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thought–action fusion in comparison to other anxious and non-anxious children, as well as the highest ratings of The use of CBT with children and adolescents 21
    harm severity (that is, how bad it would be if the feared consequence happened). However, these were not statistically significant differences. The only domain that significantly differentiated the OCD group clearly from the other groups was that of cognitive control, in that the OCD group indicated that they were less able to stop themselves worrying about a thought than the others (Barrett and Healy, 2003).
    There is also some evidence that levels of magical thinking – that is, the attribution of causal effects on real events by a thought or action that is physically unconnected to the event – are associated with obsessive compulsive symptoms in young people between the ages of five and 17 (Bolton et al. , 2002; Muris et al. , 2001). However, further research is required to establish whether this relationship exists in young people who fulfil criteria for a diagnosis of OCD and if it is specific to OCD.
    Together, these studies provide initial evidence for a cognitive account of OCD in young people. However, the reliance of studies to date on samples representing broad age ranges means we do not know whether these cognitive styles are present in both young and older children. Our reliance on data from cross-sectional studies also limits the conclusions that can be drawn about the direction of the association between cognitions, behaviour and affect in OCD. For example, it is unlikely that intrusive thoughts will present a problem or drive compulsive behaviour until a young person has developed the ability to reflect on thoughts and their meaning. Indeed, it is widely recognised that intrusive thoughts are experienced by the majority of people (e.g. Rachman and de Silva, 1978). So does OCD in youth represent a failure to learn to disregard these normal intrusive phenomena? If so, why do some children fail to go through this otherwise normative process of development?
    CBT models for adult populations are focused largely on the maintenance cycles, based on the premise that maladaptive thinking styles have developed during childhood which are no longer adaptive in the adult’s life (e.g. Beck et al. , 1979). When working with younger populations it is important to establish whether these beliefs continue to serve an adaptive function in the child’s life. For example, it is essential to consider the wider environmental influences that will be affecting the young person’s thoughts, behaviour and mood. However, the specific influences on the development of cognitions and behaviour associated with OCD in childhood are not well understood. Salkovskis et al. (1999) argue that the origins of obsessional problems are likely to be the result of complex interactions specific to the individual, but that there are likely to be a number of different pathways to the development of beliefs around inflated responsibility (see Chapter 1).
    Prospective, experimental and treatment studies are all urgently needed to provide a better understanding of the specific environmental influences on OCD in young people and the relative importance of these, cognitions and behaviours in order for us to know the crucial elements to target within therapy.
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    Creswell and Waite
    • Similar cognitive styles have been identified in children and adults with OCD. However it is not yet clear whether the nature of the relationship between cognitions, affect and behaviour is the same throughout development.
    • The specific influences on the development of cognitions and behaviour associated with OCD in childhood are not well understood and further research is necessary.
    An overview of CBT with young people
    A cornerstone of the practice of CBT is collaboration between the therapist and the client, whether that client is an adult or a young person (or a family).
    The therapist is working with