MARA GOVERMAN: Many families struggle to find OCD treatment for their children. Specialty-trained therapists are limited, and wait lists are usually long. Online therapy is an option, but how well does it work? Today, we discuss a study that examines online cognitive behavioral therapy with exposure and response prevention for kids with OCD. 

JOSH FEDER:  I'm Dr. Josh Feder, the editor-in-chief of the Carlat Child Psychiatry Report and co-author of the Child Medication Factbook for Psychiatric Practice, second edition, 2023, and the other book, Prescribing Psychotropics.

MARA GOVERMAN: And I am Mara Goverman, a licensed clinical social worker in Southern California with a private practice and an avid reader of The Carlat Psychiatry Reports. Online therapy is a big topic right now, especially when access to specially trained therapists is limited.  

JOSH FEDER: Yes, and we can turn to a 2022 Hollmann study for insight. This study looks at whether online CBT is as effective as in-person treatment. The researchers recruited 60 children ages 6 to 18, all with primary diagnosis of OCD and with moderate symptom severity. The treatment lasted 14 weeks, and they compared immediate treatment with a delayed start control group.  

MARA GOVERMAN: And here's what they found. There was a significant reduction in symptoms in the treatment group after 16 weeks, and the effect size is large with a Cohen's d of 1.63. An impressive 64% of kids reached remission.  

JOSH FEDER: The researchers tracked outcomes for almost a year post-treatment and found sustained improvements. Families generally said they preferred the online format, which suggests that remote care may be a viable alternative. So here's my thought about this, because successive generations are tied to online kinds of work, especially after the pandemic, even before the pandemic, there were online treatments that were available—there was a free set through the government of Australia that I give people the link to—and then the pandemic hits, and so many more people are online. I think they're more accustomed to it at this point, and so, a package like this, if it's working, I think it's got legs. There are some issues I want to talk about a little bit later, having to do with the design of the study and the need for more research, but we'll get to that part in a little bit.  

MARA GOVERMAN: I think it is a viable alternative to start first with that, if the families and parents have very busylives, some treatment is better than nothing at all. 

JOSH FEDER: And this seems, so far in this study, like it's pretty good. 

MARA GOVERMAN: There are very few local providers trained to use exposure and response prevention. Some parents spend months on wait lists, and by the time they get an appointment, their child's symptoms have worsened. Having an online option could prevent that delay.  

JOSH FEDER: Let's talk about this worsening that happens. So you've got a kid, let's say they're worried about germs, so they're washing their hands pretty often, and then they're worried, about a bunch of surfaces, and they won't touch the surfaces, and they're eating less or you have to do something very special with the food for them to eat. I mean, these things start becoming more and more complex, and what families often do, because they're worried about the distress of their child. 

MARA GOVERMAN: The depression. 

JOSH FEDER: Well, they accommodate. 

MARA GOVERMAN: Mm-hmm. They give in. 

JOSH FEDER: Yeah, they give in, they make things cleaner, they bleach everything. Just this process where things become more constricted, tighter over time. So waiting for treatment is truly problematic.  

MARA GOVERMAN: Mm-hmm. 

JOSH FEDER: Mara, in your experience, how do children and families adjust to online therapy compared to in-person sessions?  

MARA GOVERMAN: I think that's an individualized answer. Some children and families respond well to online therapy and are able to attend and execute the homework. But then there are other families and children who need in-person care, and they need the structure. So if in-person provides a structure and environment, and atmosphere, where children and families have to pay attention, you're getting immediate response, and you're seeing what works, what doesn't work, and you're able to provide immediate feedback for families. 

JOSH FEDER: I agree. I mean, sometimes with online kinds of approaches, there are so many things that are distracting you at the same time. Other messages that are coming in, other things going on at home in the environment for online care, when it's us talking with somebody, that can be a big problem in itself, because you don't know who's listening in the room. If you need privacy or if you need other people there, but they're distracted doing their own thing and you can't get the parent in to kind of help you talk with the kid about whatever it is you're trying to do. 

So, there are a lot of advantages and also disadvantages; online as well as, of course, in person, with the hassle of coming across town, and especially if it's after school, it's during rush hour and all the disruption from that. But look, we've been doing this for generations, having people come into our offices for care, and I think we've demonstrated that there is merit to coming in person and going through, as you say, the exercise of getting in front of somebody and working with them.  

MARA GOVERMAN: You also bring up a good point about a blended model because a robust therapeutic relationship can be built in one or two sessions, and then we can go online when we are beginning to execute the cognitive behavioral exposure and response training, but there's already been an established trust and therapeutic relationship built into moving forward to allow the child and family to have faith and trust in trying the uncomfortable things that we're asking them to do.  

JOSH FEDER: That's a good point. Well, this study also has limitations. The dropout rate was high, and kids in this study already expressed openness to online therapy, so the results might not apply to everyone. And in addition to that, this idea of using a multiple baseline approach where you've got one group who's starting and another group who's waiting, right? And then after a period of time, you're measuring what's happened to the people who are getting the treatment and then looking at the people who've been on the wait list. Well, there are a couple problems with that. 

MARA GOVERMAN: Mm-hmm. 

JOSH FEDER: Generally speaking, we've already talked a little bit about how people can be getting worse just because they're waiting. And then the other piece is that the math is, is kind of wonky when you do effect size calculations with multiple baseline studies, it artificially inflates the effect size. So much so that in other parts of our field, like in the autism world, which is replete with multiple baseline studies, a lot of people have set those aside, saying we can't really trust them, so this is good that people got better, but what we really need are head-to-head types of studies and not multiple baseline studies to really understand how big the effect size is. 

MARA GOVERMAN: Still, it can be encouraging to see online CBT producing results similar to face-to-face therapy.  

JOSH FEDER: So, another thing that we should talk about is the role of medication to support online or in-person CBT for obsessive compulsive disorder. We know that particularly high-dose SSRIs can be helpful, and while we usually recommend that people consider non-pharmacological approaches, first you gotta ask the question, when do you, cut bait if kids aren't getting better. So another kind of study that I'd love to see is one that tracks medication usage and decision making about when people decide, okay, we're not getting enough of an improvement, so we're gonna add medication and see what happens. 

MARA GOVERMAN: I also suggest wondering, taking a look at the child or adolescent to see how common settled they are, because if you have a young person who is anxious and rattled, they are less available to take in the education and then execute the model that you know is successful.  

JOSH FEDER: Well said, and you know, this supports expanding treatment options, both medication, online, in-person, just really having an arsenal of a lot of different ways that we can help families, especially families in remote areas. Have you seen any challenges with online therapy in terms of practical barriers?  

MARA GOVERMAN:  I find that an online relationship is more challenging in developing a trusting therapeutic relationship. It just takes a longer amount of time.  

 JOSH FEDER: Clinicians may need to assess whether online therapy is a good fit for each patient, just like you said, Mara. And I think the takeaway is that online, CBT for pediatric OCD shows some promise, but it's not a one-size-fits-all all thing.  

MARA GOVERMAN: Additional research studies on long-term outcomes can help guide clinical decisions. Dr. Mariel Zeccola 's article in our 2024 newsletter is the inspiration for today's podcast, and it contains additional insights on OCD treatments in the home. If you find this episode valuable, please share it with others who need to hear this message.  

JOSH FEDER: And as always, everything from Carlat Publishing is independently researched and produced. There's no funding from the pharmaceutical industry.  

MARA GOVERMAN: Yes, the newsletters and books we produce depend entirely on reader support. There are no ads, and our authors don't receive industry funding that helps us bring you unbiased information that you can trust.  

JOSH FEDER: I hope this conversation helps our listeners make informed choices. If you found this discussion helpful, subscribe for more episodes on mental health and psychiatric care. And remember, keep looking for good things, and more good things can happen.