Flexible Manualized Treatment for Pediatric Obsessive–Compulsive Disorder: A Case Study

The following case study describes the treatment of an 8 year-old girl with early-onset obsessive compulsive disorder using a manualized cognitive-behavioral therapy with exposure and response prevention (CBT/EPR) protocol, implemented using a “flexibility within fidelity” approach. The case study focuses on how the treatment manual was successfully implemented in a flexible manner to address unique aspects of the case. These unique factors included the child’s extreme shyness at the beginning of treatment (with implications for rapport building), the primarily obsessional presentation of this child’s symptoms, the child’s avoidance of discussing the content of her obsessive thoughts, and secondary depressive symptoms (excessive guilt, frequent crying, and sadness) that contributed to the child’s impairment and distress. Assessment of progress indicated improvement in symptoms after four sessions of cognitive skill building and again in the last five sessions after implementing increased exposure to obsessive thoughts using narrative techniques. The implications for clinicians and student therapists, including the importance of rapport building, developmentally tailoring treatment, and flexibly implementing treatment to address the unique characteristics of the individual patient are discussed.