Internet-based cognitive behavioral therapy in children and adolescents with obsessive compulsive disorder: a feasibility study

Cognitive behavioral therapy for pediatric obsessive-compulsive disorder delivered via internet videoconferencing: a manualized sensor-assisted feasibility approach

BACKGROUND

Between 1 and 4% of children and adolescents suffer from obsessive-compulsive disorder (OCD) worldwide, but the majority of these young people do not have access to cognitive behavioral therapy (CBT) as a first-line treatment. CBT delivered via online videoconferencing (vCBT) offers a new way to provide young people with therapy, especially in the home environment where symptoms usually occur.

METHODS

In this study, we investigated the feasibility of a newly revised vCBT manual, symptom change during treatment, and effects on family life and social functioning. 20 patients with OCD, aged 12-18 years, were treated during 14 weekly sessions while using a multimodal sensor system that assessed their physiological and behavioral responses during therapy. Treatment was delivered in real time via an online videoconferencing platform. Measurements of feasibility, acceptance, and implementation were evaluated descriptively, and clinical measures were assessed with t tests.

RESULTS

The primary results showed that patients and parents perceived the manual-based vCBT as feasible and easy to understand. According to the therapists' ratings, all treatment modules and the content could be carried out in accordance with the manual. As a secondary outcome, OCD symptoms improved significantly during treatment (p <.001, d = 1.87), revealed by an average decrease of more than half in the Children's Yale-Brown Obsessive-Compulsive Scale (CY-BOCS) score. As the psychotherapy could be implemented directly in the patients' home environment, low barriers to participation were reported, and the majority of participants reported improvements in family life after treatment.

CONCLUSIONS

In summary, the results of this feasibility study indicated a successful application of manual-based psychotherapy delivered via videoconferencing for pediatric OCD supported by a sensor system. This method should be further investigated in future randomized controlled trials with larger patient samples.

CLINICAL TRIAL REGISTRATION

[ www.

CLINICALTRIALS

gov ], identifier [NCT05291611], first submission: 2021-12-10.

Examining the Effectiveness of an Intensive Telemental Health Treatment for Pediatric Anxiety and OCD During the COVID-19 Pandemic and Pediatric Mental Health Crisis

Despite research supporting the efficacy of weekly outpatient videoconferencing-based cognitive behavioral therapy (VCBT), limited evidence exists about the benefits of leveraging VCBT for brief intensive formats. We examined the effectiveness of an intensive outpatient VCBT targeting pediatric anxiety and OCD. Quasi-experimental design was used to compare outcomes of intensive, in-person, group-based cognitive-behavioral therapy with medication management and caregiver guidance pre-pandemic, to a similar VCBT peri-pandemic (n = 130). Pretreatment and posttreatment assessments included patient- and caregiver-report of anxiety and functional impairment. Analyses of covariance were conducted, examining changes in anxiety and impairment between treatment groups, controlling for admission levels. No significant differences in posttreatment anxiety or impairment were observed between conditions. This study illustrates that intensive, group-based treatment for pediatric anxiety and OCD using VCBT is associated with comparable reductions in anxiety and impairment. It marks a crucial step toward providing broader access to quality care for youth in need.

Lessons learned from a multimodal sensor-based eHealth approach for treating pediatric obsessive-compulsive disorder

Introduction

The present study investigates the feasibility and usability of a sensor-based eHealth treatment in psychotherapy for pediatric obsessive-compulsive disorder (OCD), and explores the promises and pitfalls of this novel approach. With eHealth interventions, therapy can be delivered in a patient's home environment, leading to a more ecologically valid symptom assessment and access to experts even in rural areas. Furthermore, sensors can help indicate a patient's emotional and physical state during treatment. Finally, using sensors during exposure with response prevention (E/RP) can help individualize therapy and prevent avoidance behavior.

Methods

In this study, we developed and subsequently evaluated a multimodal sensor-based eHealth intervention during 14 video sessions of cognitive-behavioral therapy (CBT) in 20 patients with OCD aged 12-18. During E/RP, we recorded eye movements and gaze direction via eye trackers, and an ECG chest strap captured heart rate (HR) to identify stress responses. Additionally, motion sensors detected approach and avoidance behavior.

Results

The results indicate a promising application of sensor-supported therapy for pediatric OCD, such that the technology was well-accepted by the participants, and the therapeutic relationship was successfully established in the context of internet-based treatment. Patients, their parents, and the therapists all showed high levels of satisfaction with this form of therapy and rated the wearable approach in the home environment as helpful, with fewer OCD symptoms perceived at the end of the treatment.

Discussion

The goal of this study was to gain a better understanding of the psychological and physiological processes that occur in pediatric patients during exposure-based online treatment. In addition, 10 key considerations in preparing and conducting sensor-supported CBT for children and adolescents with OCD are explored at the end of the article. This approach has the potential to overcome limitations in eHealth interventions by allowing the real-time transmission of objective data to therapists, once challenges regarding technical support and hardware and software usability are addressed.

Clinical Trial Registration

www.ClinicalTrials.gov, identifier (NCT05291611).

Hybrid approaches to allied health services for children and young people: a scoping review

BACKGROUND

Hybrid models that integrate both in-person and remote health services are increasingly recognized as a promising approach. Nevertheless, research that defines and characterizes these models in children and young people is scarce and essential for establishing guidelines for implementation of hybrid allied health services. This scoping review evaluates four key aspects of hybrid allied health services in children and young people: 1. definitions, 2. service characteristics, 3. outcome measures, and 4. results of hybrid allied health services.

METHODS

Six databases were searched: Medline (Ovid), Embase, CINHAL, Psycinfo, Cochrane CENTRAL, and Web of Science. Of the 9,868 studies potentially meeting the inclusion criteria, 49 studies focused on children and young people. Following full-text review, n = 21 studies were included.

RESULTS

Terminology used for hybrid allied health services varied across studies which targeted diverse clinical populations and varied in study design, type and frequency of remote and in-person treatments. Over 75% of cases used custom-written software, limiting scalability. All interventions started in-person, possibly to establish a therapeutic alliance and solve technological issues. Most hybrid allied health services (67%) were in mental health, while only a minority involved physical, occupational or speech therapy. The most common outcomes were feasibility and satisfaction, but tools used to measure them were inconsistent. Although 57% of studies demonstrated effectiveness of hybrid allied health services, none measured cost-effectiveness.

DISCUSSION

Despite the potential of hybrid allied health services for children and young people, the literature remains at a preliminary stage. Standardization of definitions and outcome measures, and clearer reporting of service characteristics and results would likely promote consolidation of hybrid allied health services in children and young people into clinical practice.

The SSTeP-KiZ System-Secure Real-Time Communication Based on Open Web Standards for Multimodal Sensor-Assisted Tele-Psychotherapy

In this manuscript, we describe the soft- and hardware architecture as well as the implementation of a modern Internet of Medical Things (IoMT) system for sensor-assisted telepsychotherapy. It enables telepsychotherapy sessions in which the patient exercises therapy-relevant behaviors in their home environment under the remote supervision of the therapist. Wearable sensor information (electrocardiogram (ECG), movement sensors, and eye tracking) is streamed in real time to the therapist to deliver objective information about specific behavior-triggering situations and the stress level of the patients. We describe the IT infrastructure of the system which uses open standards such as WebRTC and OpenID Connect (OIDC). We also describe the system's security concept, its container-based deployment, and demonstrate performance analyses. The system is used in the ongoing study SSTeP-KiZ (smart sensor technology in telepsychotherapy for children and adolescents with obsessive-compulsive disorder) and shows sufficient technical performance.

Webcam-Based Online Coaching with Children and Adolescents with Obsessive-Compulsive Disorders – A Single-Case Study

Abstract. Objective: Although there is clear evidence-based knowledge regarding state-of-the-art treatment for pediatric obsessive-compulsive disorder (OCD), two main issues remain in clinical practice: (1) Exposure-based cognitive behavioral therapy (CBT) is limited in terms of availability and accessibility or is not adequately provided, and (2) despite large effect sizes of exposure-based CBT, the achieved recovery rates of 50–60 % still show room for improvement. These issues have prompted an increasing focus on delivering exposure-based CBT in new and innovative ways. This study aims to evaluate an intensive therapist-administered online coaching program consisting of exposure with response prevention via video teleconferencing (VTC) as an add-on to weekly outpatient CBT (blended therapy). Method: The blended therapy is examined in n = 5 children and adolescents with OCD using an AB design and multi-informant ratings. Results: This single-case study shows promising results, indicating that a decrease in OCD severity and related functional impairment can be attributed to blended therapy. Moreover, satisfaction with online coaching was high. Conclusions: Despite some principal limitations, the results support the effectiveness and feasibility of blended therapy.

Multimodal Sensor-Based Identification of Stress and Compulsive Actions in Children with Obsessive-Compulsive Disorder for Telemedical Treatment

In modern psychotherapy, digital health technology offers advanced and personalized therapy options, increasing availability as well as ecological validity. These aspects have proven to be highly relevant for children and adolescents with obsessive-compulsive disorder (OCD). Exposure and Response Prevention therapy, which is the state-of-the-art treatment for OCD, builds on the reconstruction of everyday life exposure to anxious situations. However, while compulsive behavior pre-dominantly occurs in home environments, exposure situations during therapy are limited to clinical settings. Telemedical treatment allows to shift from this limited exposure reconstruction to exposure situations in real life. In the SSTeP KiZ study (smart sensor technology in telepsychotherapy for children and adolescents with OCD), we combine video therapy with wearable sensors delivering physiological and behavioral measures to objectively determine the stress level of patients. The setup allows to gain information from exposure to stress in a realistic environment both during and outside of therapy sessions. In a first pilot study, we explored the sensitivity of individual sensor modalities to different levels of stress and anxiety. For this, we captured the obsessive-compulsive behavior of five adolescents with an ECG chest belt, inertial sensors capturing hand movements, and an eye tracker. Despite their prototypical nature, our results deliver strong evidence that the examined sensor modalities yield biomarkers allowing for personalized detection and quantification of stress and anxiety. This opens up future possibilities to evaluate the severity of individual compulsive behavior based on multi-variate state classification in real-life situations. Clinical Relevance- Our results demonstrate the potential for efficient personalized psychotherapy by monitoring physiological and behavioral changes with multiple sensor modalities in ecologically valid real-life scenarios.

Internet-based psychotherapy in children with obsessive-compulsive disorder (OCD): protocol of a randomized controlled trial

Background

Obsessive-compulsive disorder (OCD) in children can lead to a huge burden on the concerned patients and their family members. While successful state-of-the art cognitive behavioral interventions exist, there is still a lack of available experts for treatment at home, where most symptoms manifest. Internet-based cognitive behavioral therapy (iCBT) could overcome these restrictions; however, studies about iCBT in children with OCD are rare and mostly target computerized self-help resources and only email contact with the therapist. Therefore, we intended to build up and to evaluate an iCBT approach for children with OCD, replacing successful elements of traditional in-office face-to-face CBT, with face-to-face teleconferences, online materials, and apps.

Methods

With the help of a pilot feasibility study, we developed the iCBT consisting of 14 teleconference sessions with the child and parents. The sessions are supported by an app assessing daily and weekly symptoms and treatment course completed by children and parents. Additionally, we obtain heart rate and activity scores from the child via wristbands during several days and exposure sessions. Using a waiting list randomized control trial design, we aim to treat and analyze 20 children with OCD immediately after a diagnostic session whereas the control group of another set of 20 OCD patients will be treated after waiting period of 16 weeks. We will recruit 30 patients in each group to take account for potential dropouts. Outcomes for the treatment group are evaluated before randomization (baseline, t0), 16 weeks (end of treatment, t1), 32 weeks (follow-up 1, t2), and 48 weeks after randomization (follow-up 2, t3). For the waiting list group, outcomes are measured before the first randomization (baseline), at 16 weeks (waiting list period), 32 weeks (end of treatment), 48 weeks after the first randomization (follow-up I), and 64 weeks after the first randomization (follow-up II).

Discussion

Based on our experience of feasibility during the pilot study, we were able to develop the iCBT approach and the current study will investigate treatment effectiveness. Building up an iCBT approach, resembling traditional in-office face-to-face therapy, may ensure the achievement of well-known therapy effect factors, the acceptance in both patients and clinicians, and the wide distribution within the health system.

Trial registration

ClinicalTrials.govNCT05037344. Registered May 2019, last release August 13th, 2021.

Internet-based cognitive behavioral therapy in children and adolescents with obsessive-compulsive disorder: A randomized controlled trial

OBJECTIVES

Obsessive-compulsive disorder (OCD) in childhood and adolescence often leads to significant impairment in various areas of life and has a high risk of becoming chronic. Cognitive behavioral therapy (CBT) is the recommended first-line treatment, but it is too rarely implemented in accordance with guidelines and is often not available close to the patient's home. Importantly, internet-based CBT could help to reduce this gap in care. Having previously successfully demonstrated the feasibility of an internet-based CBT approach, we aimed to assess its effectiveness in a waiting list controlled randomized trial.

METHODS

Children and adolescents aged 6-18 years with a principal diagnosis of OCD received 14 sessions of therapist-delivered CBT via videoconference distributed over 16 weeks. After inclusion, participants were randomly assigned to either the treatment or waiting list group. Participants in the treatment group began treatment immediately after baseline diagnostics, and participants in the waiting list group began treatment after a 16-week waiting period. The primary outcome was a pre-post comparison of OCD symptoms as measured with the Children's Yale-Brown Obsessive Compulsive Scale (CY-BOCS). Additionally, remission was an important outcome measure. Follow-up assessments were conducted for all measures 16 and 32 weeks after completion of treatment.

RESULTS

A total of 60 children and adolescents were included into the analyses. Over the course of the treatment, OCD symptoms according to the CY-BOCS significantly decreased in the treatment group compared to the waiting-list control group. Cohen's d between groups was 1.63. After the patients in the waiting list group also received the treatment, the OCD symptoms decreased significantly in this group as well. This improvement of symptoms increased over the course of the follow-up assessments. Remission rate peaked at the 32-week follow-up, with 68% in the treatment group and 79% in the waiting list group. Importantly, patient satisfaction with treatment was high to very high.

CONCLUSION

In our study, OCD symptoms decreased significantly and remission rate was high after internet-based CBT. Those effects were comparable to those found in studies of face-to-face treatment. Although further evidence is needed, these are early indications that our approach may be a viable way to provide access to adequate treatment for children and adolescents affected by OCD.

CLINICAL TRIAL REGISTRATION

[www.ClinicalTrials.gov], identifier [NCT05037344].