Family-based exposure and response prevention therapy for preschool-aged children with obsessive-compulsive disorder: A pilot randomized controlled trial

A META-ANALYSIS OF COGNITIVE BEHAVIOR THERAPY AND MEDICATION FOR CHILD OBSESSIVE-COMPULSIVE DISORDER: MODERATORS OF TREATMENT EFFICACY, RESPONSE, AND REMISSION

BACKGROUND

Individual randomized controlled trials (RCTs) have demonstrated the efficacy of cognitive behavioral therapy (CBT) and serotonin reuptake inhibitors (SRIs) for the treatment of youth with obsessive-compulsive disorder (OCD). Although meta-analyses have confirmed these results, there has been minimal examination of treatment moderators or an examination of treatment response and symptom/diagnostic remission for these two treatment types. The present report examined the treatment efficacy, treatment response, and symptom/diagnostic remission for youth with OCD receiving either CBT or SRIs relative to comparison conditions, and examined treatment moderators.

METHOD

A comprehensive literature search identified 20 RCTs that met inclusion criteria, and produced a sample size of 507 CBT participants and 789 SRI participants.

RESULTS

Random effects meta-analyses of CBT trials found large treatment effects for treatment efficacy (g = 1.21), treatment response (relative risk [RR] = 3.93), and symptom/diagnostic remission (RR = 5.40). Greater co-occurring anxiety disorders, therapeutic contact, and lower treatment attrition were associated with greater CBT effects. The number needed to treat (NNT) was three for treatment response and symptom/diagnostic remission. Random effects meta-analyses of SRI trials found a moderate treatment effect for treatment efficacy (g = 0.50), treatment response (RR = 1.80), and symptom/diagnostic remission (RR = 2.06). Greater methodological quality was associated with a lower treatment response for SRI trials. The NNT was five for treatment response and symptom/diagnostic remission.

CONCLUSIONS

Findings demonstrate the treatment effects for CBT and SRIs across three important outcome metrics, and provide evidence for moderators of CBT across trials.

Evidence-Based Psychological Treatments of Pediatric Mental Disorders

With many youth presenting to primary care settings for mental health difficulties, knowledge of the respective evidence-based psychotherapies is imperative in ensuring that these youth receive the appropriate interventions in a timely manner. Most frequently, children present with internalizing and/or externalizing disorders, which cover a broad range of common pediatric mental disorders. Treatments of these disorders generally incorporate cognitive and/or behavioral components, which are derived from theoretical underpinnings and empirical support. Although the interventions share common components, they are distinctive in nature and are further tailored toward the idiosyncratic needs of children and their families. Careful consideration of the apposite intervention and individual needs of youth are pertinent to the effective amelioration of symptomology.

Family-Based Treatment of Pediatric Obsessive-Compulsive Disorder: Clinical Considerations and Application

Pediatric obsessive-compulsive disorder (OCD) can be effectively treated with family-based intervention by expanding and enhancing family members' behavioral repertoire to more effectively manage OCD symptoms and affected family interactions. This article provides an overview and practical understanding of the implementation of family-based treatment of pediatric OCD. Special attention is given to relevant contextual family processes that influence symptom presentation, current empirical support for family-based treatment, and the clinical application of family-based cognitive-behavioral therapy. Case vignettes illustrate important clinical considerations for providers.

Genetic and environmental influences on obsessive-compulsive behaviour across development: a longitudinal twin study

BACKGROUND

Little is known about the factors influencing the stability of obsessive-compulsive behaviour (OCB) from childhood to adolescence. The current study aimed to investigate: (1) the stability of paediatric OCB over a 12-year period; (2) the extent to which genetic and environmental factors influence stability; and (3) the extent to which these influences are stable or dynamic across development.

METHOD

The sample included 14 743 twins from a population-based study. Parental ratings of severity of OCB were collected at ages 4, 7, 9 and 16 years.

RESULTS

OCB was found to be moderately stable over time. The genetic influence on OCB at each age was moderate, with significant effects also of non-shared environment. Genetic factors exerted a substantial influence on OCB persistence, explaining 59-80% of the stability over time. The results indicated genetic continuity, whereby genetic influences at each age continue to affect the expression of OCB at subsequent ages. However, we also found evidence for genetic attenuation in that genetic influences at one age decline in their influence over time, and genetic innovation whereby new genes 'come on line' at each age. Non-shared environment influenced stability of OCB to a lesser extent and effects were largely unique to each age and displayed negligible influences on OCB at later time points.

CONCLUSIONS

OCB appears to be moderately stable across development, and stability is largely driven by genetic factors. However, the genetic effects are not entirely constant, but rather the genetic influence on OCB appears to be a developmentally dynamic process.

Obsessive-compulsive disorder in children and adolescents

Obsessive-compulsive disorder (OCD) in childhood and adolescence is an impairing condition, associated with a specific set of distressing symptoms incorporating repetitive, intrusive thoughts (obsessions) and distressing, time-consuming rituals (compulsions). This review considers current knowledge of causes and mechanisms underlying OCD, as well as assessment and treatment. Issues relating to differential diagnosis are summarised, including the challenges of distinguishing OCD from autism spectrum disorders and tic disorders in youth. The recommended treatments, namely cognitive behaviour therapy and serotonin reuptake inhibiting/selective serotonin reuptake inhibitor medications, are outlined along with the existing evidence-based and factors associated with treatment resistance. Finally, novel clinical developments that are emerging in the field and future directions for research are discussed.

Standard individual cognitive behaviour therapy for paediatric obsessive-compulsive disorder: a systematic review of effect estimates across comparisons

BACKGROUND

Previous meta-analyses of paediatric obsessive-compulsive disorder (OCD) have shown much higher effect size for standard individual cognitive behaviour therapy (SI-CBT) compared with control conditions than for serotonin reuptake inhibitors (SRIs) compared with placebo. Other factors, such as systematic differences in the provided care or exposure to factors other than the interventions of interest (performance bias) may be stronger confounders in psychotherapy research than in pharmacological research.

AIMS

These facts led us to review SI-CBT studies of paediatric OCD with the aim to compare the effect estimates across different comparisons, including active treatments.

METHOD

We included only randomized controlled trials (RCTs) or cluster RCTs with treatment periods of 12-16 weeks. Outcome was post-test score on the Children's Yale-Brown Obsessive Compulsive Scale (CYBOCS).

RESULTS

Thirteen papers reporting from 13 RCTs with 17 comparison conditions were included. SI-CBT was superior to wait-list and placebo therapy but not active treatments. Effect estimates for SI-CBT in wait-list comparison studies were significantly larger than in placebo-therapy comparison studies. In addition, the SI-CBT effect estimate was not significantly different when compared with SRIs alone or combined SRIs and CBT.

CONCLUSIONS

Performance bias may have inflated previous effect estimates for SI-CBT when comparison contingencies included wait-list. However, the calculated SI-CBT effect estimate was lower but significant when compared with placebo therapy. The effects of SI-CBT and active treatments were not significantly different. In conclusion, our data support the current clinical guidelines, although better comparisons between SI-CBT and SRIs are needed.

Symptom Accommodation Related to Social Anxiety Symptoms in Adults: Phenomenology, Correlates, and Impairment

BACKGROUND AND OBJECTIVES

Socially anxious individuals often engage in various safety and avoidant behaviors to temporarily decrease distress. Similarly, friends or family members may engage in accommodating behaviors, commonly manifesting through the facilitation of avoidance, completion of tasks, or schedule modifications. Studies examining symptom accommodation in adult social anxiety are lacking, so this study seeks to better understand symptom accommodation and its consequent impairment in socially anxious adults.

DESIGN AND METHODS

There were 380 undergraduate students who completed a battery of self-report questionnaires through an online system. Constructs assessed include social anxiety, symptom accommodation, and impairment as well as related variables such as general anxiety, fear of negative evaluation, alcohol use, and anxiety sensitivity.

RESULTS

Symptom accommodation was positively correlated with social anxiety symptoms, functional impairment, general anxiety, anxiety sensitivity, fear of negative evaluation, and alcohol use. Individuals with considerable social anxiety reported significantly higher levels of symptom accommodation than individuals who reported lower levels of social anxiety. Anxiety sensitivity predicted symptom accommodation beyond the contribution of social anxiety. Symptom accommodation mediated the relationship between social anxiety and impairment.

CONCLUSIONS

These data help elucidate the presentation and impact of symptom accommodation related to social anxiety. Implications for assessment, treatment, and future directions are presented.

Variations in symptom prevalence and clinical correlates in younger versus older youth with obsessive-compulsive disorder

Few studies have examined the phenomenology of obsessive-compulsive disorder (OCD) in younger children. A sample of 292 treatment seeking youth with a primary diagnosis of OCD was divided into the young child (3-9 years old) and older child (10-18 years old) groups. Overall OCD severity did not differ between groups. However, older youth demonstrated stronger intensity of obsessive and compulsive symptoms, while younger children were rated as having less resistance and control of compulsions. Older youth exhibited increased occurrence of comorbid depression, and an increased occurrence of sexual, magical thinking, and somatic obsessions, as well as, checking, counting and magical thinking compulsions. Conversely, the group of younger children exhibited significantly poorer insight, increased incidence of hoarding compulsions, higher rates of comorbid attention deficit/hyperactivity disorder, disruptive behavior, and parent-rated anxiety, and more frequently exhibited hoarding compulsions. These differences suggest domains to consider when screening for OCD among younger/older pediatric cohorts.

Cognitive behavior therapy for obsessive-compulsive and related disorders

Cognitive behavior therapy (CBT) is considered a first-line intervention for obsessive-compulsive disorder (OCD) across the lifespan. Efficacy studies of CBT with exposure and response prevention suggest robust symptom reduction, often with sustained remission. Acceptability of CBT is high, and the treatment is devoid of adverse side effects. The primary mechanism of CBT is based on operant principles, specifically extinction learning. The efficacy of extinction-based treatments such as CBT is being shown for other obsessive-compulsive spectrum disorders. This article reviews the theoretic basis, clinical application, and relevant treatment outcome research for CBT and related therapies for several obsessive-compulsive spectrum disorders.