Exposure and response prevention with or without parent management training for children with obsessive-compulsive disorder complicated by disruptive behavior: a multiple-baseline across-responses design study

Predictive associations of executive functions and oppositional defiant problems and obsessive-compulsive problems in preschoolers

Oppositional defiant problems (ODP) and obsessive-compulsive problems (OCP) may co-occur in children, though the way they interact is not known. The aim of the study was to examine longitudinal associations between executive functions at age 3 and ODP, ODP dimensions, and OCP at age 6. The sample consisted of 622 preschoolers (50% were boys) from the general population. Executive functions were assessed by teachers using the Behavior Rating Inventory of Executive Functioning - Preschool version questionnaire when children were 3 years old, and ODP and OCP were informed by parents and teachers at the age of 6 years. Multiple linear regression analyses indicated that higher Inhibit and Emotional Control and lower Shift deficits were associated with higher ODP reported by teachers, while higher Shift but lower Inhibit deficits were related to higher OCP. Moreover, ODP and OCP shared difficulties on the Flexibility Index, which means that the capacity to modulate emotions and behavior according to contextual and environmental demands is compromised in both disorders. The findings inform etiology and prevention, pointing out not only the executive function specificities related to each problem, but also common cognitive challenges related to Flexibility. Young children could benefit from training and programs designed to improve executive function processes at an early age to prevent later behavioral difficulties.

Do single-case experimental designs lead to randomised controlled trials of cognitive behavioural therapy interventions for adolescent anxiety and related disorders recommended in the National Institute of Clinical Excellence guidelines? A systematic review

Background

Although Cognitive Behavioural Therapy (CBT) is effective for 60% of adolescents with anxiety disorders, only 36% are in remission post-intervention. This indicates that more effective treatments are needed which should be reflected in the NICE guidelines. We hypothesised that Single-case experimental designs (SCEDs) may provide a framework for accelerating the development of novel interventions. The primary purpose of this review was to investigate whether SCEDs are currently followed by randomised controlled trials (RCTs) of CBT intervention for adolescent anxiety disorders named in the NICE guidelines. The secondary objective was to investigate whether using SCEDs prior to RCTs could be a helpful approach.

Method

For the primary search of SCEDs five databases were used (PsycINFO, PubMed, PsycArticles, Web of Science and ProQuest). Nineteen articles met eligibility criteria including a total of 107 participants. For the secondary search of RCTs named in the NICE guidelines for adolescent anxiety disorders 53 articles met inclusion criteria and were included in the systematic review.

Results

The 19 SCED studies included in the review were conducted with participants with a diverse range of anxiety disorders and across a range of CBT formats. Two of the SCEDs were followed by RCTs, but neither of these were named in the NICE guidelines for anxiety disorders. All of the SCEDs identified were rated as low quality with none meeting the criteria for the highest or second highest quality rating. From the secondary searches, none of the RCTs named in the NICE guide were preceded by SCEDs.

Conclusions

It was concluded that currently SCEDs were not followed by RCTs of CBT interventions named in the NICE guidelines for adolescent anxiety disorders. However, it was suggested that SCEDs may provide an important framework for the development of more effective interventions for adolescents with anxiety.

Parent Management Training Augmentation to Address Coercive and Disruptive Behavior in Cognitive-Behavioral Therapy for Pediatric Obsessive-Compulsive Disorder

Coercive and disruptive behaviors commonly interfere with cognitive-behavioral therapy (CBT) trials among youths with obsessive-compulsive disorder (OCD). Although evidence supports parent management training (PMT) for reducing disruptive behavior, no group-based PMT interventions exist for OCD-related disruptive behaviors. We studied feasibility and effectiveness of group-based adjunctive PMT among non-randomized, OCD-affected families receiving family-based group CBT. Linear mixed models estimated treatment effects across OCD-related and parenting outcomes at post-treatment and 1-month follow-up. Treatment response for 37 families receiving CBT + PMT (M_age = 13.90) was compared to 80 families receiving only CBT (M_age = 13.93). CBT + PMT was highly accepted by families. Families who received CBT + PMT had improved disruptive behaviors, parental distress tolerance, and other OCD-related outcomes. OCD-related outcomes did not significantly differ between groups. Results support CBT + PMT as effective treatment for pediatric OCD that may not provide incremental benefits beyond CBT alone. Future research should determine feasible and effective ways to incorporate key PMT components into CBT-based interventions.

Relaxation training with and without Comprehensive Behavioral Intervention for Tics for Tourette's disorder: A multiple baseline across participants consecutive case series

BACKGROUND AND OBJECTIVES

Behavioral therapies such as the Comprehensive Behavioral Intervention for Tics (CBIT) are recommended as the first-line treatment for Tourette's Disorder. This treatment approach is comprised of three central components: habit reversal training, functional assessment/intervention, and relaxation training. Despite its combined efficacy, the contribution of each therapeutic component in CBIT for reducing tic severity remains undetermined. The study evaluated the efficacy of relaxation training alone or alongside other CBIT components for reducing tic severity.

METHODS

In this multiple-baseline study, participants completed a baseline assessment (A), 4 weekly sessions of relaxation training followed by a posttreatment assessment (B), 8 weekly sessions of CBIT followed by a posttreatment assessment (C), and a 1 month posttreatment follow up assessment (D). Six participants (83% male) aged 10-18 with Tourette's Disorder completed study procedures. Primary outcomes of tic severity was the Yale Global Tic Severity Scale (YGTSS).

RESULTS

A repeated measures ANOVA revealed a significance reduction in tic severity over time (p = .010). While post-hoc tests revealed a moderate non-significant reduction in tic severity after relaxation training (d =.23), large significant reductions in tic severity were observed after the combined treatment of relaxation training and CBIT (d = 1.17) that were maintained at a 1-month follow-up visit (d = 1.53).

LIMITATIONS

Findings are limited by the small sample size.

CONCLUSIONS

While relaxation training is effective when included in conjunction with CBIT, relaxation training alone is not effective in reducing tic severity in patients with Tourette's Disorder.

Overcoming barriers in cognitive-behavioral therapy for youth anxiety and obsessive-compulsive disorder: Addressing parent behaviors

Exposure-based cognitive-behavioral therapy (CBT) is a well-established treatment for anxiety disorders and obsessive-compulsive disorder (OCD) in youth. Although a majority of youth respond to CBT, a substantial portion remain symptomatic and/or experience a return of symptoms after completing a course of treatment. This highlights the need for further improvements to this evidence-based treatment. Given that parent behaviors can negatively influence treatment, addressing parental behaviors in CBT serves as a novel and promising treatment target to improve youth's therapeutic outcomes. The authors review three common parent behaviors that influence anxiety and treatment outcomes: family accommodation, parent anxious behaviors, and management of disruptive behaviors. The authors then discuss each behavior, its effect on anxiety/OCD and treatment, and how to address the behavior within the context of CBT. In doing so, therapeutic learning can be optimized to improve CBT outcomes for youth with anxiety disorders and/or OCD.

Specialty knowledge and competency standards for pharmacotherapy for pediatric obsessive-compulsive disorder

Evidence based treatments for pediatric Obsessive-Compulsive Disorder (OCD) are delivered with varying levels of expertise. This paper is part of the phase two series by the International OCD Accreditation Task Force (ATF) to advance a standardized high level of care globally. This paper presents specific knowledge and competencies recommended for specialized practice for pediatric psychopharmacologists working with OCD, developed by an international group of clinicians with extensive expertise in assessment and treatment of OCD. Tabulated knowledge and competency standards are operationalized as clinician abilities with specification of evidence for each standard. The distinction between current practice guidelines and ATF standards is discussed. Drug treatment has a solid evidence base. However, it should not be applied isolated, but informed by broad competence in general child and adolescent psychiatry and pediatrics. Other treatment relevant areas such as specialty CBT, family functioning, developmental issues, and neurobiology require consideration. Drug treatment includes several phases with varying degrees of evidence: Starting up medication, titration to maximum tolerated dose, maintenance, termination, and relapse prevention. In complex cases, pharmacotherapy with weak evidence may be needed to target symptoms and/or co-morbidity. The ATF knowledge and competency standards presented will be reviewed and updated commensurate with research.

Predictors of Parental Accommodation and Response Treatment in Young Children With Obsessive-Compulsive Disorder

Background: Cognitive-behavioral family-based treatment (CBFT) is the treatment standard in very young children with obsessive-compulsive disorder (OCD), which includes the same core components of cognitive-behavioral therapy (CBT) with significant family involvement. Although the latter reports high rates of remission, some children do not improve with treatments. Therefore, it is necessary to identify possible moderating variables such as comorbidity, severity of disorder, years of onset, parental anxiety, and parental accommodation. This study has two main aims: (1) to propose a predictive model on family accommodation (father and mother), taking into account variables related to the children (severity of obsessive-compulsive responses, internalizing and externalizing symptoms, and comorbidity) and with the parents before intervention (worry, accommodation of one parental member over the other) and (2) to examine the mediating role of externalizing symptoms and mother's accommodation in the relation between initial severity and improvement of severity of obsessive-compulsive responses in children aged 5-8 years. Methods: Participants comprised 56 children with OCD [mean = 6.61 (SD = 0.76)] and their parents; 79% of the sample was men. Treatment was implemented by two clinicians specialized in OCD (>15 years of experience). Clinicians were trained to administer CBT protocol in the same way. They were doctors of clinical psychology and researchers at the OCD. Results: Mother's accommodation was associated with child variables (Child Behavior Checklist-Externalizing and Initial Severity, Children's Yale-Brown Obsessive-Compulsive Scale). Father's accommodation could be explained by parent variables (mother's accommodation and worry). Simple mediation model tested using the SPSS macro PROCESS supported the relation of the initial severity of symptoms with that following intervention, through the simple indirect effect of externalizing symptoms of the child. Conclusions: Comorbidities with externalizing symptoms, father's worry, and mother's accommodation were variables that should be controlled in treatment of pediatric OCD.

Parents' Perceptions of Internalizing and Externalizing Features in Childhood OCD

Although obsessive-compulsive disorder (OCD) has often been characterized as an internalizing disorder, some children with OCD exhibit externalizing behaviors that are specific to their OCD. This study sought to demonstrate that parents perceive both internalizing and externalizing behaviors in childhood OCD by examining the factor structure of the Child Obsessive-Compulsive Externalizing/Internalizing Scale (COCEIS), a parent-report questionnaire intended to measure these constructs. This study also investigated clinical correlates of internalizing and externalizing factors in the COCEIS. A factor analysis of questionnaire responses from 122 parents of youth with OCD revealed both externalizing and internalizing factors in the COCEIS. Externalizing behaviors in childhood OCD were associated with other, co-occurring externalizing behavior problems, while both factors were positively correlated with OCD severity and co-occurring internalizing symptoms. They were positively associated with each other at a trend level, and neither showed a significant relationship with insight. Sixty-two percent of parents endorsed "often" or "always" to at least one externalizing item, though modal responses to items suggested that each individual feature captured by the COCEIS may be relatively uncommon. Mean responses were significantly greater for internalizing items. This study provides evidence for distinct but related externalizing and internalizing behaviors specific to childhood OCD. Treatment for children with OCD presenting with more externalizing behaviors may require a greater emphasis on behavioral parent training and motivational enhancement.

Coercive and disruptive behaviors mediate group cognitive-behavioral therapy response in pediatric obsessive-compulsive disorder

PURPOSE

Coercive and disruptive behaviors (CDBs) are commonplace in pediatric obsessive-compulsive disorder (OCD) and are associated with increased disorder impact and reduced treatment response. Prior research suggests that CDBs mediate the cross-sectional relationship between family accommodation and OCD symptom severity; however, the impact of reducing CDBs on other treatment outcomes has yet to be studied.

METHODS

Participants comprised 49 OCD-affected youth (42.9% male, M_age at baseline = 13.7) and their parent(s) who completed a 12-week, group family-based cognitive-behavioral treatment at an OCD specialty clinic. Outcomes included parent-report measures of CDBs, family accommodation, symptom severity, and both child- and family-level impairment. Descriptive, correlation, and regression analyses were followed by tests of indirect effects (mediation).

RESULTS

Changes in all outcome variables had moderate to strong correlations with each other. As hypothesized, CDB decreases predicted positive changes in OCD severity as well as in child and family impairment. Further, whereas improvement in OCD severity predicted changes in child and family impairment, improvements in family accommodation were not directly predictive of any outcomes. Consistent with hypotheses, changes in CDBs mediated relationships between changes in accommodation and child- and family-level impairment, as well as relationships between changes in OCD severity and both levels of impairment. Additional exploratory analyses found that changes in symptom severity significantly mediated relationships between changes in CDBs and both levels of impairments.

CONCLUSIONS

Findings suggest that attention to reducing CDBs is warranted in the treatment of pediatric OCD, and that accommodation reductions lead to meaningful improvements in child and family functioning only when CDBs and/or symptoms are also reduced. Future family-based treatments may benefit from inclusion of components specifically targeting CDBs that occur within the context of accommodating OCD symptoms.

Quality of Life in Children and Youth with Obsessive-Compulsive Disorder

OBJECTIVE

The study examined clinical correlates of quality of life (QoL), impact of treatment on QoL, and predictors of QoL change among children with obsessive-compulsive disorder (OCD).

METHODS

One hundred forty-two children with primary OCD who were enrolled as part of a larger clinical trial participated. Children were administered a structured diagnostic interview, as well as clinician-administered measures of OCD and depression symptom severity. Children and parents completed reports of QoL, as well as measures of impairment and internalizing and externalizing symptoms. Youth received 10 sessions of family-based cognitive-behavioral therapy (CBT).

RESULTS

At baseline, QoL was inversely related to obsessive-compulsive symptom severity, impairment, externalizing and internalizing symptoms, and severity of depression symptoms according to children and parents. After CBT, QoL improved according to parent ratings, but not child ratings. None of the predictors examined were associated with changes in QoL scores over time. Impairment, and externalizing and internalizing symptoms predicted QoL after accounting for OCD symptom severity. After accounting for OCD symptoms, externalizing symptoms inversely predicted changes in QoL.

CONCLUSION

These data suggest that QoL is related to more severe clinical presentation and improves with evidence-based treatment, but QoL improvements may be inversely related to externalizing symptomology.

Clinical Management of Pediatric Acute-Onset Neuropsychiatric Syndrome: Part I-Psychiatric and Behavioral Interventions

OBJECTIVE

This article outlines the consensus guidelines for symptomatic treatment for children with Pediatric Acute-Onset Neuropsychiatric Syndrome (PANS) and Pediatric Autoimmune Neuropsychiatric Syndrome Associated with Streptococcal Infection (PANDAS).

METHODS

Extant literature on behavioral, psychotherapeutic, and psychopharmacologic treatments for PANS and PANDAS was reviewed. Members of the PANS Research Consortium pooled their clinical experiences to find agreement on treatment of PANS and PANDAS symptoms.

RESULTS

Current guidelines result from consensus among the Consortium members.

CONCLUSION

While underlying infectious and inflammatory processes in PANS and PANDAS patients are treated, psychiatric and behavioral symptoms need simultaneous treatment to decrease suffering and improve adherence to therapeutic intervention. Psychological, behavioral, and psychopharmacologic interventions tailored to each child's presentation can provide symptom improvement and improve functioning during both the acute and chronic stages of illness. In general, typical evidence-based interventions are appropriate for the varied symptoms of PANS and PANDAS. Individual differences in expected response to psychotropic medication may require marked reduction of initial treatment dose. Antimicrobials and immunomodulatory therapies may be indicated, as discussed in Parts 2 and 3 of this guideline series.

Behavioral Interventions for Anger, Irritability, and Aggression in Children and Adolescents

OBJECTIVE

Anger, irritability, and aggression are among the most common reasons for child mental health referrals. This review is focused on two forms of behavioral interventions for these behavioral problems: Parent management training (PMT) and cognitive-behavioral therapy (CBT).

METHODS

First, we provide an overview of anger/irritability and aggression as the treatment targets of behavioral interventions, followed by a discussion of the general principles and techniques of these treatment modalities. Then we discuss our current work concerning the transdiagnostic approach to CBT for anger, irritability, and aggression.

RESULTS

PMT is aimed at improving aversive patterns of family interactions that engender children's disruptive behavior. CBT targets deficits in emotion regulation and social problem-solving that are associated with aggressive behavior. Both forms of treatment have received extensive support in randomized controlled trials. Given that anger/irritability and aggressive behavior are common in children with a variety of psychiatric diagnoses, a transdiagnostic approach to CBT for anger and aggression is described in detail.

CONCLUSIONS

PMT and CBT have been well studied in randomized controlled trials in children with disruptive behavior disorders, and studies of transdiagnostic approaches to CBT for anger and aggression are currently underway. More work is needed to develop treatments for other types of aggressive behavior (e.g., relational aggression) that have been relatively neglected in clinical research. The role of callous-unemotional traits in response to behavioral interventions and treatment of irritability in children with anxiety and mood disorders also warrants further investigation.

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.

A Cognitive-Behavioral Approach for Anxiety in a Preschool-Aged Child With Autism Spectrum Disorder

Empirical support exists for behaviorally oriented psychosocial interventions to reduce functional impairment related to autism spectrum disorder (ASD) symptoms in young children, but little research exists examining the effectiveness of such treatments when applied to preschool-aged children with comorbid anxiety symptoms. With this in mind, the authors report on the case of “Marcus,” a 4-year-old boy with autistic disorder and impairing comorbid anxiety. Marcus participated in 8 weekly sessions of family-based cognitive-behavioral therapy, addressing his fear-based avoidance of social interactions and sensory stimuli, using an anxiety treatment protocol for youth with ASD modified to account for his young age. This protocol consisted of modular components addressing affective education, exposure, cognitive restructuring, and social coaching. At post-treatment assessment, Marcus exhibited markedly decreased impairment, as evidenced by parent responses to clinical interview and rating scales. In addition, Marcus displayed improvement in severity of anxiety symptoms as illustrated by a decrease in his scores on the Pediatric Anxiety Rating Scale from 17 at baseline to 8 at post-treatment. Therapeutic gains were maintained at 4-month follow-up. Implications and clinical considerations are 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.

Cognitive-behavioral therapy for anxiety in children with high-functioning autism: a meta-analysis

BACKGROUND

Anxiety is a common and impairing problem in children and adolescents with autism spectrum disorder (ASD). There is emerging evidence that cognitive-behavioral therapy (CBT) could reduce anxiety in children with high-functioning ASD.

OBJECTIVE

To systematically review the evidence of using CBT to treat anxiety in children and adolescents with ASD. Methods for this review were registered with PROSPERO (CRD42012002722).

METHODS

We included randomized controlled trials published in English in peer-reviewed journals comparing CBT with another treatment, no treatment control, or waitlist control. Two authors independently screened 396 records obtained from database searches and hand searched relevant journals. Two authors independently extracted and reconciled all data used in analyses from study reports.

RESULTS

Eight studies involving 469 participants (252 treatment, 217 comparison) met our inclusion criteria and were included in meta-analyses. Overall effect sizes for clinician- and parent-rated outcome measures of anxiety across all studies were d = 1.19 and d = 1.21, respectively. Five studies that included child self-report yielded an average d = 0.68 across self-reported anxiety.

CONCLUSIONS

Parent ratings and clinician ratings of anxiety are sensitive to detecting treatment change with CBT for anxiety relative to waitlist and treatment-as-usual control conditions in children with high-functioning ASD. Clinical studies are needed to evaluate CBT for anxiety against attention control conditions in samples of children with ASD that are well characterized with regard to ASD diagnosis and co-occurring anxiety symptoms.

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.

Family-Based Behavioral Treatment of Pediatric Compulsive Hoarding

Although compulsive hoarding may pose health, social, and developmental impairment for children, there are few phenomenological and treatment studies to guide assessment and treatment. Current evidence-based questions the link between hoarding and obsessive compulsive disorder (OCD) and the effectiveness of cognitive behavioral therapy protocols for OCD to adequately address the unique challenges of poor insight, poor emotion regulation, and increased family accommodation in children with compulsive hoarding. This case study seeks to illustrate a family-based behavioral approach to outpatient treatment of compulsive hoarding with a 9-year-old girl (pseudonym Lily). Treatment included psychoeducation, exposure to discarding items, exposure to acquiring cues, and parent behavior management techniques.