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approaches adopted. Most forms of CBT have focused on encouraging the young person to manage the anxiety or discomfort associated with ERP (e.g. see March and Mulle, 1998). In this book we describe a different approach which encourages the young person to find out for themselves how their thinking is the problem rather than their behaviour and draws on the developments made in the adult field. There are no direct comparisons of this approach with others.
Introduction to obsessive compulsive disorder
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    CBT is based on modifying key beliefs and appraisals with the aim of helping the individual to construct and test a new and less threatening model of their experience.
    The role of medication
    Studies suggest that serotonin reuptake inhibitors are effective in treating young people with OCD (e.g. Flament et al. , 1985; Leonard et al. , 1989; March and Mulle, 1998). Geller et al. (2003) completed a meta-analysis of pharmacotherapy trials in young people with OCD and found clomipramine to be more effective than four newer selective serotonin reuptake inhibitors (SSRIs). However, the side effects from clomipramine mean that it is no longer widely used. There was no significant difference between the newer SSRIs and overall medication appeared to be reasonably effective for around 60 per cent of young people. However, there are concerns that antidepres-sant medication may increase suicidality and consequently the advice in the UK is to carefully monitor potential adverse outcomes. A significant problem with medication is the relapse rate and consequently the National Institute for Health and Clinical Excellence (NICE) guidelines (2005) for the UK
    suggest long-term use.
    The paediatric OCD treatment study (POTS) randomised controlled trial (March et al. , 2004) compared medication, CBT and a combination of medication and CBT. They found that the young people treated with CBT alone or in combination with medication showed the greatest improvement, although medication alone was better than a placebo. However, it has not yet been established who benefits from which treatment.
    There is an evidence base for the use of medication with young people.
    However, CBT alone or in combination with medication appears to be more effective and less likely to lead to relapse.
    Choice of treatment
    The consensus guidelines produced by the American Psychiatric Association (March et al. , 1997) suggested that CBT was the first choice treatment for children and young people. More recently, NICE described a stepped care model beginning with self-help materials for mild cases through to CBT, medication and finally combined treatments (NICE, 2005). However, self-help materials for young people with OCD are not readily available and have 18
    Williams and Waite
    not been evaluated. Consequently, it is not clear how effective they are.
    There is a danger that by beginning with interventions that do not have an adequate evidence base we are delaying the young person receiving effective treatment and this may lead to additional problems, such as symptoms increasing in frequency and severity, as well as leading the young person, family and professionals to believe that the problem is difficult to treat.
    When deciding what treatment should be used in treating OCD, the general consensus is for a stepped care approach with CBT as a first line treatment.
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    The use of CBT with children
    and adolescents
    Cathy Creswell and Polly Waite
    Introduction
    CBT is based on the general notion that a psychological disorder is caused or maintained by ‘dysfunctional’ patterns of thoughts and behaviours (e.g. Beck et al. , 1979). That is, the disorder is conceptualised as resulting at least in part from the individual’s cognitive distortions (such as false attribu-tions or expectations about the self, others or the world) that then undermine positive coping or problem-solving behaviour. CBT has its roots in behaviour therapy, which applies learning theory to