Long-term outcome of pediatric obsessive-compulsive disorder: a meta-analysis and qualitative review of the literature

Cool and Hot Aspects of Executive Function in Childhood Obsessive-Compulsive Disorder

Aspects of executive functioning (EF) have been put forward as endophenotypes in obsessive- compulsive disorder (OCD) and meta-analyses support EF underperformance in adult samples. Childhood-onset OCD has been suggested to constitute a separate neurodevelopmental subtype of the disorder but studies on neuropsychological functioning in childhood OCD are limited. The aim of the present study was to investigate performance-based EF in pediatric OCD using observed and latent variable analyses. A case-control design was applied including 50 unmedicated children and adolescents with OCD aged 7-17 years of which 70% were female, 50 pairwise age and gender matched non-psychiatric controls (NP) and 38 children and adolescents with mixed anxiety disorders (MA). Participants underwent structured diagnostic interviews and assessment with a battery encompassing cool EF tasks of working memory, set shifting, inhibition, and planning, and hot EF tasks of decision making and dot probe paradigm affective interference. First, groups were compared on observed variables with multilevel mixed-effects linear regression and analysis of variance. Then the latent structure of cool EF was tested with confirmatory factor analysis (CFA) and groups were compared on the CFA scores. No significant differences between groups appeared on individual cool EF tasks. On the hot EF tasks the OCD group displayed significant interference effects on the dot probe paradigm OCD-specific stimuli relative to NP, but not compared to MA and no group differences emerged for decision making. In the CFA a one-factor solution showed best fit, but the groups did not differ significantly on the resulting latent variable. The present study does not support cool or hot EF impairments in childhood OCD.

Children's Naive Concepts of OCD and How They Are Affected by Biomedical Versus Cognitive Behavioural Psychoeducation

BACKGROUND

How we conceptualize mental health conditions is important as it impacts on a wide range of mediators of treatment outcome. We do not know how children intuitively conceptualize obsessive-compulsive disorder (OCD), nor do we know the relative impact of biomedical or cognitive behavioural conceptual explanations, yet both are being widely used in psychoeducation for children with OCD.

AIMS

This study identified children's naive concepts of OCD, and the comparative impact of biomedical versus cognitive behavioural psychoeducation on perceived prognosis.

METHOD

A within- and between-subjects experimental design was used. After watching a video of a young person describing their OCD, 202 children completed a questionnaire examining their concepts of the condition. They repeated the questionnaire following a second equivalent video, this time preceded by either biomedical or cognitive behavioural psychoeducation.

RESULTS

Participants' naive concepts of OCD reflected predominant models of OCD in healthcare. Even at the minimal dose of psychoeducation, participants' conceptualizations of OCD changed. Prior exposure to OCD resulted in a stronger alignment with the biomedical model. Exposure to biomedical psychoeducation resulted in participants predicting a slower recovery with less chance of complete remission.

CONCLUSION

Psychoeducation for childhood OCD is impactful. Despite its wide use by clinicians and mental health services, biomedical psychoeducation appears to have deleterious effects. Children's concepts of OCD merit attention but caution should be applied in how they are targeted.

Vitamin D levels in children and adolescents with obsessive compulsive disorder

BACKGROUND

Recent studies showed that vitamin D deficiency may lead to dysfunctional changes in the brain and may be associated with neuropsychiatric diseases.

AIMS

The present study aims to investigate vitamin D, calcium, phosphorus and alkaline phosphatase levels in children and adolescents diagnosed with obsessive-compulsive disorder (OCD) and compared them to healthy controls. Additionally, the correlation of OCD symptom severity with serum vitamin D level will be analyzed.

METHODS

A semi-structured interview form (K-SADS-PL) was used to diagnose OCD and other comorbidities in accordance with DSM-IV criteria. In addition, all participants were assessed with clinical interviews based on DSM-5 OCD diagnostic criteria. Children's Yale Brown Obsession Compulsion Scale (CY-BOCS) and Children's Depression Inventory were used in the clinical evaluation.

RESULTS

Vitamin D levels were lower in patients diagnosed with OCD (15.88 ± 6.96 ng/mL) when compared to healthy controls (18.21 ± 13.24 ng/mL), but the difference was not statistically significant (p = .234). Serum calcium, serum phosphate and serum alkaline phosphatase levels were not different between the groups. A negative correlation was found between serum 25OH-D3 levels and obsession scale scores in CY-BOCS.

CONCLUSIONS

To our knowledge this is the first study that evaluated vitamin D levels in OCD patients without comorbidity. The vitamin D levels of newly diagnosed OCD cases were lower but not statistically different than healthy controls. Furthermore, the study does also not support the presence of a significant association between serum vitamin D levels and OCD.

Clinical profile and outcome in a large sample of children and adolescents with obsessive-compulsive disorder: A chart review from a tertiary care center in India

BACKGROUND

Obsessive-compulsive disorder (OCD) is a common psychiatric illness in children and adolescents. Till date, the sample sizes in the Indian studies have been relatively small.

METHODOLOGY

The present study is a retrospective chart review of a large sample of children and adolescents diagnosed with OCD in a tertiary care center.

OBJECTIVES

The objectives of this study were to characterize the clinical profile and to evaluate outcome of OCD in children and adolescents.

RESULTS

Fear of contamination and washing/cleaning compulsions were the most common presenting symptoms. Most of the patients were male with two-thirds having a comorbid disorder. Major depressive disorder was the most common comorbid disorder. The rates of attention deficit hyperactivity disorder, disruptive behavioral disorders, and tic disorders were low when compared to Western studies. One-third of the patients received adequate trial of serotonin reuptake inhibitors and 36% received cognitive behavior therapy. Fifty-four percent of patients had a poor outcome with hospitalization, longer duration of illness, earlier onset of OC symptoms, and family history of OCD being the predictors of poor outcome.

CONCLUSION

The present study of a large sample of patients with juvenile OCD highlights the low rate of comorbid disruptive behavior disorders as reported in the earlier Indian studies and a favorable short-term outcome in approximately 56% of the patients.

Prediction of outcome in internet-delivered cognitive behaviour therapy for paediatric obsessive-compulsive disorder: A machine learning approach

BACKGROUND

There are no consistent predictors of treatment outcome in paediatric obsessive-compulsive disorder (OCD). One reason for this might be the use of suboptimal statistical methodology. Machine learning is an approach to efficiently analyse complex data. Machine learning has been widely used within other fields, but has rarely been tested in the prediction of paediatric mental health treatment outcomes.

OBJECTIVE

To test four different machine learning methods in the prediction of treatment response in a sample of paediatric OCD patients who had received Internet-delivered cognitive behaviour therapy (ICBT).

METHODS

Participants were 61 adolescents (12-17 years) who enrolled in a randomized controlled trial and received ICBT. All clinical baseline variables were used to predict strictly defined treatment response status three months after ICBT. Four machine learning algorithms were implemented. For comparison, we also employed a traditional logistic regression approach.

RESULTS

Multivariate logistic regression could not detect any significant predictors. In contrast, all four machine learning algorithms performed well in the prediction of treatment response, with 75 to 83% accuracy.

CONCLUSIONS

The results suggest that machine learning algorithms can successfully be applied to predict paediatric OCD treatment outcome. Validation studies and studies in other disorders are warranted.

Moderators and predictors of response to cognitive behaviour therapy for pediatric obsessive-compulsive disorder: A systematic review

We report a systematic review of moderators of CBT efficacy for pediatric OCD relative to other treatments. CENTRAL, MEDLINE, EMBASE, CINAHL, and PsycINFO were searched for RCTs reporting on effect moderation for CBT outcomes. Five studies (N = 365) examined 17 variables with three significant moderators identified. Compared to pill-placebo, CBT monotherapy was not effective for children with a family history of OCD but was for those without a family history. For children with a family history, CBT plus sertraline efficacy was attenuated but remained significant. For children with tics, CBT but not sertraline remained superior to pill-placebo. For non-responders to initial treatment with CBT, continuing CBT was inferior to commencing sertraline for those with tics but was not different for those without tics. A supplementary review identified older age, symptom and impairment severity, co-morbidity and family accommodation as consistent predictors of a poorer outcome to CBT. Current evidence for moderation effects is post-hoc, from single RCTs, has small Ns and requires replication. The review identifies family history of OCD and the presence of tics as factors requiring further examination in properly conducted trials and about which clinicians need to show care in their treatment recommendations.

Who Should Transition? Defining a Target Population of Youth with Depression and Anxiety That Will Require Adult Mental Health Care

The process of transitioning youth from child to adult mental health services is poorly managed, and many adolescents disengage from services during transfer. The waxing and waning of symptoms over time means that some youth who are asymptomatic prior to transfer (15-17 years) will be at high risk for recurrence during the transition period. There are no clear, evidence-based guidelines about who should transfer to adult care. Objectives were to propose: (1) criteria to define anxious or depressed youth (16-21 years) that should transfer and (2) levels of service needed in young adulthood. Natural history of psychopathology and treatment response for depression and anxiety was reviewed. Risk factors for recurrence and persistence, such as initial severity, comorbidity, and family functioning, can help to identify youth requiring transfer. Few controlled treatment studies have examined predictors of long-term course. Recommendations for follow-up care and ongoing monitoring during young adulthood are discussed.

A systematic review of the clinical effectiveness and cost-effectiveness of pharmacological and psychological interventions for the management of obsessive-compulsive disorder in children/adolescents and adults

BACKGROUND

Obsessive-compulsive disorder (OCD) is a relatively common and disabling condition.

OBJECTIVES

To determine the clinical effectiveness, acceptability and cost-effectiveness of pharmacological and psychological interventions for the treatment of OCD in children, adolescents and adults.

DATA SOURCES

We searched the Cochrane Collaboration Depression, Anxiety and Neurosis Trials Registers, which includes trials from routine searches of all the major databases. Searches were conducted from inception to 31 December 2014.

REVIEW METHODS

We undertook a systematic review and network meta-analysis (NMA) of the clinical effectiveness and acceptability of available treatments. Outcomes for effectiveness included mean differences in the total scores of the Yale-Brown Obsessive-Compulsive Scale or its children's version and total dropouts for acceptability. For the cost-effectiveness analysis, we developed a probabilistic model informed by the results of the NMA. All analyses were performed using OpenBUGS version 3.2.3 (members of OpenBUGS Project Management Group; see www.openbugs.net ).

RESULTS

We included 86 randomised controlled trials (RCTs) in our systematic review. In the NMA we included 71 RCTs (54 in adults and 17 in children and adolescents) for effectiveness and 71 for acceptability (53 in adults and 18 in children and adolescents), comprising 7643 and 7942 randomised patients available for analysis, respectively. In general, the studies were of medium quality. The results of the NMA showed that in adults all selective serotonin reuptake inhibitors (SSRIs) and clomipramine had greater effects than drug placebo. There were no differences between SSRIs, and a trend for clomipramine to be more effective did not reach statistical significance. All active psychological therapies had greater effects than drug placebo. Behavioural therapy (BT) and cognitive therapy (CT) had greater effects than psychological placebo, but cognitive-behavioural therapy (CBT) did not. BT and CT, but not CBT, had greater effects than medications, but there are considerable uncertainty and methodological limitations that should be taken into account. In children and adolescents, CBT and BT had greater effects than drug placebo, but differences compared with psychological placebo did not reach statistical significance. SSRIs as a class showed a trend for superiority over drug placebo, but the difference did not reach statistical significance. However, the superiority of some individual drugs (fluoxetine, sertraline) was marginally statistically significant. Regarding acceptability, all interventions except clomipramine had good tolerability. In adults, CT and BT had the highest probability of being most cost-effective at conventional National Institute for Health and Care Excellence thresholds. In children and adolescents, CBT or CBT combined with a SSRI were more likely to be cost-effective. The results are uncertain and sensitive to assumptions about treatment effect and the exclusion of trials at high risk of bias.

LIMITATIONS

The majority of psychological trials included patients who were taking medications. There were few studies in children and adolescents.

CONCLUSIONS

In adults, psychological interventions, clomipramine, SSRIs or combinations of these are all effective, whereas in children and adolescents, psychological interventions, either as monotherapy or combined with specific SSRIs, were more likely to be effective. Future RCTs should improve their design, in particular for psychotherapy or combined interventions.

STUDY REGISTRATION

The study is registered as PROSPERO CRD42012002441.

FUNDING DETAILS

The National Institute for Health Research Health Technology Assessment programme.

Preschool-onset obsessive-compulsive disorder with complete remission

Early-onset obsessive-compulsive disorder (OCD) is more severe than later-onset OCD. There are no reports of any early-onset OCD patients being cured, especially with respect to preschoolers. In this case report, we describe the successful treatment and cure of a 6-year-old preschool girl with severe OCD since the age of 3. At the age of 3, the patient began to fear contamination and danger to herself and her family, leading to excessive hand-washing, and several months later, ritualized checking. The OCD symptoms waxed and waned for about 3 years and thereafter worsened gradually over a few weeks, culminating in a refusal to eat and dress. At the age of 6, after a week of inpatient pediatric treatment with no improvement, the patient was transferred to Osaka City University Hospital to seek psychiatric treatment. The patient fully recovered from OCD following family-based cognitive-behavioral therapy (CBT) and short-term use of low-dose fluvoxamine in an inpatient setting. After treatment, the OCD symptoms disappeared with complete remission for over 3 years. Now, aged 9, the patient has good global functioning and is well adjusted in her daily life with no need for any treatment. To the best of our knowledge, this is the first report of preschool-onset OCD with long-term complete remission with inpatient treatment in a preschooler with severe OCD. Some preschoolers with very early-onset OCD may have good prognosis without continuous pharmacotherapy, although the symptoms with the onset are severe enough to require hospitalization. Preschool-onset OCD is likely to be misdiagnosed as separation anxiety disorder. Our findings suggest that family-based CBT, which is the treatment of choice for preschool-onset OCD, can be applicable to inpatient treatment. Early detection and intensive intervention of OCD in preschoolers may improve the chance of remission.

Effects of traumatic experiences on obsessive-compulsive and internalizing symptoms: The role of avoidance and mindfulness

BACKGROUND

Trauma exposure is associated with adverse psychological outcomes including anxiety, depression, and obsessive-compulsive (OC) symptoms. Adolescence is increasingly recognized as a period of vulnerability for the onset of these types of psychological symptoms. The current study explored the mediating roles of experiential avoidance and mindfulness processes in the association between retrospective reports of childhood trauma and current internalizing and OC symptoms in adolescents.

METHOD

A group of at-risk adolescents (N = 51) and a group of college students (N = 400) reported on childhood trauma, experiential avoidance, mindfulness, anxiety, depressive, and OC symptoms. Mediation analyses were performed to examine the mechanistic roles of avoidance and mindfulness in the association between trauma and internalizing and OC-specific symptoms.

RESULTS

In the group of at-risk adolescents, experiential avoidance and mindfulness both significantly mediated the association between childhood trauma and OC symptoms. In the college student sample, experiential avoidance mediated the association between trauma and OC symptoms. Experiential avoidance, as well as the observe, act with awareness, and nonjudgmental facets of mindfulness all significantly mediated the association between trauma and internalizing symptoms.

LIMITATIONS

The group of at-risk adolescents was small, and the college student group was demographically homogeneous. All data was self-report and cross-sectional.

CONCLUSION

The current study demonstrated that experiential avoidance and mindfulness processes may be the mechanisms through which the association between trauma and obsessive-compulsive and trauma and internalizing symptoms exist in adolescents. These findings provide potential targets for clinical intervention to improve outcomes for adolescents who have experienced trauma.

Inflammatory dysregulation of monocytes in pediatric patients with obsessive-compulsive disorder

BACKGROUND

Although the exact etiology of obsessive-compulsive disorder (OCD) is unknown, there is growing evidence of a role for immune dysregulation in the pathophysiology of the disease, especially in the innate immune system including the microglia. To test this hypothesis, we studied inflammatory markers in monocytes from pediatric patients with OCD and from healthy controls.

METHODS

We determined the percentages of total monocytes, CD16+ monocytes, and classical (CD14^highCD16-), intermediate (CD14^highCD16^low), and non-classical (CD14^lowCD16^high) monocyte subsets in 102 patients with early-onset OCD and in 47 healthy controls. Moreover, proinflammatory cytokine production (GM-CSF, IL-1β, IL-6, IL-8, and TNF-α) was measured by multiplex Luminex analysis in isolated monocyte cultures, in basal conditions, after exposure to lipopolysaccharide (LPS) to stimulate immune response or after exposure to LPS and the immunosuppressant dexamethasone.

RESULTS

OCD patients had significantly higher percentages of total monocytes and CD16+ monocytes than healthy controls, mainly due to an increase in the intermediate subset but also in the non-classical monocytes. Monocytes from OCD patients released higher amounts of GM-CSF, IL-1β, IL-6, IL-8, and TNF-α than healthy controls after exposure to LPS. However, there were no significant differences in basal cytokine production or the sensitivity of monocytes to dexamethasone treatment between both groups. Based on monocyte subset distribution and cytokine production after LPS stimulation, patients receiving psychoactive medications seem to have an intermediate inflammatory profile, that is, lower than non-medicated OCD individuals and higher than healthy controls.

CONCLUSIONS

These results strongly support the involvement of an enhanced proinflammatory innate immune response in the etiopathogenesis of early-onset OCD.

A multilevel longitudinal study of obsessive compulsive symptoms in adolescence: male gender and emotional stability as protective factors

The severity of obsessive compulsive symptoms (OCS) is suggested to be normally distributed in the general population, and they appear to have an impact on a range of aspects of adolescent development. Importantly, there are individual differences regarding susceptibility to OCS. In the present repeated measures study, OCS were studied in relation to gender and emotional stability (as a personality trait) using a normative sample of 515 adolescents at ages 16 and 18 years. OCS were assessed with the relevant subscale of the SCL-90-R and emotional stability with the Five Factor Questionnaire. A three-level hierarchical linear model was calculated to longitudinally assess the over time variations of OCS and their over time links to gender and emotional stability, while controlling for random effects due to the nesting of the data. Experiencing OCS increased with age (between 16 and 18 years). Additionally, male gender and higher emotional stability were associated with lower OCS at 16 years and these remained stable over time. Results indicate age-related and between individual differences on reported OCS that need to be considered for prevention and intervention planning.

One-Year Outcome for Responders of Cognitive-Behavioral Therapy for Pediatric Obsessive-Compulsive Disorder

OBJECTIVE

This study describes 1-year treatment outcomes from a large sample of cognitive-behavioral therapy (CBT) responders, investigates age as a possible moderator of these treatment outcomes, and evaluates clinical relapse at the 1-year follow-up.

METHOD

This study is the planned follow-up to the Nordic Long-term OCD [obsessive-compulsive disorder] Treatment Study (NordLOTS), which included 177 children and adolescents who were rated as treatment responders following CBT for OCD. Participants were assessed with the Children's Yale-Brown Obsessive-Compulsive Scale (CY-BOCS) at 6- and 12-month follow-up. Treatment response and remission were defined as CY-BOCS total scores ≤15 and ≤10, respectively. Linear mixed-effects models were used to analyze all outcomes.

RESULTS

At 1 year, a total of 155 children and adolescents (87.6%) were available for follow-up assessment, with 142 of these (91.6%) rated below a total score of ≤15 on the CY-BOCS. At 1-year follow-up, 121 (78.1%) were in remission. On average, CY-BOCS total scores dropped by 1.72 points during the first year after terminating treatment (p = .001). A total of 28 participants (15.8%) relapsed (CY-BOCS ≥ 16) at either the 6- or 12-month assessment; only 2 patients required additional CBT.

CONCLUSION

Results suggest that manualized CBT in a community setting for pediatric OCD has durable effects for those who respond to an initial course of treatment; children and adolescents who respond to such treatment can be expected to maintain their treatment gains for at least 1 year following acute care. Clinical trial registration information- Nordic Long-term Obsessive-Compulsive Disorder (OCD) Treatment Study; www.controlled-trials.com; ISRCTN66385119.

Successful Treatment Response with Aripiprazole Augmentation of SSRIs in Refractory Obsessive-Compulsive Disorder in Childhood

The aim of this study is to evaluate the aripiprazole augmentation of selective seratonine reuptake inhibitors (SSRIs) in children and adolescents with treatment-resistant OCD. Forty-eight children and adolescents (14 girls, 34 boys), who are non-responders to treatment with at least two types of SSRIs and CBT, were administered a 12-week of augmentation. Children's Yale-Brown Obsessive Compulsive Scale (CY-BOCS), and Clinical Global Impression-Severity and Improvement (CGI-S and CGI-I) sub-scales were used for evaluation of the treatment outcomes. The results showed that total CY-BOCS scores were decreased from 33.3 ± 7.5 to 11.7 ± 9.3 (p < 0.001), CGI-S scores decreased from 6.3 ± 0.9 to 2.7 ± 1.6 (p < 0.001), and CGI-I scores improved from 4.3 ± 0.6 to 2.2 ± 1.1 (p < 0.001). Sensitivity analyses in 29 patients without SSRI dose escalation along with aripiprazole augmentation have also revealed that improvement effect was still significant, and CY-BOCS scores were improved from 34.2 ± 7.9 to 13 ± 10.3, CGI-S improved from 6.4 ± 1.0 to 3.0 ± 1.7, and CGI-I improved from 4.4 ± 1.0 to 2.3 ± 1.1 (p < 0.001 for all). Analyses revealed that a significant clinical improvement has been observed with aripiprazole augmentation. Aripiprazole augmentation of SSRIs is a promising strategy in the management of treatment-refractory OCD children and adolescents.

Children with Obsessive-Compulsive Symptomology in the General Population: Different Subtypes?

OBJECTIVE

Obsessive-compulsive disorder (OCD) is a moderately prevalent neurodevelopmental disorder, and many children suffer from subclinical obsessive-compulsive (OC) symptoms. The disorder is heterogeneous and has high comorbidity rates. In early disease stages of psychiatric disorders, symptoms are typically hard to attribute exclusively to specific disorders. The authors investigated whether profiles of neuropsychiatric symptoms can be distinguished within a large population-based study of school-aged children (7-10 years) scoring high on OC symptoms.

METHODS

OC symptoms and comorbid symptoms common in pediatric OCD were assessed: symptoms of attention-deficit hyperactivity disorder, oppositional defiant disorder, autism, and anxiety. Latent profile analysis was performed on the subgroup of children scoring high on OC symptoms (high-OC sample, n = 209, i.e., 4.5% of total sample, n = 4632) using the z scores of the measures of comorbid symptoms as indicators.

RESULTS

Three distinguishable profiles were found within the high-OC sample. The first subgroup ("OC-specific"; 81.3%, 3.7% of total sample) had only OC-specific problems, the second subgroup ("Comorbid OC"; 11.0%, 0.5% of total sample) had high scores on all measures of comorbid symptomology, and the third subgroup ("Autistic OC"; 7.7%, 0.3%, of total sample) scored especially high on autism.

CONCLUSION

The findings show that profiles based on neuropsychiatric symptoms can be distinguished within a population-based sample of school-aged children scoring high on obsessive-compulsive symptoms. These profiles may be useful in establishing patterns of symptom course during development. Longitudinal follow-up is necessary to ascertain whether at a later age these subgroups still differ in their symptom profile and neuropsychiatric trajectory.

Epidemiology and comorbidity of obsessive-compulsive disorder in late adolescence: a cross-sectional study in senior high schools in Greece

OBJECTIVE

The aim of this study was to examine the epidemiology, comorbidity and use of health services of obsessive-compulsive disorder (OCD) and subclinical obsessive-compulsive symptoms in late adolescence.

METHODS

A total of 2427 adolescents attending senior high schools in Greece were selected for a detailed psychiatric interview using the revised clinical interview schedule (CIS-R). Use of alcohol, nicotine and cannabis, and several socio-demographic and socio-economic variables were also assessed.

RESULTS

The prevalence of OCD was 1.39% (95% confidence interval [CI]: 1.05-1.84) while that of subclinical obsessive-compulsive symptoms was 2.77% (2.22-3.45). There was a female preponderance for subclinical symptoms. Financial difficulties of the family was the only socio-demographic variable that was significantly associated with OCD but not with subclinical symptoms. The pattern of comorbidity was similar for both conditions but milder in the subclinical form. About one in three reported use of general health services and one in ten use of psychiatric services.

CONCLUSIONS

OCD and subclinical obsessive-compulsive symptoms were relatively common. Comorbidity with other psychiatric disorders and use of substances was considerable even in subclinical status, but use of specialised health services was small. Clinical and research implications are discussed.

Outpatient Treatment Patterns of Pediatric Obsessive-Compulsive Disorder

INTRODUCTION

Little is known about community physician treatment practices for children with obsessive-compulsive disorder (OCD). This study is the first to describe the treatment of pediatric OCD in office-based and outpatient department-based physicians in the United States.

METHODS

Data from the 2003-2011 National Ambulatory Medical Care Survey and the National Hospital Ambulatory Medical Care Survey were used. We provided descriptive statistics for sample characteristics and treatments administered during the visit, and examined differences in treatment by comorbid conditions and settings using logistic regression.

RESULTS

Psychotherapy was provided in 46% of visits in children with OCD overall, while serotonin reuptake inhibitor (SRI) medication was prescribed to 55% overall, atypical antipsychotics were prescribed to 22% of youth either alone or in combination with another medication; 11% received no psychotherapy or pharmacotherapy. Psychotherapy and at least one pharmacotherapy were provided to 36% of patients. There were no significant differences in characteristics of patients receiving each class of medication.

CONCLUSION

Among children and adolescents, OCD was primarily treated by physicians using SRI medication and/or psychotherapy. A sizeable proportion of children were given atypical antipsychotic medications. Wider dissemination of evidence-based psychological treatments and continued monitoring of adherence to guidelines is warranted.

How can technology enhance cognitive behavioral therapy: the case of pediatric obsessive compulsive disorder

Many children with mental health disorders do not receive adequate treatment due to the uneven dissemination of resources, and other barriers to treatment. In the case of pediatric obsessive compulsive disorder treatment progress is also hindered by partial or non-response to treatment in addition to poor compliance. This debate paper focuses on new technologies as a potential vehicle to address the challenges faced by traditional treatment, with special reference to cognitive behavioral therapy for pediatric obsessive compulsive disorder. We discuss the achievements and challenges that previous studies have faced, debate ways to overcome them, and we offer specific suggestions for further research in the area.

Measurement Issues: The measurement of obsessive compulsive disorder in children and young people in clinical practice

BACKGROUND

If left untreated, obsessive compulsive disorder (OCD) can cause significant distress and impact on functioning throughout the lifespan. Despite the severity of the disorder, there is often a significant delay between the onset of symptoms and successful treatment. This is in part due to delays in recognising OCD symptoms in young people, particularly if the symptom forms are less common. Once OCD is accurately diagnosed, cognitive behavioural therapy (CBT) is known to be an efficacious treatment, sometimes in combination with medication, producing good long-term prognosis. It is therefore important to accurately detect OCD in children and young people so that they can be offered timely intervention. Use of the best tools in clinical and research settings improves detection and diagnosis, as well as enabling the tracking of progress through treatment. The aim of this current paper was to review measurement tools for OCD in young people with a focus on the practicalities of using tools in busy child mental health clinical settings.

METHOD

To discover what measurement tools are available for OCD in young people, we conducted a pragmatic literature of measurement tools for OCD in young people. We searched PsycINFO, Med-Line and the Cochrane databases for reports relating to the measurement of OCD. Additionally, we sought information from the National Institute for Health and Care Excellence (NICE) guidance, the Child Outcomes Research Consortium (CORC) website and the Children and Young People's Improving Access to Psychological Therapies (CYP IAPT) Programme. We also reviewed large trials and meta-analyses of the treatment of OCD in young people and communicated with relevant researchers/clinicians.

RESULTS

Seventeen questionnaire measurement tools, with variable psychometric properties, and four commonly used semistructured clinician administered interview measures were identified.

CONCLUSIONS

There are several measurement tools with good psychometric properties that are useful for initial screening/identification of OCD, as well as formal diagnosis, symptom tracking and treatment evaluation. With the availability of brief screens, as well as online diagnostic measures, such tools should not be a burden on clinical practice, but rather a helpful aid to support clinicians' assessment and treatment of OCD.

Distinguishing Fear Versus Distress Symptomatology in Pediatric OCD

Prior research has identified OCD subtypes or "clusters" of symptoms that differentially relate to clinical features of the disorder. Given the high comorbidity between OCD and anxiety, OCD symptom clusters may more broadly associate with fear and/or distress internalizing constructs. This study examines fear and distress dimensions, including physical concerns (fear), separation anxiety (fear), perfectionism (distress), and anxious coping (distress), as predictors of previously empirically-derived OCD symptom clusters in a sample of 215 youth diagnosed with primary OCD (ages 7-17, mean age = 12.25). Self-reported separation fears predicted membership in Cluster 1 (aggressive, sexual, religious, somatic obsessions, and checking compulsions) while somatic/autonomic fears predicted membership in Cluster 2 (symmetry obsessions and ordering, counting, repeating compulsions). Results highlight the diversity of pediatric OCD symptoms and their differential association with fear, suggesting the need to carefully assess both OCD and global fear constructs that might be directly targeted in treatment.

A preliminary study of cognitive-behavioral family-based treatment versus parent training for young children with obsessive-compulsive disorder

BACKGROUND

Cognitive-Behavioral Family-Based Treatment (CBFT) is the standard of care in young children with OCD. Developmental considerations, parent desires, and cost-effective advantages motivate research to explore the relative efficacy of parent-only interventions. The main goal in this study was to test the effectiveness and feasibility of a parent only intervention for OCD in young children, comparing, in a preliminary fashion the relative efficacy of reducing obsessive-compulsive symptoms through two treatment conditions: 1) an individual CBFT for early OCD involving both parents and children, and 2) the family component of the intervention involving only individual Parent Training (PT).

METHODS

Twenty treatment-seeking families from two private outpatient clinics in Spain were alternately assigned to one of the two treatment conditions. Participants had a primary diagnosis of OCD and a mean age of 6.62 years (65% males). Interventions were conducted by the same therapist and the assessments were administered by independent clinicians who were blind to the experimental conditions of the participants. Assessment time-points were pretreatment, posttreatment, and 3-month follow-up (including diagnosis, symptom severity, global functioning, family accommodation, externalizing and internalizing symptoms, and satisfaction measures).

RESULTS

The two ways of implementation, involving child and parents (CBFT) or involving only parents (PT), produced clinical improvements and were well-accepted by parents and children. The CBFT condition was superior to the PT condition in reducing externalizing problems.

LIMITATIONS

reduced sample size and absence of randomization were the main limitations of this study.

CONCLUSIONS

these results suggest, in a preliminary manner, that the need to have the child present at session with the clinician could be decreased for some children, as well as the overall feasibility of working only with parents for the implementation of CBT for OCD in very young children.

Defining cognitive-behavior therapy response and remission in pediatric OCD: a signal detection analysis of the Children's Yale-Brown Obsessive Compulsive Scale

The objective of the study was to examine the optimal Children's Yale-Brown Obsessive-Compulsive Scale (CY-BOCS) percent reduction and raw cutoffs for predicting cognitive-behavioral treatment (CBT) response among children and adolescents with obsessive-compulsive disorder (OCD). The sample consisted of children and adolescents with OCD (N = 241) participating in the first step of the Nordic long-term OCD treatment study and receiving 14 weekly sessions of CBT in the form of exposure and response prevention. Evaluations were conducted pre- and post-treatment, included the CY-BOCS, Clinical Global Impressions-severity/improvement. The results showed that the most efficient CY-BOCS cutoffs were 35 % reduction for treatment response, 55 % reduction for remission, and a post-treatment CY-BOCS raw total score of 11 for treatment remission. Overall, our results diverge from previous research on pediatric OCD with more conservative cutoffs (higher cutoff reduction for response and remission, and lower raw score for remission). Further research on optimal cutoffs is needed.

Persistence of impulsivity in pediatric and adolescent patients with obsessive-compulsive disorder

AIM

Increasing clinical evidence points to impulsivity as a symptom of obsessive-compulsive disorder (OCD). However, little is known about its persistence over time.

METHODS

In this study, we evaluated the performance of 12 pediatric patients with OCD on the Stroop color-word task, which assesses impulsivity, and compared this with age- and sex-matched controls. In parallel, we measured changes in hemodynamic responses during the task, using near-infrared spectroscopy. As patients in the OCD group were naïve to treatment, we compared results before and after 3-year medication with serotonin reuptake inhibitors.

RESULTS

We report that, compared with controls, the OCD group had significantly poorer performance and less activation in the prefrontal cortex during the Stroop color-word task. Surprisingly, while serotonin-reuptake-inhibitors treatment reduced OCD symptomology, it did not improve the diminished hemodynamic responses or task performance of these patients.

CONCLUSION

Our findings suggest that a persistent deficit exists in the inhibitory control of pediatric patients with OCD; they also provide insight into the pathophysiology of OCD.

Distinct Subcortical Volume Alterations in Pediatric and Adult OCD: A Worldwide Meta- and Mega-Analysis

OBJECTIVE

Structural brain imaging studies in obsessive-compulsive disorder (OCD) have produced inconsistent findings. This may be partially due to limited statistical power from relatively small samples and clinical heterogeneity related to variation in illness profile and developmental stage. To address these limitations, the authors conducted meta- and mega-analyses of data from OCD sites worldwide.

METHOD

T1 images from 1,830 OCD patients and 1,759 control subjects were analyzed, using coordinated and standardized processing, to identify subcortical brain volumes that differ between OCD patients and healthy subjects. The authors performed a meta-analysis on the mean of the left and right hemisphere measures of each subcortical structure, and they performed a mega-analysis by pooling these volumetric measurements from each site. The authors additionally examined potential modulating effects of clinical characteristics on morphological differences in OCD patients.

RESULTS

The meta-analysis indicated that adult patients had significantly smaller hippocampal volumes (Cohen's d=-0.13; % difference=-2.80) and larger pallidum volumes (d=0.16; % difference=3.16) compared with adult controls. Both effects were stronger in medicated patients compared with controls (d=-0.29, % difference=-4.18, and d=0.29, % difference=4.38, respectively). Unmedicated pediatric patients had significantly larger thalamic volumes (d=0.38, % difference=3.08) compared with pediatric controls. None of these findings were mediated by sample characteristics, such as mean age or scanning field strength. The mega-analysis yielded similar results.

CONCLUSIONS

The results indicate different patterns of subcortical abnormalities in pediatric and adult OCD patients. The pallidum and hippocampus seem to be of importance in adult OCD, whereas the thalamus seems to be key in pediatric OCD. These findings highlight the potential importance of neurodevelopmental alterations in OCD and suggest that further research on neuroplasticity in OCD may be useful.

Predictors of treatment response to group cognitive behavioural therapy for pediatric obsessive-compulsive disorder

Obsessive-compulsive disorder (OCD) is a debilitating mental health disorder, occurring in 1-2% of children and adolescents. Current evidence-based treatments produce promising rates of remission; however, many children and youth do not fully remit from symptoms. The current study explored predictors of treatment response to a group cognitive-behavioural treatment program for pediatric OCD (N=43). Higher levels of child depression and parental rejection at baseline were found to be associated with higher OCD symptoms at post-treatment. Family accommodation was found to be associated with OCD symptom severity at 12-months follow-up. Further, children who were classified as treatment responders at 12-months follow-up had fewer depressive symptoms at baseline than non-responders at 12-months. Results indicate that child depression and adverse family factors may contribute to poorer treatment response for children and youth with OCD. This finding suggests current treatments should be refined for these young people in order to better suit their individual needs.

A longitudinal event-related potential study of selective serotonin reuptake inhibitor therapy in treatment-naïve pediatric obsessive compulsive disorder patients

Obsessive-compulsive disorder (OCD) is characterized by obsessive thoughts and/or compulsive behaviors, involving specific cognition and/or information processing disorders. Event-related potentials (ERPs) are commonly used as physiological measures of cognitive function. In conscious patients, ERPs are easily and non-invasively measured. Previous ERP studies have revealed differences between OCD patients and control subjects. Whether ERPs reflect the pharmacological effects of OCD treatment, particularly in treatment-naïve pediatric patients, remains unknown. We used the Child's Yale-Brown Obsessive-Compulsive Scale (CY-BOCS) to evaluate the symptomatic severity of 12 treatment-naïve pediatric OCD patients. Comparisons were made with 12 age-, sex-, and intelligence-matched controls. The P300 and mismatch negativity (MMN) components were measured during an auditory odd-ball task at baseline in both groups and after the 3-year serotonin reuptake inhibitor (SSRI) treatment in OCD patients. Compared with controls, P300 amplitudes were smaller n the OCD group at Fz, Cz, Pz, C3, and C4. After SSRI treatment, P300 amplitudes increased partly at Fz and C4 in association with symptomatic improvements. We found a significant positive correlation between P300 amplitude in C4 and CY-BOCS scores. Our findings confirm the utility of SSRIs in pediatric OCD, and suggest the utility of ERPs for evaluating pharmacological effects in treatment-naïve pediatric OCD patients.

Uncovering obsessive-compulsive disorder risk genes in a pediatric cohort by high-resolution analysis of copy number variation

BACKGROUND

Obsessive-compulsive disorder (OCD) is a heterogeneous neuropsychiatric condition, thought to have a significant genetic component. When onset occurs in childhood, affected individuals generally exhibit different characteristics from adult-onset OCD, including higher prevalence in males and increased heritability. Since neuropsychiatric conditions are associated with copy number variations (CNVs), we considered their potential role in the etiology of OCD.

METHODS

We genotyped 307 unrelated pediatric probands with idiopathic OCD (including 174 that were part of complete parent-child trios) and compared their genotypes with those of 3861 population controls, to identify rare CNVs (<0.5 % frequency) of at least 15 kb in size that might contribute to OCD.

RESULTS

We uncovered de novo CNVs in 4/174 probands (2.3 %). Our case cohort was enriched for CNVs in genes that encode targets of the fragile X mental retardation protein (nominal p = 1.85 × 10-03; FDR=0.09), similar to previous findings in autism and schizophrenia. These results also identified deletions or duplications of exons in genes involved in neuronal migration (ASTN2), synapse formation (NLGN1 and PTPRD), and postsynaptic scaffolding (DLGAP1 and DLGAP2), which may be relevant to the pathogenesis of OCD. Four cases had CNVs involving known genomic disorder loci (1q21.1-21.2, 15q11.2-q13.1, 16p13.11, and 17p12). Further, we identified BTBD9 as a candidate gene for OCD. We also sequenced exomes of ten "CNV positive" trios and identified in one an additional plausibly relevant mutation: a 13 bp exonic deletion in DRD4.

CONCLUSIONS

Our findings suggest that rare CNVs may contribute to the etiology of OCD.

Cognitive behavioral and pharmacological treatments of OCD in children: A systematic review and meta-analysis

Obsessive-compulsive disorder (OCD) is ranked by the World Health Organization (WHO) among the 10 most debilitating disorders. The treatments which have been found effective are cognitive behavior therapy (CBT) and serotonin reuptake inhibitors (SRI). This meta-analysis includes all RCTs of CBT (25) and SRI (9) for OCD in youth using the Children's Yale-Brown Obsessive Compulsive Scale (C-YBOCS). CBT yielded significantly lower attrition (12.7%) than SRI (23.5%) and placebo (24.7%). The effect sizes for comparisons of CBT with waiting-list (1.53), placebo (0.93), and SRI with placebo (0.51) were significant, whereas CBT vs. SRI (0.22) and Combo (CBT+SRI) vs. CBT (0.14) were not. Regarding response rate CBT (70%) and Combo (66%) were significantly higher than SRI (49%), which was higher than placebo (29%) and WLC (13%). As for remission CBT (53%) and Combo (49%) were significantly higher than SRI (24%), placebo (15%), and WLC (10%), which did not differ from each other. Combo was not more effective than CBT alone irrespective of initial severity of the samples. The randomized controlled trials (RCTs) have a number of methodological problems and recommendations for improving research methodology are discussed as well as clinical implications of the findings.

Association between genetic variants of serotonergic and glutamatergic pathways and the concentration of neurometabolites of the anterior cingulate cortex in paediatric patients with obsessive-compulsive disorder

OBJECTIVES

The present study aimed to assess the relationship between variability in genes related to the pathophysiology of obsessive-compulsive disorder (OCD) and the concentration of different neurometabolites in the anterior cingulate cortex (ACC).

METHODS

We concomitantly assessed neurometabolite concentrations using 3-T (1)H-MRS and 262 single nucleotide polymorphism (SNPs) in 35 genes in 41 paediatric OCD patients.

RESULTS

There were significant associations, after Bonferroni correction, between the concentration of inositol, glutamate and glutamine, and total choline and five polymorphisms located in genes related to serotonin and glutamate (i.e., the vesicular monoamine transporter 1 gene, SLC18A1 [rs6586896]; the serotonin receptor 1B gene, HTR1B [rs6296 and rs6298]; and the glutamate receptor, ionotropic, AMPA1 gene, GRIA1 [rs707176 and rs2963944]).

CONCLUSIONS

The association observed between these polymorphisms and the neurometabolite concentrations could indicate the presence of a biological interaction between the serotonin and the glutamate pathways that could be involved in the pathophysiology of OCD. More studies with this methodology could increase our understanding of the aetiology and pathophysiology of OCD in children.

Developmental Neuroimaging in Pediatric Obsessive-Compulsive Disorder

Purpose of review

This review examines emerging neuroimaging research in pediatric obsessive compulsive disorder (OCD) and explores the possibility that developmentally sensitive mechanisms may underlie OCD across the lifespan.

Recent findings

Diffusion tensor imaging (DTI) studies of pediatric OCD reveal abnormal structural connectivity within frontal-striato-thalamic circuity (FSTC). Resting-state functional magnetic resonance imaging (fMRI) studies further support atypical FSTC connectivity in young patients, but also suggest altered connectivity within cortical networks for task-control. Task-based fMRI studies show that hyper- and hypo-activation of task control networks may depend on task difficulty in pediatric patients similar to recent findings in adults.

Summary

This review suggests that atypical neurodevelopmental trajectories may underlie the emergence and early course of OCD. Abnormalities of structural and functional connectivity may vary with age, while functional engagement during task may vary with age and task complexity. Future research should combine DTI, resting-state fMRI and task-based fMRI methods and incorporate longitudinal designs to reveal developmentally sensitive targets for intervention.

Online Obsessive-Compulsive Disorder Treatment: Preliminary Results of the "OCD? Not Me!" Self-Guided Internet-Based Cognitive Behavioral Therapy Program for Young People

BACKGROUND

The development and evaluation of Internet-delivered cognitive behavioral therapy (iCBT) interventions provides a potential solution for current limitations in the acceptability, availability, and accessibility of mental health care for young people with obsessive-compulsive disorder (OCD). Preliminary results support the effectiveness of therapist-assisted iCBT for young people with OCD; however, no previous studies have examined the effectiveness of completely self-guided iCBT for OCD in young people.

OBJECTIVE

We aimed to conduct a preliminary evaluation of the effectiveness of the OCD? Not Me! program for reducing OCD-related psychopathology in young people (12-18 years). This program is an eight-stage, completely self-guided iCBT treatment for OCD, which is based on exposure and response prevention.

METHODS

These data were early and preliminary results of a longer study in which an open trial design is being used to evaluate the effectiveness of the OCD? Not Me!

PROGRAM

Participants were required to have at least subclinical levels of OCD to be offered the online program. Participants with moderate-high suicide/self-harm risk or symptoms of eating disorder or psychosis were not offered the program. OCD symptoms and severity were measured at pre- and posttest, and at the beginning of each stage of the program. Data was analyzed using generalized linear mixed models.

RESULTS

A total of 334 people were screened for inclusion in the study, with 132 participants aged 12 to 18 years providing data for the final analysis. Participants showed significant reductions in OCD symptoms (P<.001) and severity (P<.001) between pre- and posttest.

CONCLUSIONS

These preliminary results suggest that fully automated iCBT holds promise as a way of increasing access to treatment for young people with OCD; however, further research needs to be conducted to replicate the results and to determine the feasibility of the program.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry (ANZCTR): ACTRN12613000152729; https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=363654 (Archived by WebCite at http://www.webcitation.org/ 6iD7EDFqH).

Challenges in developing drugs for pediatric CNS disorders: A focus on psychopharmacology

Many psychiatric and behavioral disorders manifest in childhood (attention deficit hyperactivity disorder, obsessive compulsive disorder, anxiety, depression, schizophrenia, autism spectrum disorder, etc.) and the opportunity for intervening early may attenuate full development of the disorder and lessen long term disability. Yet, pediatric drug approvals for CNS indications are limited, and pediatric testing generally occurs only after establishing adult efficacy, more as an afterthought rather than with the initial goal of developing the medication for a pediatric CNS indication. With pharmaceutical companies decreasing funding of their neuroscience research divisions overall, the prospects for moving promising investigational drugs forward into pediatrics will only decline. The goal of this review is to highlight important challenges around pediatric drug development for psychiatric disorders, specifically during clinical development, and to present opportunities for filling these gaps, using new strategies for de-risking investigational drugs in new clinical trial designs/models. We will first present the current trends in pediatric drug efficacy testing in academic research and in industry trials, we will then discuss the regulatory landscape of pediatric drug testing, including policies intended to support and encourage more testing. Obstacles that remain will then be presented, followed by new designs, funding opportunities and considerations for testing investigational drugs safely.

Clinical significance of psychiatric comorbidity in children and adolescents with obsessive-compulsive disorder: subtyping a complex disorder

A promising approach in relation to reducing phenotypic heterogeneity involves the identification of homogeneous subtypes of OCD based on age of onset, gender, clinical course and comorbidity. This study aims to assess the sociodemographic characteristics and clinical features of OCD patients in relation to gender and the presence or absence of another comorbid disorder. The sample comprised 112 children and adolescents of both sexes and aged 8-18 years, all of whom had a diagnosis of OCD. Overall, 67 % of OCD patients had one comorbid diagnosis, 20.5 % had two such diagnoses and 2.6 % had three comorbid diagnoses. The group of OCD patients with a comorbid neurodevelopmental disorder had significantly more family history of OCD in parents (p = .049), as compared with the no comorbidity group and the group with a comorbid internalizing disorder, and they also showed a greater predominance of males (p = .013) than did the group with a comorbid internalizing disorder. The group of OCD patients with internalizing comorbidity had a later age of onset of OCD (p = .001) compared with both the other groups. Although the initial severity was similar in all three groups, the need for pharmacological treatment and for hospitalization due to OCD symptomatology was greater in the groups with a comorbid neurodevelopmental disorder (p = .038 and p = .009, respectively) and a comorbid internalizing disorder (p = .008 and p = .004, respectively) than in the group without comorbidity. Our findings suggest that two subtypes of OCD can be defined on the basis of the comorbid pathology presented. The identification of different subtypes according to comorbidity is potentially useful in terms of understanding clinical variations, as well as in relation to treatment management and the use of therapeutic resources.

Evaluation of cognitive behaviour therapy for paediatric obsessive-compulsive disorder in the context of tic disorders

BACKGROUND AND OBJECTIVES

Paediatric obsessive-compulsive disorder (OCD) and tic disorders (TD) often present together. However, there has been relatively little research on whether comorbid tic disorders influence response to cognitive behaviour therapy (CBT) for OCD. This study aimed to examine the outcomes of CBT for paediatric patients with OCD and a tic disorder compared to a matched group of children with OCD and no tics. Outcomes were compared post-treatment and at 3 or 6 month follow-up.

METHODS

Participants were 29 young people with tic disorders and OCD (OCD + TD) and 29 young people with OCD without tic disorders (OCD-TD) who were matched according to age, gender and baseline OCD symptom severity. All participants received a course of CBT and outcomes were assessed using the Children's Yale-Brown Obsessive-Compulsive Scale (CY-BOCS).

RESULTS

OCD symptoms reduced over the course of CBT to an equivalent extent in the OCD + TD and OCD-TD groups. Response or remission rates did not differ significantly at either post-intervention or follow-up between those with OCD + TD and those with OCD-TD. For both groups, response rates were high - 72% of both groups were classified as responders post-intervention and, at follow-up, 81% of the OCD + TD group and 82% of the OCD no tics group responded. Those with OCD + TD responded in significantly fewer sessions than those with OCD without tics.

LIMITATIONS

A number of potential confounding factors were not assessed and therefore could not be controlled for, such as other comorbidities and stability of medication.

CONCLUSIONS

Paediatric patients with OCD and tic disorders respond equally well to standard CBT for OCD as compared to those with OCD and no tics.

Obsessive-compulsive symptoms in children and adolescents: symptomatology, impairment and quality of life

Although the "presence of obsessive-compulsive (OC) symptoms" and "OC-related impairment" are the main criteria to diagnose obsessive-compulsive disorder, the significance of symptomatology versus impairment in explaining quality of life remains unclear. The present study relies on two samples including 462 children (8-11 years old) and 265 children and adolescents (10-17 years old) and explores how self-ratings of specific OC symptoms and OC impairment are associated with father ratings of childhood quality of life. Hierarchical regression analysis was used to investigate the additive effect of OC impairment beyond OC symptomatology (and vice versa) in predicting quality of life. The results demonstrated that specific OC symptoms and OC impairment are differentially related to quality of life, underscoring the additive value of OC impairment beyond OC symptomatology, whereas the reverse was not the case. This finding highlights the importance of measuring impairment besides symptomatology to identify those OC features in childhood that are most significantly related to decreased quality of life.

Child-focused treatment of pediatric OCD affects parental behavior and family environment

This study aimed to investigate the impact of child-focused pediatric OCD treatment on parental anxiety, family accommodation and family environment. Forty-three parents (72.1% female, mean age±SD=43.1±5.6 years) were evaluated at baseline and after their children's (n=33, 54.5% female, mean age±SD=12.9±2.7 years) randomized treatment with Group Cognitive-Behavioral Therapy or fluoxetine for 14 weeks. Validated instruments were administered by trained clinicians. Parents were assessed with the State-Trait Anxiety Inventory (STAI), the Family Accommodation Scale (FAS) and the Family Environment Scale (FES). The Yale-Brown Obsessive-Compulsive Scale was administered to children. Significant findings after the children's treatment include decreased family accommodation levels (participation, modification and distress/consequences domains); increased cohesion and active-recreational components of the family environment. In addition, changes in the FAS distress/consequences and the FES cohesion subscores were correlated with the children's clinical improvement. These results suggest that child-focused OCD treatment may have a positive impact on family accommodation and family environment. Future studies should further clarify the reciprocal influences of pediatric OCD treatment and family factors.

Quality of life in children with OCD before and after treatment

Quality of life (QoL) is a well-established outcome measure. In contrast to adult obsessive-compulsive disorder (OCD), little is known about the effects of treatment on QoL in children with OCD. This study aimed to assess QoL after cognitive behavioural therapy (CBT) in children and adolescents with OCD compared with the general population and to explore factors associated with potential changes in QoL after treatment. QoL was assessed in 135 children and adolescents (ages 7-17; mean 13 [SD 2.7] years; 48.1% female) before and after 14 CBT sessions, using self-report and a caregivers proxy report of the Questionnaire for Measuring Health-related Quality of Life in Children and Adolescents (KINDL-R). QoL was compared with an age- and gender-matched sample from the general population. Before treatment, QoL was markedly lower in children with OCD compared with the general population. QoL improved significantly in CBT responders (mean score change 7.4), to the same range as QoL in the general population. Non-responders reported no QoL changes after treatment, except for one patient. Comorbidity, family accommodation and psychosocial functioning were not associated with changes in QoL after treatment. To our knowledge, this is the first study of the changes in QoL after treatment of paediatric OCD. The assessment of QoL beyond symptoms and function in children with OCD has been shown to be reliable and informative. The results of this study support the application of QoL assessment as an additional measure of treatment outcome in children and adolescents with OCD.

Sertraline Treatment of Nonresponders to Extended Cognitive-Behavior Therapy in Pediatric Obsessive-Compulsive Disorder

OBJECTIVE

The purpose of this study was to investigate the effect of sertraline (SRT) in children and adolescents with obsessive-compulsive disorder (OCD) who did not respond to two consecutive courses of cognitive-behavior therapy (CBT).

METHODS

Observational study with 11 participants (males, n=6), 7-17 years of age with Diagnostic and Statistical Manual of Mental Disorders, 4th ed. (DSM-IV) primary OCD. All had received 14 plus 10 sessions of CBT over the course of 218-532 days (mean=342.2, SD=85.5). Outcome measures were mean reduction of the Children's Yale-Brown Obsessive Compulsive Scale (CY-BOCS) total score and adequate clinical response (CY-BOCS<16). All participants received SRT (maximum dose 200 mg/day). The study was a part of the Nordic Long-Term OCD Treatment Study (NordLOTS).

RESULTS

Participants were treated with SRT over 72-300 days (mean=164.2, SD=68.3). The mean CY-BOCS score was reduced from 21.5 (SD=2.6) to 17.5 (SD=3.3). Only three participants obtained adequate clinical response (27.2%), and only two obtained >25% CY-BOCS total score reduction (close to 50%).

CONCLUSIONS

A clinical response in approximately one third of the participants suggests that SRT treatment might be beneficial to a minority of patients who have consistently failed CBT.

Research Review: Neuropsychological test performance in pediatric obsessive-compulsive disorder--a meta-analysis

BACKGROUND

Research into the neuropsychology of pediatric obsessive-compulsive disorder (OCD) reveals inconsistent results, limiting the ability to draw conclusions about possible neurocognitive deficits in youth with OCD. The aim of this study was to conduct a meta-analysis of the available literature.

METHODS

We identified 36 studies, of which 11 studies met inclusion criteria. Results were categorized into nine functional subdomains: planning, response inhibition/interference control, set shifting/cognitive flexibility, verbal memory, nonverbal memory, processing speed, working memory, visuospatial functions, and attention. For each domain, weighted pooled Hedges' g effect size was calculated using random model analyses.

RESULTS

Small effect sizes were found across all subdomains, none of which were found to be statistically significant.

DISCUSSION

Results indicate that youth with OCD do not exhibit noteworthy neuropsychological deficits. This is in line with recent suggestions that OCD may not be characterized by clinically meaningful neuropsychological impairments. However, the small number of available controlled studies highlights the urgent need for more neuropsychological research in this population, as well as for further exploration of the neurodevelopmental hypothesis in pediatric OCD. Finally, the relatively low persistence rates of OCD into adulthood should be taken under consideration, especially in the context of the putative neuropsychological performance differences between adult and pediatric OCD populations.

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.

Cognitive-behavioral therapy for obsessive-compulsive disorder: access to treatment, prediction of long-term outcome with neuroimaging

This article reviews issues related to a major challenge to the field for obsessive-compulsive disorder (OCD): improving access to cognitive-behavioral therapy (CBT). Patient-related barriers to access include the stigma of OCD and reluctance to take on the demands of CBT. Patient-external factors include the shortage of trained CBT therapists and the high costs of CBT. The second half of the review focuses on one partial, yet plausible aid to improve access - prediction of long-term response to CBT, particularly using neuroimaging methods. Recent pilot data are presented revealing a potential for pretreatment resting-state functional magnetic resonance imaging and magnetic resonance spectroscopy of the brain to forecast OCD symptom severity up to 1 year after completing CBT.

The place of and evidence for serotonin reuptake inhibitors (SRIs) for obsessive compulsive disorder (OCD) in children and adolescents: Views based on a systematic review and meta-analysis

Serotonin reuptake inhibiting drugs (SRI) have been used in the treatment of paediatric obsessive-compulsive disorder over the past 30 years. We performed a systematic review and meta-analysis of the literature to discuss the place of and evidence for the use of SRI in paediatric OCD, based on 14 publications of methodologically sound, randomized and controlled studies. Both SRI and specific SRIs were examined and comparisons of SRI, placebo, cognitive behaviour therapy (CBT), combined (COMBO) treatments (SRI+CBT) made to investigate their relative efficacy. Using the Cochrane methodology, and as measures of effect size mean difference and Hedge's g, SRIs proved to be superior to drug placebo, with a modest effect size. From direct comparisons of CBT and SRI treatments, we conclude that CBT has the superior efficacy. COMBO versus CBT shows that SRI treatment adds little to concomitant CBT, while COMBO shows favourable outcome versus SRI alone. In pre-trial partial treatment responders, those who failed a SRI had better outcome from adding CBT as compared to continuing a SRI. Those who failed CBT treatment did as well with continued CBT as with switching to a SRI. The studies of combinations and sequences of treatments need to be developed further.

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.