- Email: [email protected]
Childhood obsessive-compulsive disorder: Extinction of compulsive reassurance-seeking
Journal Pruned
of Anwry Disorders. Vol. 2. pp. 361-366. in the USA. All rights reserved.
1988 Copyright
CLINICAL
0887-6185188 S3.M) c .M) 0 1988 Pcrgamon Rcss plc
REPORT
Childhood Obsessive-Compulsive Disorder: Extinction of Compulsive Reassurance-Seeking GRETA FRANCIS,
PH.D.
Western Psychiatric Institute and Clinic, Pittsburgh
Abstract --In this study an extinction procedure was used to treat reassuranceseeking behavior in an obsessive-compulsive child. An ABAB single subject experimental design was used to evaluate the procedure, which was implemented on an outpatient basis by the child’s parents. Results indicated that the treatment produced a marked decrease in the frequency of reassurance-seeking behavior. At the time of the one-month follow-up assessment, the frequency of reassurance-seeking behavior was zero. These results are discussed in light of the chronic nature of obsessive-compulsive disorder.
Childhood obsessive-compulsive disorder is a rare and typically debilitating psychiatric illness. Estimates of the prevalence of obsessive-compulsive disorder in children have been placed at two percent or less of childhood disorders. Moreover, the prognosis for childhood obsessivecompulsive disorder is poor (Hollingsworth, Tanquay, Grossman, & Pabst, 1980; Judd, 1965). There are few accounts of the treatment of childhood obsessive-compulsive disorder in the literature. However, a small number of investigations of pharmacotherapy (Flament, et al., 1985; Rapoport, Elkins, & Mikkelson, 1980) and behavior therapy (Bolton, Collins, & Steinberg, 1983; Hallam, 1974; Mills, Agras, Barlow, & Mills, 1973; Phillips & Wolpe, 1981; Stanley, 1980) have been conducted. The majority of these studies have been conducted with adolescents. Currently, there is a need for much more research before empirically-based treatment recommendations can be made (Carlson, Figueroa, & Lahey, 1986). Hallam (1974) noted that compulsive reassurance-seeking is a common manifestation of obsessive-compulsive disorder observed in children. He I would like to thank Cyd Strauss and Cynthia Last for their helpful comments. Address correspondence and reprint requests to Greta Francis, Ph.D., Bradley Hospital, 1101 Veteran’s Memorial Parkway, East Providence, RI 02915.
361
362
G. FRANCIS
described the use of extinction to treat compulsive reassurance-seeking in a IS-year-old, hospitalized, female. This adolescent had a three-year history of repetitive questions about whether people were spreading rumors and saying nasty things about her. The initial phase of treatment consisted of instructing staff to respond to her questions by saying “I can’t answer that” or “That is a ritual.” The author reported that this strategy made no impact on the frequency of the child’s reassuranceseeking questions. Thereafter, an extinction procedure was started. The extinction procedure consisted of the complete absence of attention to reassurance-seeking questions 24 hours per day. Staff were instructed not to comment directly upon questions, but rather to look away and redirect conversation when faced with questions from the patient. Although at first the patient was described as agitated and highly anxious, within three to four weeks her reassurance-seeking had been eliminated. About half-way through the extinction phase, a response cost procedure was added in which the patient lost one minute out of her recreation hour for each question asked. This study presented a promising approach to the modification of reassurance-seeking behavior in an obsessive-compulsive child. Unfortunately, the case study design and lack of pretreatment baseline data collection make it difficult to evaluate the results empirically. The purpose of the present study was to expand on Hallam’s (1974) work by empirically evaluating the use of extinction to modify compulsive reassurance-seeking behavior. Therefore, in the present study an ABAB single case design was used. The present study further extended the previous investigation in that the subject was a prepubertal child who was treated on an outpatient basis, the parents implemented the treatment procedures in the home, and the treatment consisted only of extinction. In addition, a one-month follow-up assessment was conducted. METHOD Subject The subject was an 1 l-year-old, white male of average intelligence who presented at an outpatient psychiatric clinic specializing in the assessment and treatment of children with anxiety disorders. He was assessed using a version of the Schedule for Affective Disorders and Schizophrenia for School-Aged Children (K-SADS: Puig-Antich & Chambers, 1982) modified by Last (1986) for use with anxiety-disordered populations. The modified K-SADS allowed for diagnoses to be made using the criteria specified in the third edition of the Diagnostic and Statistical Manual of Mental Disorders (American Psychiatric Association, 1980). The parents and the child were interviewed individually by a clinical child psychologist using the modified K-SADS. The clinical child psychologist then consulted with the assessment team, which consisted
CHILDHOOD OCD: EXTINCTION OF REASSURANCE-SEEKING
363
of a child psychiatrist and another clinical psychologist, who are experts in the diagnosis of anxiety disorders in children. A consensus diagnosis of obsessive-compulsive disorder was given based on the symptom picture described below. At the time of his psychiatric evaluation, the child’s presenting complaint was an acute onset of obsessive thoughts about illness and death of approximately four month’s duration. He frequently voiced fears of dying or becoming handicapped from various diseases. For example, on one occasion the child superficially scratched himself with a pencil and became obsessed with the thought that he might die from lead poisoning. He reported that he “couldn’t stop thinking about scary stuff, like diseases and dying,” acknowledged that the thoughts did not make sense, and described the thoughts as extremely distressing. These thoughts occurred many times per day, both while at school and at home. The child was equally likely to be bothered by such obsessive thoughts regardless of whether or not he was in the presence of his parents. The child stated that he tried, typically unsuccessfully, to distract himself from these thoughts by playing, reading, or talking to someone. In addition, the child persistently asked his parents for reassurance. For example, he repeatedly asked “Am I going blind?,” “Do you think I have a tumor?,” “Am I going to die?,” or “Do you think I’m going to throw up today?” Oftentimes he would try to avoid anxiety-provoking situations. For example, he would be reluctant to eat meals because he feared that he would vomit later. His parents attempted to provide reassurance, but reported that his behavior continued to worsen. Typically, after running back and forth from his mother to his father, asking each for reassurance, the child became even more anxious and agitated. Two weeks prior to his clinic evaluation, he was telephoning home from school each day, crying, and asking his parents if they thought he would be all right and if he would make it through the day. Eventually, his parents instructed him not to discuss his worries at school and refused to accept his phone calls. However, the parents continued to provide reassurance in the home. Assessment The child’s parents were instructed to record his reassurance-seeking behavior four times per day: at breakfast time, at three p.m., at dinnertime, and before bed. That is, the parents monitored his reassuranceseeking behavior from the time he got up in the morning until breakfast time, from the time he got home from school (i.e., two p.m.) until three p.m., from three p.m. until dinnertime, and from dinnertime until bedtime. Reassurance-seeking behavior was defined as any question regarding his physical health. Reassurance-seeking was scored as “present” or “absent” at each of the four monitoring points each day. Although the child was asked initially to self-monitor his behavior, his
364
G.
FRANCIS
compliance with this task was inconsistent not be used.
and his self-report
data could
Design An ABAB single subject experimental design was used to evaluate the extinction procedure. Although the initial treatment plan for this child did not include a reversal phase, a naturalistic return to baseline did occur (see Return to baseline, below, for details). Baseline. During Baseline (A) the parents were instructed to respond in their usual way to the child’s reassurance-seeking behavior. They completed eight consecutive days of baseline monitoring. Extinction. During Extinction (B) the parents were instructed to ignore all reassurance-seeking behavior by not responding directly to the request for reassurance. Instead they were instructed to look/turn away or redirect the conversation. During this phase, the therapist maintained frequent phone contact with the parents in order to encourage and check on compliance with the treatment procedure. This phase lasted for eight consecutive days. Return to Baseline. The Return to Baseline (A) phase consisted of a return to attending to the reassurance-seeking behavior. This phase occurred naturally when the parents again began attending to the reassurance-seeking behavior during a time when the mother and a sibling each developed a mild flu. The parents reported being too tired to implement the program consistently during this time. This phase lasted for five consecutive days. Of note, the family illness persisted for another five days following the end of this phase. Return to Extinction. The Return to Extinction (B) phase consisted of the reimplemention of the extinction procedure. This phase lasted for 20 consecutive days. Follow-Up. A one month posttreatment parents monitored reassurance-seeking days.
assessment was conducted. The behavior for three consecutive
RESULTS As displayed in Figure 1, a relatively stable baseline was seen during the first eight days of monitoring. The child evidenced reassuranceseeking behavior between 25% and 50% of the intervals during which he was being monitored. Once treatment was initiated, his behavior temporarily worsened, as would be expected given the “extinction burst” phe-
CHILDHOOD OCD: EXTINCTION OF REASSURANCE-SEEKING
365
Baseline 1
I I I
I
:V-k@ I 1
3
5
7
9 11 13 15 17 19 21 23 25 27 29 31 33 35 37 39 41
73
Day5
FIG. I. Reassurance-seeking
behavior. ‘RSB = reassurance-seeking
behavior.
nomenon. In fact, his parents reported that he was more tearful, panicky, and demanding during this time. He began to try to get their attention in other ways (e.g., he would call for his mother first and then ask for reassurance, or he would complain that nobody loved him). However, within six days, the frequency of the child’s reassurance-seeking behavior was zero and remained absent for three consecutive days. During the withdrawal of extinction, the child’s behavior worsened dramatically, and was occurring at rates higher than those seen during baseline. During this phase, the child was exhibiting reassurance-seeking behavior between 50 and 100 percent of the intervals that his behavior was being monitored. Once extinction was reimplemented, the frequency of reassuranceseeking behavior fell to zero within 12 days, and remained at zero for 9 consecutive days. At the time of the one-month follow-up assessment, the frequency of his reassurance-seeking behavior had remained at zero. DISCUSSION An extinction procedure was effective in eliminating compulsive reassurance-seeking behavior in an 1l-year-old male with obsessive-compulsive disorder. The procedure was implemented on an outpatient basis by the child’s parents. The ABAB design allowed for an empirical evaluation of the extinction procedure, and results indicated that the procedure produced the desired behavior change. A possible confound is that the return to baseline phase was prompted by illness in the family rather than planned a priori. Given the nature of the child’s obsessive worries, the family situation itself could have produced an increase in reassuranceseeking behavior. However, if the increase in reassurance-seeking was due only to family illness, one would have expected the behavior to persist even with the reimplementation of extinction. As the results clearly show, the reassurance-seeking behavior decreased with the reimplementation of extinction, even though the family illness persisted.. A weakness of this study is the reliance on parent report as the sole means of data collection. As noted above, an unsuccessful attempt was made to collect self-report data from the child. Ideally, the inclusion of direct observation would have been preferable. However, as the child was treated on an outpatient basis and the family lived a considerable
366
G.
FRANCIS
distance from the clinic, direct observation of the reassurance-seeking behavior was not practical in this particular case. The use of multiple informants to provide behavior ratings would further advance the literature. In sum, this study provides the first empirical evaluation of an extinction procedure for the treatment of reassurance-seeking in an obsessivecompulsive child. Although positive results were obtained, replication is required before definitive statements regarding the application of this technique can be made. It is important to emphasize that this study addressed the short-term treatment of a long-term disorder. Given the chronic nature of obsessive-compulsive disorder, future researchers need to evaluate the long-term efficacy of such treatment strategies. REFERENCES American Psychiatric Association. (1980). Diagnostic and statistical manual ofmental disorders: (3rd ed.). Washington, DC: Author. Bolton, D., Collins, S., & Steinberg, D. (1983). The treatment of obsessive-compulsive disorder in adolescence: A report of fifteen cases. British Journal of Psychiatry, 142, 456-464. Carlson, C. L., Figueroa, R. G., & Lahey, B. B. (1986). Behavior therapy for childhood anxiety disorders. In R. Gittelman (Ed.), Anxiefy disorders of childhood. New York: Guilford Press. Flament, M. F., Rapoport, J. L., Berg, C. J., Sceery, W., Kilts, C., Mellstrom. B., & Linniola, M. (1985). Clomipramine treatment of childhood obsessive-compulsive disorder: A double blind controlled study. Archives of General Psychiafry, 42, 977-983. Hallam, R. S. (1974). Extinction of ruminations: A case study. Behavior Therapy, 5, 565-568.
Hollingsworth, C. E.. Tanquay, P. E., Grossman, L., & Pabst, P. (1980). Long-term outcome of obsessive-compulsive disorder in childhood. Journal of the American Academy of Child Psychiatry,
19, 134-I-U.
Judd, L. L. (1965). Obsessive compulsive neurosis in children. Archives of General Psychiatry, 12, 136-145.
Last, C. G. (1986). Modification of the K-SADS for use with anxiety-disordered populations. Unpublished manuscript, University of Pittsburgh School of Medicine. Mills, H. L., Agras, W. S., Barlow, P. H., & Mills, J. R. (1973). Compulsive rituals treated by response prevention: An experimental analysis. Archives of General Psychiatry, 38, 524-529.
Phillips, D. & Wolpe, S. (1981). Multiple behavior techniques in severe separation anxiety of a 12 year old. Journal of Behavior Therapy and Experimenral Psychiatry, 12, 329-332.
Puig-Antich, J. & Chambers, for school-age
W. (1982). Schedule for affective disorders and schizophrenia years)-KiddieSADS. New York: New York State Psy-
children (6-16
chiatric Institute. Rapoport, J., Elkins, R., & Mikkelsen, E. (1980). Clinical controlled trial of chlorimipramine in adolescents with obsessive-compulsive disorder (Part 3). Psychopharmacology Bulletin,
16, 61-63.
Stanley, L. (1980). Treatment of ritualistic behavior in an b-year-old girl by response vention: A case report. Journal of Child Psychology and Psychiatry, 21, 85-90.
pre-
of Anwry Disorders. Vol. 2. pp. 361-366. in the USA. All rights reserved.
1988 Copyright
CLINICAL
0887-6185188 S3.M) c .M) 0 1988 Pcrgamon Rcss plc
REPORT
Childhood Obsessive-Compulsive Disorder: Extinction of Compulsive Reassurance-Seeking GRETA FRANCIS,
PH.D.
Western Psychiatric Institute and Clinic, Pittsburgh
Abstract --In this study an extinction procedure was used to treat reassuranceseeking behavior in an obsessive-compulsive child. An ABAB single subject experimental design was used to evaluate the procedure, which was implemented on an outpatient basis by the child’s parents. Results indicated that the treatment produced a marked decrease in the frequency of reassurance-seeking behavior. At the time of the one-month follow-up assessment, the frequency of reassurance-seeking behavior was zero. These results are discussed in light of the chronic nature of obsessive-compulsive disorder.
Childhood obsessive-compulsive disorder is a rare and typically debilitating psychiatric illness. Estimates of the prevalence of obsessive-compulsive disorder in children have been placed at two percent or less of childhood disorders. Moreover, the prognosis for childhood obsessivecompulsive disorder is poor (Hollingsworth, Tanquay, Grossman, & Pabst, 1980; Judd, 1965). There are few accounts of the treatment of childhood obsessive-compulsive disorder in the literature. However, a small number of investigations of pharmacotherapy (Flament, et al., 1985; Rapoport, Elkins, & Mikkelson, 1980) and behavior therapy (Bolton, Collins, & Steinberg, 1983; Hallam, 1974; Mills, Agras, Barlow, & Mills, 1973; Phillips & Wolpe, 1981; Stanley, 1980) have been conducted. The majority of these studies have been conducted with adolescents. Currently, there is a need for much more research before empirically-based treatment recommendations can be made (Carlson, Figueroa, & Lahey, 1986). Hallam (1974) noted that compulsive reassurance-seeking is a common manifestation of obsessive-compulsive disorder observed in children. He I would like to thank Cyd Strauss and Cynthia Last for their helpful comments. Address correspondence and reprint requests to Greta Francis, Ph.D., Bradley Hospital, 1101 Veteran’s Memorial Parkway, East Providence, RI 02915.
361
362
G. FRANCIS
described the use of extinction to treat compulsive reassurance-seeking in a IS-year-old, hospitalized, female. This adolescent had a three-year history of repetitive questions about whether people were spreading rumors and saying nasty things about her. The initial phase of treatment consisted of instructing staff to respond to her questions by saying “I can’t answer that” or “That is a ritual.” The author reported that this strategy made no impact on the frequency of the child’s reassuranceseeking questions. Thereafter, an extinction procedure was started. The extinction procedure consisted of the complete absence of attention to reassurance-seeking questions 24 hours per day. Staff were instructed not to comment directly upon questions, but rather to look away and redirect conversation when faced with questions from the patient. Although at first the patient was described as agitated and highly anxious, within three to four weeks her reassurance-seeking had been eliminated. About half-way through the extinction phase, a response cost procedure was added in which the patient lost one minute out of her recreation hour for each question asked. This study presented a promising approach to the modification of reassurance-seeking behavior in an obsessive-compulsive child. Unfortunately, the case study design and lack of pretreatment baseline data collection make it difficult to evaluate the results empirically. The purpose of the present study was to expand on Hallam’s (1974) work by empirically evaluating the use of extinction to modify compulsive reassurance-seeking behavior. Therefore, in the present study an ABAB single case design was used. The present study further extended the previous investigation in that the subject was a prepubertal child who was treated on an outpatient basis, the parents implemented the treatment procedures in the home, and the treatment consisted only of extinction. In addition, a one-month follow-up assessment was conducted. METHOD Subject The subject was an 1 l-year-old, white male of average intelligence who presented at an outpatient psychiatric clinic specializing in the assessment and treatment of children with anxiety disorders. He was assessed using a version of the Schedule for Affective Disorders and Schizophrenia for School-Aged Children (K-SADS: Puig-Antich & Chambers, 1982) modified by Last (1986) for use with anxiety-disordered populations. The modified K-SADS allowed for diagnoses to be made using the criteria specified in the third edition of the Diagnostic and Statistical Manual of Mental Disorders (American Psychiatric Association, 1980). The parents and the child were interviewed individually by a clinical child psychologist using the modified K-SADS. The clinical child psychologist then consulted with the assessment team, which consisted
CHILDHOOD OCD: EXTINCTION OF REASSURANCE-SEEKING
363
of a child psychiatrist and another clinical psychologist, who are experts in the diagnosis of anxiety disorders in children. A consensus diagnosis of obsessive-compulsive disorder was given based on the symptom picture described below. At the time of his psychiatric evaluation, the child’s presenting complaint was an acute onset of obsessive thoughts about illness and death of approximately four month’s duration. He frequently voiced fears of dying or becoming handicapped from various diseases. For example, on one occasion the child superficially scratched himself with a pencil and became obsessed with the thought that he might die from lead poisoning. He reported that he “couldn’t stop thinking about scary stuff, like diseases and dying,” acknowledged that the thoughts did not make sense, and described the thoughts as extremely distressing. These thoughts occurred many times per day, both while at school and at home. The child was equally likely to be bothered by such obsessive thoughts regardless of whether or not he was in the presence of his parents. The child stated that he tried, typically unsuccessfully, to distract himself from these thoughts by playing, reading, or talking to someone. In addition, the child persistently asked his parents for reassurance. For example, he repeatedly asked “Am I going blind?,” “Do you think I have a tumor?,” “Am I going to die?,” or “Do you think I’m going to throw up today?” Oftentimes he would try to avoid anxiety-provoking situations. For example, he would be reluctant to eat meals because he feared that he would vomit later. His parents attempted to provide reassurance, but reported that his behavior continued to worsen. Typically, after running back and forth from his mother to his father, asking each for reassurance, the child became even more anxious and agitated. Two weeks prior to his clinic evaluation, he was telephoning home from school each day, crying, and asking his parents if they thought he would be all right and if he would make it through the day. Eventually, his parents instructed him not to discuss his worries at school and refused to accept his phone calls. However, the parents continued to provide reassurance in the home. Assessment The child’s parents were instructed to record his reassurance-seeking behavior four times per day: at breakfast time, at three p.m., at dinnertime, and before bed. That is, the parents monitored his reassuranceseeking behavior from the time he got up in the morning until breakfast time, from the time he got home from school (i.e., two p.m.) until three p.m., from three p.m. until dinnertime, and from dinnertime until bedtime. Reassurance-seeking behavior was defined as any question regarding his physical health. Reassurance-seeking was scored as “present” or “absent” at each of the four monitoring points each day. Although the child was asked initially to self-monitor his behavior, his
364
G.
FRANCIS
compliance with this task was inconsistent not be used.
and his self-report
data could
Design An ABAB single subject experimental design was used to evaluate the extinction procedure. Although the initial treatment plan for this child did not include a reversal phase, a naturalistic return to baseline did occur (see Return to baseline, below, for details). Baseline. During Baseline (A) the parents were instructed to respond in their usual way to the child’s reassurance-seeking behavior. They completed eight consecutive days of baseline monitoring. Extinction. During Extinction (B) the parents were instructed to ignore all reassurance-seeking behavior by not responding directly to the request for reassurance. Instead they were instructed to look/turn away or redirect the conversation. During this phase, the therapist maintained frequent phone contact with the parents in order to encourage and check on compliance with the treatment procedure. This phase lasted for eight consecutive days. Return to Baseline. The Return to Baseline (A) phase consisted of a return to attending to the reassurance-seeking behavior. This phase occurred naturally when the parents again began attending to the reassurance-seeking behavior during a time when the mother and a sibling each developed a mild flu. The parents reported being too tired to implement the program consistently during this time. This phase lasted for five consecutive days. Of note, the family illness persisted for another five days following the end of this phase. Return to Extinction. The Return to Extinction (B) phase consisted of the reimplemention of the extinction procedure. This phase lasted for 20 consecutive days. Follow-Up. A one month posttreatment parents monitored reassurance-seeking days.
assessment was conducted. The behavior for three consecutive
RESULTS As displayed in Figure 1, a relatively stable baseline was seen during the first eight days of monitoring. The child evidenced reassuranceseeking behavior between 25% and 50% of the intervals during which he was being monitored. Once treatment was initiated, his behavior temporarily worsened, as would be expected given the “extinction burst” phe-
CHILDHOOD OCD: EXTINCTION OF REASSURANCE-SEEKING
365
Baseline 1
I I I
I
:V-k@ I 1
3
5
7
9 11 13 15 17 19 21 23 25 27 29 31 33 35 37 39 41
73
Day5
FIG. I. Reassurance-seeking
behavior. ‘RSB = reassurance-seeking
behavior.
nomenon. In fact, his parents reported that he was more tearful, panicky, and demanding during this time. He began to try to get their attention in other ways (e.g., he would call for his mother first and then ask for reassurance, or he would complain that nobody loved him). However, within six days, the frequency of the child’s reassurance-seeking behavior was zero and remained absent for three consecutive days. During the withdrawal of extinction, the child’s behavior worsened dramatically, and was occurring at rates higher than those seen during baseline. During this phase, the child was exhibiting reassurance-seeking behavior between 50 and 100 percent of the intervals that his behavior was being monitored. Once extinction was reimplemented, the frequency of reassuranceseeking behavior fell to zero within 12 days, and remained at zero for 9 consecutive days. At the time of the one-month follow-up assessment, the frequency of his reassurance-seeking behavior had remained at zero. DISCUSSION An extinction procedure was effective in eliminating compulsive reassurance-seeking behavior in an 1l-year-old male with obsessive-compulsive disorder. The procedure was implemented on an outpatient basis by the child’s parents. The ABAB design allowed for an empirical evaluation of the extinction procedure, and results indicated that the procedure produced the desired behavior change. A possible confound is that the return to baseline phase was prompted by illness in the family rather than planned a priori. Given the nature of the child’s obsessive worries, the family situation itself could have produced an increase in reassuranceseeking behavior. However, if the increase in reassurance-seeking was due only to family illness, one would have expected the behavior to persist even with the reimplementation of extinction. As the results clearly show, the reassurance-seeking behavior decreased with the reimplementation of extinction, even though the family illness persisted.. A weakness of this study is the reliance on parent report as the sole means of data collection. As noted above, an unsuccessful attempt was made to collect self-report data from the child. Ideally, the inclusion of direct observation would have been preferable. However, as the child was treated on an outpatient basis and the family lived a considerable
366
G.
FRANCIS
distance from the clinic, direct observation of the reassurance-seeking behavior was not practical in this particular case. The use of multiple informants to provide behavior ratings would further advance the literature. In sum, this study provides the first empirical evaluation of an extinction procedure for the treatment of reassurance-seeking in an obsessivecompulsive child. Although positive results were obtained, replication is required before definitive statements regarding the application of this technique can be made. It is important to emphasize that this study addressed the short-term treatment of a long-term disorder. Given the chronic nature of obsessive-compulsive disorder, future researchers need to evaluate the long-term efficacy of such treatment strategies. REFERENCES American Psychiatric Association. (1980). Diagnostic and statistical manual ofmental disorders: (3rd ed.). Washington, DC: Author. Bolton, D., Collins, S., & Steinberg, D. (1983). The treatment of obsessive-compulsive disorder in adolescence: A report of fifteen cases. British Journal of Psychiatry, 142, 456-464. Carlson, C. L., Figueroa, R. G., & Lahey, B. B. (1986). Behavior therapy for childhood anxiety disorders. In R. Gittelman (Ed.), Anxiefy disorders of childhood. New York: Guilford Press. Flament, M. F., Rapoport, J. L., Berg, C. J., Sceery, W., Kilts, C., Mellstrom. B., & Linniola, M. (1985). Clomipramine treatment of childhood obsessive-compulsive disorder: A double blind controlled study. Archives of General Psychiafry, 42, 977-983. Hallam, R. S. (1974). Extinction of ruminations: A case study. Behavior Therapy, 5, 565-568.
Hollingsworth, C. E.. Tanquay, P. E., Grossman, L., & Pabst, P. (1980). Long-term outcome of obsessive-compulsive disorder in childhood. Journal of the American Academy of Child Psychiatry,
19, 134-I-U.
Judd, L. L. (1965). Obsessive compulsive neurosis in children. Archives of General Psychiatry, 12, 136-145.
Last, C. G. (1986). Modification of the K-SADS for use with anxiety-disordered populations. Unpublished manuscript, University of Pittsburgh School of Medicine. Mills, H. L., Agras, W. S., Barlow, P. H., & Mills, J. R. (1973). Compulsive rituals treated by response prevention: An experimental analysis. Archives of General Psychiatry, 38, 524-529.
Phillips, D. & Wolpe, S. (1981). Multiple behavior techniques in severe separation anxiety of a 12 year old. Journal of Behavior Therapy and Experimenral Psychiatry, 12, 329-332.
Puig-Antich, J. & Chambers, for school-age
W. (1982). Schedule for affective disorders and schizophrenia years)-KiddieSADS. New York: New York State Psy-
children (6-16
chiatric Institute. Rapoport, J., Elkins, R., & Mikkelsen, E. (1980). Clinical controlled trial of chlorimipramine in adolescents with obsessive-compulsive disorder (Part 3). Psychopharmacology Bulletin,
16, 61-63.
Stanley, L. (1980). Treatment of ritualistic behavior in an b-year-old girl by response vention: A case report. Journal of Child Psychology and Psychiatry, 21, 85-90.
pre-