Preliminary investigation of web-camera delivered cognitive-behavioral therapy for youth with obsessive-compulsive disorder

Cognitive-behavioral therapy for pediatric obsessive-compulsive disorder: Empirical review and clinical recommendations

The efficacy of cognitive-behavioral therapy (CBT) for pediatric obsessive-compulsive disorder (OCD) has been the subject of much study over the past fifteen years. Building on a foundation of case studies and open clinical trials, the literature now contains many methodologically sound studies that have compared full CBT protocols to waitlist controls, pill placebo, psychosocial comparison conditions, active medication, combined treatments, and brief CBT. This review is part of a series commissioned by The Canadian Institute for Obsessive Compulsive Disorders (CIOCD) in an effort to publish in one place what is known about the efficacy of treatments for OCD. A total of fourteen studies were identified; collectively their findings support the efficacy of CBT for youth with OCD. CBT protocols that emphasized either strictly behavioral or cognitive conceptualizations have each been found efficacious relative to waitlist controls. Efforts to enhance CBT׳s efficacy and reach have been undertaken. These trials provide guidance regarding next steps to be taken to maximize efficacy and treatment availability. Findings from studies in community clinics suggest that significant treatment benefits can be realized and are not reported only from within academic contexts. These findings bode well for broader dissemination efforts. Recommendations for future research directions are provided.

A pilot trial of cognitive-behavioral therapy augmentation of antibiotic treatment in youth with pediatric acute-onset neuropsychiatric syndrome-related obsessive-compulsive disorder

BACKGROUND

This study reports an open trial of family-based cognitive-behavioral therapy (CBT) in children and adolescents with obsessive-compulsive disorder (OCD) exhibiting an onset pattern consistent with pediatric acute-onset neuropsychiatric syndrome (PANS).

METHODS

Eleven primarily Caucasian youth with PANS-related OCD (range=4-14 years; 6 boys) who were incomplete responders to antibiotic treatment, received family-based CBT delivered either face-to-face or via web camera.

RESULTS

All participants completing treatment (8 of 8) were considered improved at posttreatment, and average obsessive-compulsive symptom severity was reduced by 49%. Significant reductions in obsessive-compulsive symptom severity and in clinician- and parent-rated OCD-related impairment were noted. Reductions in parent- and child-rated anxiety, child-rated OCD-related impairment, and comorbid neuropsychiatric symptoms were not statistically significant.

CONCLUSIONS

Gains were maintained at follow-up, with 100% (6 of 6) of those assessed remaining improved. Implications for treatment and further research are discussed.

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.

Psychological Treatment of Obsessive-Compulsive Disorder in Children and Adolescents: a Meta-Analysis

Although several meta-analyses have investigated the efficacy of psychological treatments for pediatric obsessive-compulsive disorder (OCD), there is not yet a consensus on the most efficacious treatment components. A meta-analysis was carried out to examine the efficacy of the different treatment techniques used in the psychological interventions of pediatric OCD. An exhaustive literature search from 1983 to February 2014 enabled us to locate 46 published articles that applied some kind of cognitive-behavioral therapy (CBT). For each group the effect size was the standardized pretest-posttest mean change, and it was calculated for obsessive-compulsive symptoms and for other outcome measures. The results clearly showed large effect sizes for CBT in reducing obsessive-compulsive symptoms and, to a lesser extent, other outcome measures (d+ = 1.860; 95% CI: 1.639; 2.081). The most promising treatments are those based on multicomponent programs comprising ERP, cognitive strategies, and relapse prevention. The analysis of other potential moderator variables and the implications for clinical practice are discussed.

Internet and computer-based cognitive behavioral therapy for anxiety and depression in youth: a meta-analysis of randomized controlled outcome trials

Background

Anxiety and depression in children and adolescents are undertreated. Computer- and Internet-based cognitive behavioral treatments (cCBT) may be an attractive treatment alternative to regular face-to-face treatment.This meta-analysis aims to evaluate whether cCBT is effective for treating symptoms of anxiety and depression in youth.

Methods and Findings

We conducted systematic searches in bibliographical databases (Pubmed, Cochrane controlled trial register, PsychInfo) up to December 4, 2013. Only randomized controlled trials in which a computer-, Internet- or mobile-based cognitive behavioral intervention targeting either depression, anxiety or both in children or adolescents up to the age of 25 were compared to a control condition were selected. We employed a random-effects pooling model in overall effect analyses and a mixed effect model for sub-group analyses. Searches resulted in identifying 13 randomized trials, including 796 children and adolescents that met inclusion criteria. Seven studies were directed at treating anxiety, four studies at depression, and two were of a transdiagnostic nature, targeting both anxiety and depression. The overall mean effect size (Hedges’ g) of cCBT on symptoms of anxiety or depression at post-test was g=0.72 (95% CI:0.55-0.90, numbers needed to be treated (NNT)=2.56). Heterogeneity was low (I²=20.14%, 95% CI: 0-58%). The superiority of cCBT over controls was evident for interventions targeting anxiety (g=0.68; 95% CI: 0.45-0.92; p < .001; NNT=2.70) and for interventions targeting depression (g=0.76; 95% CI: 0.41-0.12; p < .001; NNT=2.44) as well as for transdiagnostic interventions (g=0.94; 95% CI: 0.23-2.66; p < .001; NNT=2.60).

Conclusions

Results provide evidence for the efficacy of cCBT in the treatment of anxiety and depressive symptoms in youth. Hence, such interventions may be a promising treatment alternative when evidence based face-to-face treatment is not feasible. Future studies should examine long-term effects of treatments and should focus on obtaining patient-level data from existing studies, to perform an individual patient data meta-analysis.

Efficacy of technology-delivered cognitive behavioural therapy for OCD versus control conditions, and in comparison with therapist-administered CBT: meta-analysis of randomized controlled trials

Cognitive behavioural therapy (CBT) is a well-established treatment for obsessive-compulsive disorder (OCD). However, few patients receive CBT, due to factors such as geographic limitations, perceived stigmatization, and lack of CBT services. Technology-delivered cognitive behavioural therapy (T-CBT) could be an effective strategy to improve patients' access to CBT. To date, a meta-analysis on the effectiveness of T-CBT for OCD has not been conducted. This study used meta-analytic techniques to summarize evidence on the efficacy of T-CBT for OCD versus control conditions and therapist-administered CBT. A meta-analysis according to Prisma guidelines was conducted on randomized controlled trials (RCTs) of T-CBT for OCD. Treatment was classified as T-CBT if evidence-based CBT active ingredients for OCD were included (psychoeducation, ERP, and cognitive restructuring), delivered through health technologies (e.g. self-help books, leaflets, and other forms of bibliotherapy) or remote communication technologies (e.g. the Internet, web-cameras, telephones, telephone-interactive voice response systems, and CD-ROMS). Studies using validated outcomes for OCD or depression were included. Eight trials were included (N = 420). Two trials were classified as at high risk of bias. T-CBT seemed to be superior to control conditions on OCD symptom outcomes at post-treatment (d = 0.82, 99% CI = 0.55-1.08, p = 0.001), but not on comorbid depression (d = 0.33, 99% CI = - 0.01-0.67, p = 0.020). Difference in the efficacy on OCD symptoms between T-CBT and therapist-administered CBT was not significant, despite a trend favouring therapist-administered CBT emerged (d = 0.45, 95% CI = 0.03-0.87, p = 0.033). Directions for research are discussed. Further RCTs are warranted to examine the efficacy of T-CBT for OCD.

Frequency and correlates of suicidal ideation in pediatric obsessive-compulsive disorder

This study examined the frequency and sociodemographic and clinical correlates of suicidal ideation in a sample of children and adolescents with obsessive-compulsive disorder (OCD). Fifty-four youth with OCD and their parent(s) were administered the Schedule for Affective Disorders and Schizophrenia for School-Age Children-Present and Lifetime, Children's Yale-Brown Obsessive Compulsive Scale, and Children's Depression Rating Scale-Revised. Children completed the Suicidal Ideation Questionnaire-Junior (SIQ-JR), Child Obsessive Compulsive Impact Scale-Child, and Multidimensional Anxiety Scale for Children; parents completed the Child Obsessive Compulsive Impact Scale-Parent, Swanson, Nolan, and Pelham-IV Parent Scale, and Young Mania Rating Scale-Parent Version. Seven youth endorsed clinically significant levels of suicidal ideation on the SIQ-JR. Suicidal ideation was significantly related to clinician-rated depressive symptoms, age, child-rated impairment and anxiety symptoms, and symmetry, sexuality/religiosity and miscellaneous symptom dimensions. There was no significant association between suicidal ideation and obsessive-compulsive symptom severity, comorbidity patterns, or several parent-rated indices (e.g., impairment, impulsivity). These results provide initial information regarding the frequency and correlates of suicidal ideation in treatment-seeking youth with OCD. Clinical implications are discussed, as well as directions for future research.

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.

Computer-delivered cognitive-behavioural treatments for obsessive compulsive disorder: preliminary meta-analysis of randomized and non-randomized effectiveness trials

Cognitive behavioural treatments (CBTs) are well-established for obsessive compulsive disorder (OCD). However, few patients receive CBT, due to factors like geographical limitations, perceived stigmatization, and lack of CBT services. Some evidence suggests that computer-delivered cognitive-behavioural treatments (CCBTs) could be an effective strategy to improve patients’ access to CBT. To date a meta-analysis on effectiveness of CCBTs for OCD has not been conducted. The present study used meta-analytical techniques to summarize evidence on CCBTs for OCD on OCD and depression symptom outcomes at post-treatment and follow-up. A meta-analysis was conducted according to PRISMA guidelines. Treatments were classified as CCBTs if including evidence-based cognitive-behavioural components for OCD (psychoeducation, exposure and response prevention, cognitive restructuring), delivered through devices like computers, palmtops, telephone-interactive voice-response systems, CD-ROMS, and cell phones. Studies were included if they used validated outcomes for OCD. Eight studies met inclusion criteria (n= 392). A large effect favouring CCBTs over control conditions was found for OCD symptoms at post-treatment (d= 0.82,p= 0.001), but not for depression symptom outcomes (d= 0.15,p= 0.20). Theoretical implications and directions for research are discussed. A larger number of randomized controlled trials is required.

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.

Telephone cognitive-behavioral therapy for adolescents with obsessive-compulsive disorder: a randomized controlled non-inferiority trial

OBJECTIVE

Many adolescents with obsessive-compulsive disorder (OCD) do not have access to evidence-based treatment. A randomized controlled non-inferiority trial was conducted in a specialist OCD clinic to evaluate the effectiveness of telephone cognitive-behavioral therapy (TCBT) for adolescents with OCD compared to standard clinic-based, face-to-face CBT.

METHOD

Seventy-two adolescents, aged 11 through 18 years with primary OCD, and their parents were randomized to receive specialist TCBT or CBT. The intervention provided differed only in the method of treatment delivery. All participants received up to 14 sessions of CBT, incorporating exposure with response prevention (E/RP), provided by experienced therapists. The primary outcome measure was the Children's Yale-Brown Obsessive-Compulsive Scale (CY-BOCS). Blind assessor ratings were obtained at midtreatment, posttreatment, 3-month, 6-month, and 12-month follow-up.

RESULTS

Intent-to-treat analyses indicated that TCBT was not inferior to face-to-face CBT at posttreatment, 3-month, and 6-month follow-up. At 12-month follow-up, there were no significant between-group differences on the CY-BOCS, but the confidence intervals exceeded the non-inferiority threshold. All secondary measures confirmed non-inferiority at all assessment points. Improvements made during treatment were maintained through to 12-month follow-up. Participants in each condition reported high levels of satisfaction with the intervention received.

CONCLUSION

TCBT is an effective treatment and is not inferior to standard clinic-based CBT, at least in the midterm. This approach provides a means of making a specialized treatment more accessible to many adolescents with OCD. Clinical trial registration information-Evaluation of telephone-administered cognitive-behaviour therapy (CBT) for young people with obsessive-compulsive disorder (OCD); http://www.controlled-trials.com; ISRCTN27070832.

A pilot randomized controlled trial of videoconference-assisted treatment for obsessive-compulsive disorder

Evidence-based exposure and response prevention (ERP) treatment for obsessive-compulsive disorder (OCD) is not always easily accessible. Long distances from specialist treatment and other practical or motivational difficulties can interfere with ERP access and outcome. Delivery of ERP through telepsychology can help "fill the gap". The current study included 30 patients with OCD who were randomized to 12 weeks of either videoconference-assisted ERP (VCT; N = 10), self-help ERP (S-H, N = 10), or a wait-list condition (W-L, N = 10). The VCT format included use of tablet-based videoconferencing sessions (N = 6) or studio-based videoconference (N = 4), as well as telephone calls. Patients rated the VCT format as natural and reported strong working alliances with their therapists. VCT treatment produced significantly greater reductions in obsessive-compulsive symptoms compared to the two control conditions. Treatment outcomes were similar to that of regular face-to-face ERP and improvements in symptom scores remained stable at follow-up. The study indicated that ERP for OCD can be delivered efficiently with videoconferencing technology along with telephone calls. The use of such technology in psychological treatment is likely to become more common in the future and it holds promise as a method to make evidence-based treatment more accessible.

Pilot Open Case Series of Voice over Internet Protocol-delivered Assessment and Behavior Therapy for Chronic Tic Disorders

Comprehensive Behavioral Intervention for Tics (CBIT) is an efficacious treatment for children with Chronic Tic Disorders (CTDs). Nevertheless, many families of children with CTDs are unable to access CBIT due to a lack of adequately trained treatment providers, time commitment, and travel distance. This study established the interrater reliability between in-person and VoIP administrations of the Yale Global Tic Severity Scale (YGTSS), and examined the preliminary efficacy, feasibility, and acceptability of Voice over Internet Protocol (VoIP)-delivered CBIT for reducing tics in children with CTDs in an open case series. Across in-person and VoIP administrations of the YGTSS, results showed mean agreement of 91%, 96%, and 95% for motor, phonic, and total tic severity subscales. In the pilot feasibility study, four children received 8-weekly sessions of CBIT via VoIP and were assessed at pre- and post-treatment by an independent evaluator. Results showed a 29.44% decrease in clinician-rated tic severity from pre to post-assessment on the YGTSS. Two of the four patients were considered treatment responders at post treatment, using Clinical Global Impressions-Improvement ratings. Therapeutic alliance, parent and child treatment satisfaction and videoconferencing satisfaction ratings were high. CBIT was considered feasible to implement via VoIP, although further testing is recommended.

Effectiveness of internet-based interventions for children, youth, and young adults with anxiety and/or depression: a systematic review and meta-analysis

BACKGROUND

The majority of internet-based anxiety and depression intervention studies have targeted adults. An increasing number of studies of children, youth, and young adults have been conducted, but the evidence on effectiveness has not been synthesized. The objective of this research is to systematically review the most recent findings in this area and calculate overall (pooled) effect estimates of internet-based anxiety and/or depression interventions.

METHODS

We searched five literature databases (PubMed, EMBASE, CINAHL, PsychInfo, and Google Scholar) for studies published between January 1990 and December 2012. We included studies evaluating the effectiveness of internet-based interventions for children, youth, and young adults (age <25 years) with anxiety and/or depression and their parents. Two reviewers independently assessed the risk of bias regarding selection bias, allocation bias, confounding bias, blinding, data collection, and withdrawals/dropouts. We included studies rated as high or moderate quality according to the risk of bias assessment. We conducted meta-analyses using the random effects model. We calculated standardized mean difference and its 95% confidence interval (95% CI) for anxiety and depression symptom severity scores by comparing internet-based intervention vs. waitlist control and internet-based intervention vs. face-to-face intervention. We also calculated pooled remission rate ratio and 95% CI.

RESULTS

We included seven studies involving 569 participants aged between 7 and 25 years. Meta-analysis suggested that, compared to waitlist control, internet-based interventions were able to reduce anxiety symptom severity (standardized mean difference and 95% CI = -0.52 [-0.90, -0.14]) and increase remission rate (pooled remission rate ratio and 95% CI =3.63 [1.59, 8.27]). The effect in reducing depression symptom severity was not statistically significant (standardized mean difference and 95% CI = -0.16 [-0.44, 0.12]). We found no statistical difference in anxiety or depression symptoms between internet-based intervention and face-to-face intervention (or usual care).

CONCLUSIONS

The present analysis indicated that internet-based interventions were effective in reducing anxiety symptoms and increasing remission rate, but not effective in reducing depression symptom severity. Due to the small number of higher quality studies, more attention to this area of research is encouraged.

TRIAL REGISTRATION

PROSPERO registration: CRD42012002100.

Internet-delivered cognitive behavior therapy for adolescents with obsessive-compulsive disorder: an open trial

BACKGROUND

International guidelines recommend Cognitive Behavior Therapy (CBT) as the first line treatment for pediatric obsessive-compulsive disorder (OCD). However, a substantial proportion of patients do not have access to such treatment. We developed and tested the feasibility, efficacy and acceptability of a novel therapist-guided, Internet-delivered CBT (ICBT) platform for adolescents with OCD.

METHODS

An interactive, age-appropriate ICBT platform ("BiP OCD") was developed. Twenty-one adolescents (12-17 years) with a DSM-IV diagnosis of OCD and their parents were enrolled in the study. All participants received 12 weeks of ICBT with therapist support. The primary outcome measure was the Children's Yale-Brown Obsessive-Compulsive Scale (CY-BOCS). Acceptability was assessed at post-treatment.

RESULTS

Participants completed on average 8.29 (SD = 3.0) of the 12 treatment chapters. Treatment yielded significant improvements on all clinician-, parent- and most self-administered outcome measures, with a large effect size of d = 2.29 (95% CI 1.5-3.07) on the CY-BOCS. Patients continued to improve at follow-up. At 6-month follow-up, 71% were classified as responders (≥35% decrease on the CY-BOCS) and 76% as being in remission (CY-BOCS score ≤12). Average clinician support time was less than 20 minutes per patient per week. The majority of participants felt that BiP OCD was age-appropriate and rated the treatment as good or very good.

CONCLUSIONS

ICBT could be efficacious, acceptable, and cost-effective for adolescents with OCD. More rigorously controlled studies are needed to further evaluate the treatment.

TRIAL REGISTRATION

ClinicalTrials.gov; NCT01809990.

Family involvement in the psychological treatment of obsessive-compulsive disorder: a meta-analysis

Psychological treatments for obsessive-compulsive disorder (OCD) are increasingly aimed at improving outcomes by directly incorporating family members to address family disruption, dysfunction, or symptom accommodation. Much remains to be learned about the pooled effects of "family inclusive treatment" (FIT) for OCD and factors that may explain variation in response. Random-effects meta-analytic procedures were conducted to empirically evaluate the overall effect of FITs on OCD, and treatment moderators. Study search criteria yielded 29 studies examining FIT response in 1,366 OCD patients. Outcome variables included OCD symptoms and global functioning. Examined moderators included age group, gender, minority status, treatment length and format, and inclusion of specific family focused treatment elements. FITs for OCD demonstrated a large overall effect on OCD symptoms (pooled d = 1.68, SE = 0.14) and global functioning (pooled d = 0.98, SE = 0.14). Moderator analyses found that individual family treatments (vs. group) and FITs targeting family accommodation of symptoms (vs. those that did not target accommodation) were associated with greater improvements in patient functioning. Results indicate a robust overall response to FITs for OCD and clarify key moderators that inform optimal circumstances for effective treatment. Findings underscore the need for continued momentum in the development, evaluation, and dissemination of FITs for OCD.

Why are anxiety and depressive symptoms comorbid in youth? A multi-wave, longitudinal examination of competing etiological models

BACKGROUND

The present study sought to clarify the development of comorbid emotional distress by comparing different explanations for how youth develop anxiety and depressive symptoms. Specifically, we introduced the diathesis-anxiety approach (whether cognitive vulnerabilities interact with anxiety symptoms), and compared it to a causal model (anxiety symptoms predicting depressive symptoms), and a correlated liabilities model (whether cognitive vulnerabilities interacted with stressors to predict both anxiety and depressive symptoms) to examine which model best explained the relation between depressive and anxiety symptoms in youth.

METHODS

678 3rd (n=208), 6th (n=245), and 9th (n=225) grade girls (n=380) and boys (n=298) completed self-report measures at baseline assessing cognitive vulnerabilities (rumination and self-criticism), stressors, depressive and anxiety symptoms. Every 3 months over the next 18 months, youth completed follow-up measures of symptoms and stressors.

RESULTS

While limited support was found for a causal (p>0.10) or correlated-liability model (p>0.05) for comorbidity, findings did support a diathesis-anxiety approach for both self-criticism (t(2494)=3.36, p<0.001) and rumination (t(2505)=2.40, p<0.05).

LIMITATIONS

The present study׳s findings are based on self-report measure and makes inferences concerning comorbidity with a community sample.

CONCLUSIONS

These results may help clarify past research concerning comorbidity by introducing a diathesis-anxiety approach as a viable model to understand which youth are most at-risk for developing comorbid emotional distress.

Treatment of pediatric anxiety disorders

This article provides a brief review of the current available data concerning present treatment and potential new treatment advances for pediatric anxiety disorders, such as generalized anxiety disorder, separation anxiety disorder, social phobia, obsessive-compulsive disorder, and posttraumatic stress disorder. Disorder-specific treatment methods and innovations, particularly computer-assisted methods of delivery for cognitive behavioral therapy (CBT) will be reviewed. Additionally, the paper will discuss novel psychopharmacological compounds (e.g., D-cycloserine, riluzole, memantine, and anticonvulsant medications). Available evidence for the efficacy of novel medication strategies in adult studies and implications for their use in pediatrics will be discussed.

Differential efficacy of cognitive-behavioral therapy and pharmacological treatments for pediatric obsessive-compulsive disorder: a meta-analysis

The aim of this paper is to present a meta-analysis about the differential efficacy of cognitive-behavioral therapy (CBT), pharmacological and combined treatment for pediatric obsessive-compulsive disorder (OCD). The literature research and the application of the inclusion criteria enabled us to locate 18 studies, yielding a total of 24 independent comparisons between a treated (10 pharmacological, 11 CBT, and 3 combined interventions) and a control group. All types of interventions were efficacious in reducing obsessive-compulsive symptoms, with effect sizes adjusted by the type of control group of d=1.203 for CBT, d=0.745 for pharmacological treatments, and d=1.704 for mixed treatments. Depression, anxiety and other secondary responses were also improved, especially with CBT interventions. The analysis of moderator variables showed that the CBT protocol and the total of intervention hours exhibited a significant influence on the effect size. Within pharmacological treatment, clomipramine (d=1.305) was more efficacious than selective serotonin reuptake inhibitors (d=0.644), but its adverse effects were more severe. Finally, the clinical implications of the results are discussed.

The occasional case against broad dissemination and implementation: retaining a role for specialty care in the delivery of psychological treatments

Mental illness imposes a staggering public health burden in the United States. Although the past 40 years have witnessed tremendous advances in the identification of evidence-based practices (EBPs) in psychological treatments, gaps persist between treatment in experimental settings and services available in the community. In response, considerable attention and large financial commitments have focused in recent years on broad dissemination and implementation efforts designed to improve the quality of psychological services delivered by a variety of generalist practitioners across practice settings. Increasingly, under the influence of the Patient Protection and Affordable Care Act, it is envisioned that these generalists will practice in integrated primary care settings. These advances hold enormous potential, and yet, given the tremendous diversity of mental health problems and human suffering, broad dissemination and implementation efforts to generalists alone may not be sufficient to adequately address the burden of mental illness. Some EBPs may prove too complex for universal dissemination, and the time and expense required for quality dissemination and implementation preclude large-scale training in the treatment of low base rate disorders. As dissemination and implementation efforts work to ensure a quality generalist mental health care workforce, herein we highlight the vital need for available specialty care in the delivery of psychological treatments. Given traditional barriers that interfere with the accessibility of specialty care, we propose the transformative potential of a specialty behavioral telehealth care workforce, transacting with the generalist practitioner workforce to collectively ensure the highest quality and timely delivery of needed treatments to affected individuals.

Internet-delivered, family-based treatment for early-onset OCD: a preliminary case series

Given the burdens of early-onset obsessive-compulsive disorder (OCD), limitations in the broad availability and accessibility of evidence-based care for affected youth present serious public health concerns. The growing potential for technological innovations to transform care for the most traditionally remote and underserved families holds enormous promise. This article presents the rationale, key considerations, and a preliminary case series for a promising behavioral telehealth innovation in the evidence-based treatment of early-onset OCD. We developed an Internet-based format for the delivery of family-based treatment for early-onset OCD directly to families in their homes, regardless of their geographic proximity to a mental health facility. Videoteleconferencing (VTC) methods were used to deliver real-time cognitive-behavioral therapy centering on exposure and response prevention to affected families. Participants in the preliminary case series included 5 children between the ages of 4 and 8 (M Age = 6.5) who received the Internet-delivered treatment format. All youth completed a full treatment course, all showed OCD symptom improvements and global severity improvements from pre- to posttreatment, all showed at least partial diagnostic response, and 60% no longer met diagnostic criteria for OCD at posttreatment. No participants got worse, and all mothers characterized the quality of services received as "excellent." The present work adds to a growing literature supporting the potential of VTC and related computer technology for meaningfully expanding the reach of supported treatments for OCD and lays the foundation for subsequent controlled evaluations to evaluate matters of efficacy and engagement relative to standard in-office evidence-based care.

Dysregulation in pediatric obsessive compulsive disorder

Although obsessive compulsive disorder (OCD) and common co-occurring conditions share deficits in self-regulatory abilities, there has been minimal examination of impaired self-regulation (dysregulation) in youth with OCD. This study examined the association of dysregulation with symptom severity, impairment, and treatment outcome in pediatric OCD. Clinicians assessed obsessive-compulsive severity, family accommodation and global severity in 144 youth with OCD. Youth completed self-report severity ratings of anxiety and depressive symptoms. Parents completed the Child Behavior Checklist (CBCL), and both children and parents completed parallel ratings of obsessive-compulsive impairment. Ninety-seven youth received cognitive behavioral therapy (CBT) and were re-assessed after treatment. Dysregulation was assessed using the CBCL-Dysregulation Profile. Before treatment, dysregulated youth exhibited greater obsessive-compulsive symptom severity, depressive mood, family accommodation, and impairment than non-dysregulated youth. The magnitude of dysregulation directly predicted child-rated impairment, parent-rated impairment, and family accommodation, beyond obsessive-compulsive severity. The magnitude of pretreatment dysregulation predicted treatment discontinuation but not treatment response. Obsessive-compulsive symptom severity and dysregulation level significantly decreased after CBT. Dysregulated youth with OCD presented as more clinically severe than their non-dysregulated counterparts, and may require more individualized interventions to reduce dysregulated behavior to prevent CBT attrition. For treatment completers, CBT was associated with a decrease in dysregulation level.

Pediatric Obsessive-Compulsive Disorder

Effective treatment for childhood obsessive-compulsive disorder (OCD) is available, including exposure with response prevention and other cognitive-behavioral interventions. However, many children with OCD reside in locations in which few providers have adequate training to implement these procedures correctly. Family accommodation of childhood OCD symptoms further complicates the delivery of existing treatments. The advent of web camera technology has created the opportunity to provide therapy to individuals who otherwise could not access expert care. This case illustrates the treatment of an 8-year-old child with severe OCD who lived in a remote region of the United States. Treatment was administered twice daily for 5 days via web camera. At a 3-month follow-up, the child showed significant improvement in her OCD symptoms and in overall disability. Other symptoms (anxiety and anxiety sensitivity) were reduced, but not at a statistically significant level. The implications for treatment are considered.

Evidence base update for psychosocial treatments for pediatric obsessive-compulsive disorder

Pediatric obsessive-compulsive disorder (OCD) is a chronic and impairing condition that often persists into adulthood. Barrett, Farrell, Pina, Peris, and Piacentini (2008), in this journal, provided a detailed review of evidence-based psychosocial treatments for youth with OCD. The current review provides an evidence base update of the pediatric OCD psychosocial treatment literature with particular attention to advances in the field as well as to the methodological challenges inherent in evaluating such findings. Psychosocial treatment studies conducted since the last review are described and evaluated according to methodological rigor and evidence-based classification using the JCCAP evidence-based treatment evaluation criteria (Southam-Gerow & Prinstein, this issue). Findings from this review clearly converge in support of cognitive-behavioral therapy as an effective and appropriate first line treatment for youth with OCD (either alone or in combination with medication). Although no treatment for pediatric OCD has yet to be designated as "well-established," both individual and individual family-based treatments have been shown to be "probably efficacious." Moderators and predictors of treatment outcome are discussed as are the areas where we have advanced the field and the areas where we have room to grow. The methodological and clinical challenges inherent in a review of the evidence base are reviewed. Finally, future research directions are outlined.

Advances in the treatment of pediatric obsessive-compulsive d-cycloserine with exposure and response prevention

Exposure-based cognitive-behavioral therapy and serotonin reuptake inhibitor medications are efficacious treatment options for the management of pediatric obsessive-compulsive disorder. Despite established efficacy, many youths receiving either therapy remain symptomatic after acute treatment. Regardless of the rationale for persistent symptoms, a clear need emerges for treatment options that restore functioning efficiently to symptomatic youths. One innovative approach builds upon the identified role of NMDA receptors in the fear extinction process. Instead of breaking existing connections during fear extinction, new associations develop that eventually predominate over prior associations. Recent investigations have explored augmenting exposure-based cognitive-behavioral therapy with the NMDA partial agonist d-cycloserine, with preliminary results demonstrating expedited treatment gains and moderately larger effects above exposure and response prevention therapy alone. A large randomized clinical trial is underway to evaluate the efficacy and efficiency of this therapeutic combination in pediatric obsessive-compulsive disorder. Results from this trial may translate into improved management practices.

The nature, assessment, and treatment of obsessive-compulsive disorder

Obsessive-compulsive disorder (OCD) is an anxiety disorder that affects between 1% to 2% of individuals and causes considerable impairment and disability. Although > 50% of individuals experience symptom onset in childhood, symptoms can continue to develop throughout adulthood. Accurate and timely assessment of clinical presentation is critical to limit impairment and improve prognosis. Presently, there are 2 empirically supported treatments available for OCD in children and adults, namely cognitive-behavioral therapy and pharmacotherapy with serotonin reuptake inhibitors. This article provides an introduction to the phenomenology, etiology, and clinical course of OCD. Assessment practices used to evaluate symptom severity are described, and evidence-based treatment options are reviewed, with appropriate distinctions drawn between children and adults. Finally, recommendations for assessment and treatment practices for OCD are explicated.

Videoconference- and cell phone-based cognitive-behavioral therapy of obsessive-compulsive disorder: a case series

For most patients with obsessive-compulsive disorder (OCD) the availability of exposure-based therapy is limited. In our study six outpatients with obsessive-compulsive disorder (OCD) received 15 sessions of therapy delivered only over teleconference (six sessions) and cell phones (nine sessions) over a 3-month period of time. Five of the patients were women and the average age of the participants was 31.5 (SD=8.1). Patients presented a variety of OCD symptoms which were treated with standard exposure and response prevention exercises both during treatment sessions and as a part of homework exercises. All patients rated the treatment format as acceptable and rated the quality of the working alliance as high. At the end of therapy four of the six patients were highly improved and no longer met diagnostic criteria for OCD according to the Anxiety Disorders Interview Schedule for DSM-IV and the Yale-Brown Obsessive Compulsive Scale. The same was true at 3-month follow-up although some small increases in OCD symptoms had occurred. The innovative treatment format shows promise as a method of delivery that may make treatment accessible for patients with poor access to specialty clinics.

The Leyton Obsessional Inventory-Child Version Survey Form does not demonstrate adequate psychometric properties in American youth with pediatric obsessive-compulsive disorder

The psychometric properties of the Leyton Obsessional Inventory-Child Version Survey Form (LOI-CV Survey Form) and the Short Leyton Obsessional Inventory-Child Version Survey Form (Short LOI-CV Survey Form) were examined in a clinical sample of 50 children and adolescents with obsessive-compulsive disorder (OCD). The internal consistency of the LOI-CV and Short LOI-CV Survey Forms were acceptable and poor, respectively (α=.79 and .65). The LOI-CV Survey Form was significantly and moderately correlated with child-rated OCD-related impairment, but was not significantly correlated with any other measures of OCD symptom frequency or severity, OCD-related impairment, global symptom severity, child reports of anxiety and depressive symptoms, and parent reports of children's obsessive-compulsive, internalizing, and externalizing symptoms. Modest support for the cognitive-behavioral treatment sensitivity of the LOI-CV Survey Form (Cohen's d=0.98) but not the Short LOI-CV Survey Form (Cohen's d=0.09) was demonstrated. Diagnostic sensitivity was poor for the LOI-CV Survey Form at both pre- (0.14) and post-treatment (0.06). Overall, these results suggest that the psychometric properties of the LOI-CV and Short LOI-CV Survey Forms are not adequate for use as a screening instrument or in assessing symptom severity in pediatric OCD.