore, CBFT provides the fundamental principles and techniques to various empirically supported interventions and programs.

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Jing Lan & Tamara G. Sher

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Lan, J., Sher, T.G. (2019). Cognitive-Behavioral Family Therapy. In: Lebow, J.L., Chambers, A.L., Breunlin, D.C. (eds) Encyclopedia of Couple and Family Therapy. Springer, Cham. https://doi.org/10.1007/978-3-319-49425-8_40

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The International Journal of Indian Psychȯlogy

Cognitive Behavioral Therapy for Depression in an Adult: A Clinical Case Study

| Published: August 26, 2024

World Health Organization (WHO) reported, depression is the most common psychiatric disorder in the mental health field. Depression is various from habitual mood swings and short lived emotional responses to challenges in day to day life. Although strong evidence of supports that cognitive behavioral therapy for depression. The patient is a 22-year elderly a male which pre-treatment give a diagnosis of severe depressive symptoms without psychotic (based on case history + MSE + ICD-10 + BDI-II), low mood, frequently crying spell and suicidal ideation, highly dysfunctional attitudes and also decreased sleep and appetite. The CBT Treatment consisted of 12 standard individual therapy sessions. In this study used a case study method and also used the qualitative as well as quantitative data for the case is presented using self-report instruments or clinical case notes. Treatment effects such as his mood over the course of treatment was assessed using Beck Depression Inventory and after 6 months of follow up. Also enhancing his mood was accompanied by a reduction in dysfunctional beliefs and attitudes about self and relationship. Additionally, the patient was reported an improvement in his mood, Activity of Daily Living (ADL) functioning as well as socialization.

Depression , Cognitive Behaviour Therapy , Treatment Outcome , Case Report

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Received: April 15, 2024; Revision Received: August 23, 2024; Accepted: August 26, 2024

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20 Cognitive Behavioral Therapy (CBT) Techniques with Examples

Muhammad Sohail

Table of contents.

Cognitive Behavioral Therapy (CBT) stands as a powerful, evidence-based therapeutic approach for various mental health challenges. At its core lies a repertoire of techniques designed to reframe thoughts, alter behaviors, and alleviate emotional distress. This article explores 20 most commonly used cbt techniques. These therapy techniques are scientifcally valid, diverse in their application and effectiveness, serve as pivotal tools in helping individuals navigate and conquer their mental health obstacles.

Cognitive Restructuring or Reframing:

This is the most talked about of all cbt techniques. CBT employs cognitive restructuring to challenge and alter negative thought patterns. By examining beliefs and questioning their validity, individuals learn to perceive situations from different angles, fostering more adaptive thinking patterns.

John, feeling worthless after a rejected job application, questions his belief that he’s incompetent. He reflects on past achievements and reframes the situation, realizing the rejection doesn’t define his abilities.

Guided Discovery:

In guided discovery, therapists engage individuals in an exploration of their viewpoints. Through strategic questioning, individuals are prompted to examine evidence supporting their beliefs and consider alternate perspectives, fostering a more nuanced understanding and empowering them to choose healthier cognitive pathways.

During therapy, Sarah explores her fear of failure. Her therapist asks, “What evidence supports your belief that you’ll fail? Can we consider alternate outcomes?” Guided by these questions, Sarah acknowledges her exaggerated fears and explores more balanced perspectives.

Journaling and Thought Records:

Writing exercises like journaling and thought records aid in identifying and challenging negative thoughts. Tracking thoughts between sessions and noting positive alternatives enables individuals to monitor progress and recognize cognitive shifts.

James maintains a thought journal. Between sessions, he records negative thoughts about social situations. He then challenges these thoughts, jotting down positive alternatives and notices a shift in his mindset.

Activity Scheduling and Behavior Activation:

By scheduling avoided activities and implementing learned strategies, individuals establish healthier habits and confront avoidance tendencies, fostering behavioral change.

Emily, struggling with social anxiety, schedules coffee outings with friends. By implementing gradual exposure, she confronts her fear and eventually feels more comfortable in social settings.

Relaxation and Stress Reduction Techniques:

CBT incorporates relaxation techniques like deep breathing, muscle relaxation, and imagery to mitigate stress. These methods equip individuals with practical skills to manage phobias, social anxieties, and stressors effectively.

David practices deep breathing exercises when faced with work stress. By incorporating this technique into his routine, he manages work-related anxiety more effectively.

Successive Approximation:

Breaking overwhelming tasks into manageable steps cultivates confidence through incremental progress, enabling individuals to tackle challenges more effectively.

Maria, overwhelmed by academic tasks, breaks down her study sessions into smaller, manageable sections. As she masters each segment, her confidence grows, making the workload seem more manageable.

Interoceptive Exposure:

This technique targets panic and anxiety by exposing individuals to feared bodily sensations, allowing for a recalibration of beliefs around these sensations and reducing avoidance behaviors.

Tom, experiencing panic attacks, deliberately induces shortness of breath in a controlled setting. As he tolerates this discomfort without avoidance, he realizes that the sensation, though distressing, is not harmful.

Play the Script Until the End:

Encouraging individuals to envision worst-case scenarios helps alleviate fear by demonstrating the manageability of potential outcomes, reducing anxiety.

Facing fear of public speaking, Rachel imagines herself stumbling during a presentation. By playing out this scenario mentally, she realizes that even if it happens, it wouldn’t be catastrophic.

Shaping (Successive Approximation):

Shaping involves mastering simpler tasks akin to the challenging ones, aiding individuals in overcoming difficulties through gradual skill development.

Chris, struggling with public speaking, begins by speaking to small groups before gradually addressing larger audiences. Each step builds his confidence for the next challenge.

Contingency Management:

This method utilizes reinforcement and punishment to promote desirable behaviors, leveraging the consequences of actions to shape behavior positively.

To encourage healthier eating habits, Sarah rewards herself with a favorite activity after a week of sticking to a balanced diet.

Acting Out (Role-Playing):

Role-playing scenarios allow individuals to practice new behaviors in a safe environment, facilitating skill development and desensitization to challenging situations.

Alex, preparing for a job interview, engages in role-playing with a friend. They simulate the interview scenario, allowing Alex to practice responses and manage anxiety.

Sleep Hygiene Training:

Addressing the link between depression and sleep problems, this technique provides strategies for improving sleep quality, a critical aspect of mental well-being.

Lisa, struggling with sleep, follows sleep hygiene recommendations. She creates a calming bedtime routine and eliminates screen time before sleep, noticing improvements in her sleep quality.

Mastery and Pleasure Technique:

Encouraging engagement in enjoyable or accomplishment-driven activities serves as a mood enhancer and distraction from depressive thoughts.

After feeling low, Mark engages in gardening (a mastery activity) and then spends time painting (a pleasure activity). He finds joy in these activities, which uplifts his mood.

Behavioral Experiments:

This technique involves creating real-life experiments to test the validity of certain beliefs or assumptions. By actively exploring alternative thoughts or behaviors, individuals gather concrete evidence to challenge and modify their existing perspectives.

Laura believes people judge her negatively. She experiments by initiating conversations at social gatherings and observes that most interactions are positive, challenging her belief.

Externalizing:

Externalizing helps individuals separate themselves from their problems by giving those issues an identity or persona. This technique encourages individuals to view their problems as separate entities, facilitating a more objective approach to problem-solving.

Adam, dealing with anger issues, visualizes his anger as a separate entity named “Fury.” This helps him view his emotions objectively and manage them more effectively.

Acceptance and Commitment Therapy (ACT):

ACT combines mindfulness strategies with commitment and behavior-change techniques. It focuses on accepting difficult thoughts and emotions while committing to actions aligned with personal values, promoting psychological flexibility.

Sarah practices mindfulness exercises to accept her anxiety while committing to attend social events aligned with her values of connection and growth.

Imagery-Based Exposure:

This technique involves mentally visualizing feared or distressing situations, allowing individuals to confront and manage their anxieties in a controlled, imaginative setting.

Jack, afraid of flying, visualizes being on a plane, progressively picturing the experience in detail until he feels more comfortable with the idea of flying.

Mindfulness-Based Stress Reduction (MBSR):

MBSR incorporates mindfulness meditation and awareness techniques to help individuals manage stress, improve focus, and enhance overall well-being by staying present in the moment.

Rachel practices mindfulness meditation daily. By focusing on the present moment, she reduces work-related stress and enhances her overall well-being.

Systematic Desensitization:

Similar to exposure therapy, systematic desensitization involves pairing relaxation techniques with gradual exposure to anxiety-inducing stimuli. This process helps individuals associate relaxation with the feared stimuli, reducing anxiety responses over time.

Michael, with a fear of heights, gradually exposes himself to elevators first, then low floors in tall buildings, gradually working up to higher levels, reducing his fear response.

Narrative Therapy:

Narrative therapy focuses on separating individuals from their problems by helping them reconstruct and retell their life stories in a more empowering and positive light, emphasizing strengths and resilience.

Emily reevaluates her life story by focusing on instances where she overcame challenges, emphasizing her resilience and strength rather than her setbacks.

Each of these CBT techniques plays a unique role in helping individuals transform their thoughts, behaviors, and emotions. While some focus on cognitive restructuring, others emphasize behavioral modification or stress reduction. Together, they form a comprehensive toolkit empowering individuals to navigate their mental health challenges and foster positive change in their lives.

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The Availability Heuristic: Cognitive Bias in Decision Making

The availability heuristic is a cognitive bias that affects decision-making based on how easily information can be recalled or accessed.

Frank M. Dattilio, Ph.D., ABPP

Clinical and Forensic Psychology

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Cognitive-Behavioral Therapy with Couples and Families: A Comprehensive Guide for Clinicians

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From a leading expert in cognitive-behavioral therapy and couple and family therapy, this comprehensive guide combines cutting-edge research and clinical wisdom. The author shows how therapeutic techniques originally designed for individuals have been successfully adapted for use with couples and families struggling with a wide range of relationship problems and stressful life transitions. Vivid clinical examples illustrate the process of conducting thorough assessments, implementing carefully planned cognitive and behavioral interventions, and overcoming roadblocks. The book highlights ways to enhance treatment by drawing on the latest knowledge about relationship dynamics, attachment, and neurobiology. Cultural diversity issues are woven throughout.

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A Counselling Case Study Using CBT

Jocelyn works as a Human Resources Manager for a large international organisation. She is becoming more and more stressed at work as the company is constantly changing and evolving. It is a requirement of her job that she keeps up with this change by implementing new strategies as well as ensuring focus is kept on her main role of headhunting new employees.

She finds that she is working twelve-hour days, six days a week and doesn’t have time for her friends and family. She has started yelling at staff members when they ask her questions and when making small mistakes in their work. Concerned about her stress levels, Jocelyn decided to attend a counselling session.

Below is an extract from Jocelyn’s first session with her counsellor:

Transcript from counselling session

Counsellor: So Jocelyn, let’s spend a few minutes talking about the connection between your thoughts and your emotions. Can you think of some times this week when you were frustrated with work? Jocelyn : Yes, definitely. It was on Friday and I had just implemented a new policy for staff members. I had imagined that I would get a lot of phone calls about it because I always do but I ended up snapping at people over the phone. Counsellor : And how were you feeling at that time? Jocelyn : I felt quite stressed and also annoyed at other staff members because they didn’t understand the policy. Counsellor : And what was going through your mind? Jocelyn : I guess I was thinking that no-one appreciates what I do. Counsellor : Okay. You just identified what we call an automatic thought. Everyone has them. They are thoughts that immediately pop to mind without any effort on your part. Most of the time the thought occurs so quickly you don’t notice it but it has an impact on your emotions. It’s usually the emotion that you notice, rather than the thought. Often these automatic thoughts are distorted in some way but we usually don’t stop to question the validity of the thought. But today, that’s what we are going to do?

The counsellor proceeds to work through the cognitive behaviour process with Jocelyn as follow:

Step 1 – Identify the automatic thought

Together, the counsellor and Jocelyn identified Jocelyn’s automatic thought as: “No-one appreciates what I do”.

Step 2 – Question the validity of the automatic thought

To question the validity of Jocelyn’s automatic thought, the counsellor engages in the following dialogue:

Counsellor : Tell me Jocelyn, what is the effect of believing that ‘no-one appreciates you?’ Jocelyn : Well, it infuriates me! I feel so undervalued and it puts me in such a foul mood. Counsellor : Okay, now I’d just like you to think for a moment what could be the effect if you changed that way of thinking Jocelyn: You mean, if I didn’t think that ‘no-one appreciates me’? Counsellor : Yes. Jocelyn : I guess I’d be a lot happier in my job. Ha, ha, I’d probably be nicer to be around. I’d be less snappy, more patient.

Step 3 – Challenge core beliefs

To challenge Jocelyn’s core belief, the counsellor engages in the following dialogue:

Counsellor : Jocelyn, I’d like you to read through this list of common false beliefs and tell me if you relate to any of them (hands Jocelyn the list of common false beliefs). Jocelyn : (Reads list)Ah, yes,I can see how I relate to number four, ‘that it’s necessary to be competent and successful in all those things which are attempted’.That’s so true for me. Counsellor : The reason these are called “false beliefs” is because they are extreme ways of perceiving the world. They are black or white and ignore the shades of grey in between.

Applications of CBT

Cognitive approaches have been applied as means of treatment across a variety of presenting concerns and psychological conditions. Cognitive approaches emphasise the role of thought in the development and maintenance of unhelpful or distressing patterns of emotion or behaviour.

Beck originally applied his cognitive approach to the treatment of depression. Cognitive therapy has also been successfully used to treat such conditions as anxiety disorders, obsessive disorders, substance abuse, post-traumatic stress, eating disorders, dissociative identity disorder, chronic pain and many other clinical conditions. In addition, it has been widely utilised to assist clients in enhancing their coping skills and moderating extremes in unhelpful thinking.

• March 18, 2010
• Case Study , CBT , Counselling , Workplace
• Case Studies , Counselling Therapies , Workplace Issues

Comments: 11

I recently had a call (lifeline) from a young person with similar issues as Jocelyn so it was interresting to me to see that I was on the right track helping my client to change her thinking.

I am employed as a counselling psychologist in the dept. of professional studies for graduate students, it’s the way i had been challenging irrational beliefs students hold about themselves, & CBT helps a lot in improving their academic achievement, & helps my counselling to gain ground successfully.

it was a good case study helped a lot I as a student studying about case study on CBT patients !! thanks a lot

Thank you very much. it helped me as I am a student of basic counselling course.

I think the way the process is explained is very helpful.

It’s a very good article.Therapist explicitly challenged the automatic thought and could elicit it very well. CBT is more realistic and genuine. Great case study. Expect more such case details. Thanks.

I concur many students don’t fail exams because they don’t work hard but lack of confidence and negative self talk like I can never pass cbt is powerful in replacing the negative self talk

This type of case study is useful to know about the basic job awareness and what kind of stress the employee has. Mainly useful to know about the lot of information about counseling knowledge.

I am preparing for my internship in counseling and looking for case studies. I found this case study helpful and useful in how to utilize the CBT techniques when working with my potential clients. Thanks

what psychological theory would best help understand the client’s problems and how therapy from that theoretical standpoint will help them?

Cognitive Theory Behaviorism – Operant Conditioning Behaviorism – Classic Conditioning Psychoanalytic Theory Object Relations/Attachment Theory Existential Theory Humanistic Theory

As a psychology student this case study helped me alot in understanding the core values of CBT as well as how important of a role it is in counseling. Thank you!

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