Dysregulation in pediatric obsessive compulsive disorder

Resting State Psychophysiology in Youth with OCD and Their Caregivers: Preliminary Evidence for Trend Synchrony and Links to Family Functioning

The burden of OCD in children and adolescents extends to their caregivers. Prior work in other disorders and unaffected youth has found synchrony in psychophysiological arousal for youth-caregiver dyads. This preliminary study explored whether psychophysiological trend synchrony in youth-caregiver dyads (N = 48) occurred and was moderated by youth OCD diagnosis. We also explored whether psychophysiological indices (i.e., electrodermal activity, heart rate, respiratory sinus arrhythmia) were correlated with reported family functioning in the OCD subsample (n = 25). Youth with OCD had higher resting heart rate than unaffected peers; this was not replicated in caregivers. Trend synchrony was found across the full sample of dyads for electrodermal activity and heart rate, with no moderation by diagnostic group. In the OCD group, youth heart rate was correlated with family conflict and caregiver heart rate with expressiveness. Findings provide preliminary support for further examination of heart rate and family factors in OCD-affected youth and their caregivers.

Family Accommodation in Pediatric Obsessive-Compulsive Disorder: Investigating Prevalence and Clinical Correlates in the NordLOTS Study

Family accommodation (FA) involves the actions taken by family members, particularly parents, to accommodate a child´s obsessive-compulsive disorder (OCD) symptoms, reducing distress or impairment. This behavior may maintain compulsive and avoidant behavior, preventing corrective learning or habituation. This study aims to investigate the prevalence and factors influencing FA in a large Scandinavian sample of children with OCD. We assessed 238 children using standardized diagnostic interviews, OCD symptom severity assessments and questionnaires evaluating functional impairment and internalizing and externalizing symptoms. FA was measured using the Family Accommodation Scale, a 12-item clinician-rated interview. Our results confirmed a high frequency of accommodation, with approximately 70% of primary caregivers reporting some accommodation daily and 98% at least once per week. FA was associated with increased OCD symptom severity, contamination/cleaning symptoms, internalizing and externalizing behavior, and functional impairment. Linear regression analysis showed that high levels of FA are specifically associated with lower age, higher OCD symptom severity, parent-reported impairment, internalizing, and externalizing symptoms. A path analysis revealed that FA partially mediated the relationship between OCD severity, externalizing symptoms, and child's age, highlighting the role of FA in the progression of OCD and related symptoms. The findings emphasize the importance of evaluating FA before initiating treatment and specifically addressing it during the therapeutic process.

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.

Anger Outbursts in Youth with ASD and Anxiety: Phenomenology and Relationship with Family Accommodation

Anger outbursts (AO) are associated with severe symptoms, impairment and poorer treatment outcomes for anxious children, though limited research has examined AO in youth with co-occurring autism and anxiety disorders. This study examined AO in children with autism and anxiety by evaluating clinical characteristics, family accommodation, and changes in AO following anxiety-focused treatment. The sample comprised 167 youth with autism and anxiety enrolled in a multi-site randomized clinical trial comparing standard care CBT for anxiety, CBT adapted for youth with autism, and usual care. Most participants (60%) had AO, which contributed to impairment above and beyond anxiety and autism. AO impacted functional impairment indirectly through a pathway of parental accommodation. AO reduced with anxiety-focused treatment. Findings highlight that AO are common in this population and uniquely contribute to functional impairment, indicating a need for direct targeting in treatment.

A Survey of Demographics, Symptom Course, Family History, and Barriers to Treatment in Children with Pediatric Acute-Onset Neuropsychiatric Disorders and Pediatric Autoimmune Neuropsychiatric Disorder Associated with Streptococcal Infections

Objective: Few large-scale studies of pediatric acute-onset neuropsychiatric syndrome (PANS) and pediatric autoimmune neuropsychiatric disorder associated with streptococcal infections (PANDAS) have been conducted, and thus demographic data on these conditions are limited. The current study describes comorbid medical and psychiatric conditions in a self-referred cohort of children with PANS/PANDAS, along with treatment history, barriers to treatment, family medical and psychiatric history, and perceived caregiver burden in these conditions. Methods: A total of 441 primary caregivers of patients with infection-triggered PANS/PANDAS under the age of 18 were included in this online anonymous survey, reporting on a total of 490 children (due to some caregivers reporting multiple children in the family with PANS/PANDAS). Data were collected between July 2018 and May 2019. Primary caregivers completed questions pertaining to patient demographics, symptom presentation, disease course, family medical and psychiatric history, and severity of patients' obsessive-compulsive disorder (OCD) symptoms. Results: OCD was the most common psychiatric symptom reported in children at the onset of PANS/PANDAS (83.06%), along with a high percentage of medical and psychiatric comorbidities. Most psychiatric comorbidities began or worsened at the onset of PANS/PANDAS symptoms, while major depressive disorder was the most frequently reported psychiatric disorder to develop after PANS/PANDAS onset (10%). A high frequency of autoimmune and inflammatory conditions was reported in family members, with nearly 30% of mothers endorsing one or more autoimmune conditions (29.95%). Mean caregiver burden (Caregiver Burden Inventory; M = 44.0) fell above the "burnout" level, and standardized measures showed mildly elevated levels of depression, anxiety, and stress in caregivers (Depression, Anxiety, and Stress Scale-21; M = 11.85, 7.16, and 15.56, respectively). Conclusions: Primary caregivers of children with PANS/PANDAS reported a multitude of medical and psychiatric comorbidities in their children, along with a high frequency of autoimmune and psychiatric conditions in family members. Obsessive-compulsive symptoms were the most frequently reported psychiatric symptom. Caregivers of these patients experience elevated levels of burden, stress, anxiety, and depression. Further research is needed to better understand the varied disease course in PANS/PANDAS and to develop interventions to reduce caregiver burden in these disorders.

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.

Dysregulation in children: Origins and implications from age 5 to age 28

Research shows that childhood dysregulation is associated with later psychiatric disorders. It does not yet resolve discrepancies in the operationalization of dysregulation. It is also far from settled on the origins and implications of individual differences in dysregulation. This study tested several operational definitions of dysregulation using Achenbach attention, anxious/depressed, and aggression subscales. Individual growth curves of dysregulation were computed, and predictors of growth differences were considered. The study also compared the predictive utility of the dysregulation indexes to standard externalizing and internalizing indexes. Dysregulation was indexed annually for 24 years in a community sample (n = 585). Hierarchical linear models considered changes in dysregulation in relation to possible influences from parenting, family stress, child temperament, language, and peer relations. In a test of the meaning of dysregulation, it was related to functional and psychiatric outcomes in adulthood. Dysregulation predictions were further compared to those of the more standard internalizing and externalizing indexes. Growth curve analyses showed strong stability of dysregulation. Initial levels of dysregulation were predicted by temperamental resistance to control, and change in dysregulation was predicted by poor language ability and peer relations. Dysregulation and externalizing problems were associated with negative adult outcomes to a similar extent.

Family accommodation of anxiety symptoms in youth undergoing intensive multimodal treatment for anxiety disorders and obsessive-compulsive disorder: Nature, clinical correlates, and treatment response

BACKGROUND

Family accommodation is associated with a range of clinical features including symptom severity, functional impairment, and treatment response. However, most previous studies in children and adolescents investigated family accommodation in samples of youth with obsessive-compulsive disorder (OCD) or anxiety disorders receiving non-intensive outpatient services.

AIMS

In this study, we aimed to investigate family accommodation of anxiety symptoms in a sample of youth with clinical anxiety levels undergoing an intensive multimodal intervention for anxiety disorders or OCD.

PROCEDURES

We first assessed the internal consistency of the Family Accommodation Scale - Anxiety (FASA). We next examined family accommodation presentation and correlates.

RESULTS

The FASA showed high internal consistency for all subscales and total score, and good item and subscale correlations with the total score. All parents reported at least mild accommodation, and the mean levels of family accommodation were particularly high. Child age, anxiety severity, and comorbid depressive symptoms predicted baseline accommodation. However, the association between anxiety severity and family accommodation no longer remained significant after adding the other factors to the model. In addition, family accommodation partially mediated the relationship between anxiety severity and functional impairment. Finally, post-treatment changes in family accommodation predicted changes in symptom severity and functional impairment.

CONCLUSIONS

These findings suggest the FASA is an appropriate tool to assess family accommodation in intensive treatment samples. Further, they underline the importance of addressing family accommodation in this population given the particularly high levels of accommodating behaviors and the evidence for adverse outcomes associated with this feature.

Normative development of the Child Behavior Checklist Dysregulation Profile from early childhood to adolescence: Associations with personality pathology

The Dysregulation Profile (DP) is a broad indicator of concurrent affective, behavioral, and cognitive dysregulation, often measured with the anxious/depressed, aggressive behavior, and attention problems syndrome scales of the Child Behavior Checklist. Despite an expanding body of research on the DP, knowledge of the normative developmental course of the DP from early childhood to adolescence is lacking. Furthermore, although we know that the DP longitudinally predicts personality pathology, no research yet has examined whether next to the DP in early childhood, the rate of change of the DP across development predicts personality pathology. Therefore, using cohort-sequential latent growth modeling in a population-based sample (N = 668), we examined the normative developmental course of mother-reported DP from ages 4 to 17 years and its associations with a wide range of adolescent-reported personality pathology dimensions 3 years later. The results showed that the DP follows a nonlinear developmental course with a peak in early adolescence. The initial level of the DP at age 4 and, to a lesser extent, the rate of change in the DP predicted a range of personality pathology dimensions in late adolescence. The findings suggest that the DP is a broad developmental precursor of personality pathology in late adolescence.

Oxytocin response to youth-mother interactions in clinically anxious youth is associated with separation anxiety and dyadic behavior

BACKGROUND

Anxiety disorders are common in youth and cause significant distress and impairment to the individual and family. Oxytocin (OT), a nine amino acid peptide, is implicated in anxiety regulation and modulation of close interpersonal and attachment behavior. Anxiety disorders have been linked to low levels of salivary OT in youth. Research has also linked oxytocinergic functioning to social support, warm contact, and bonding, and indicated that contact with attachment figures stimulates OT response. We examined OT response to a brief, positive youth-mother interaction in clinically anxious youth. We investigated whether quality of the youth-mother interaction as well as the presence of particular anxiety disorders, are associated with youth OT response.

METHOD

Salivary OT from 41 youth with primary DSM-5 anxiety disorders was assayed before and after a 7-min youth-mother interaction that was later systematically coded by two reliable coders. Youth and mothers also completed rating scales of youth anxiety symptoms.

RESULTS

Affective touch, maternal sensitivity, maternal intrusiveness, youth engagement, and youth initiative all contributed significantly to predicting youth OT response. Repeated measures analyses showed that when affective touch was high youth had greater OT response. OT response was positively associated with the presence of separation anxiety disorder (SAD) and with child ratings of separation anxiety.

CONCLUSIONS

The findings highlight the importance of maternal and dyadic behavior patterns to oxytocinergic response in clinically anxious youth, shed light on the association between OT and SAD, and point to possible intervention strategies.

The link between ADHD-like inattention and obsessions and compulsions during treatment of youth with OCD

Attention-deficit/hyperactivity disorder (ADHD) has been found to be highly comorbid in children and adolescents with obsessive-compulsive disorder (OCD). Some have proposed, however, that obsessive anxiety may cause inattention and executive dysfunction, leading to inappropriate ADHD diagnoses in those with OCD. If this were the case, these symptoms would be expected to decrease following successful OCD treatment. The present study tested this hypothesis and evaluated whether ADHD symptoms at baseline predicted OCD treatment response. Obsessive-compulsive and ADHD symptoms were assessed in 50 youth enrolled in a randomized controlled trial investigating selective serotonin reuptake inhibitor and cognitive behavioral treatment. Repeated-measures analysis of variance (RMANOVA) revealed that ADHD symptoms at baseline do not significantly predict treatment outcome. A multivariate RMANOVA found that OCD treatment response moderated change in inattention; participants who showed greater reduction in OCD severity experienced greater reduction in ADHD-inattentive symptoms, while those with less substantial reduction in obsessions and compulsions showed less change. These findings suggest that children and adolescents with OCD and inattention may experience meaningful improvements in attention problems following OCD treatment. Thus, in many youth with OCD, inattention may be inherently tied to obsessions and compulsions. Clinicians may consider addressing OCD in treatment before targeting inattentive-type ADHD.

The premonitory urge revisited: An individualized premonitory urge for tics scale

BACKGROUND

Premonitory urge ratings have advanced our understanding of urge phenomenology among individuals with tic disorders (TD). However, these ratings have been limited by their reliance on a single global dimension of urge severity. This study examined the psychometric properties of a novel scale called the Individualized Premonitory Urge for Tics Scale (I-PUTS) that assesses urge severity across multiple dimensions (number, frequency, and intensity).

METHOD

Seventy-five youth with a TD and their parents participated. Clinicians assessed youth's tic severity, depression severity, rages, and premonitory urges. Parents completed ratings of youth's anxiety, affect lability, and general psychopathology. Youth completed self-report ratings of anxiety, urge severity, and distress tolerance.

RESULTS

The I-PUTS identified that youth experienced an average of three distinct urges, but had an average of seven tics over the past week. Urges were primarily localized in the head/face, neck/throat, and arm regions. All I-PUTS dimensions exhibited excellent inter-rater reliability. The I-PUTS dimensions exhibited good convergent validity with global urge ratings and tic severity, and appropriate divergent validity from other clinical constructs. Youth who exhibited discrepant reports between clinician-administered and self-report urge ratings had less anxiety and tic severity, and greater inattention and externalizing problems compared to youth who exhibited good agreement.

CONCLUSIONS

The I-PUTS is a reliable and valid assessment of urge phenomena, which provides additional and complementary information to existing urge scales. It highlights the existence of multiple dimensions of urge severity, and presents particular utility when assessing urges in youth with TD who have inattention and externalizing problems.

Dysregulation in Youth with Anxiety Disorders: Relationship to Acute and 7- to 19- Year Follow-Up Outcomes of Cognitive-Behavioral Therapy

This study evaluated the impact of dysregulation across cognitive, affective, and behavioral domains on acute and 7- to 19-year follow-up outcomes of cognitive-behavioral therapy (CBT) for anxiety, and explored dysregulation as a predictor of psychopathology and impairment in young adulthood among individuals who received anxiety treatment as youth. Participants (N = 64; 50 % female, 83 % non-Hispanic White) from two randomized clinical trials completed a follow-up assessment 7-19 years later. Latent profile analysis identified dysregulation based on Anxious/Depressed, Attention Problems, and Aggressive Behavior scores on the Child Behavior Checklist. Although pretreatment dysregulation was not related to acute or follow-up outcomes for anxiety diagnoses that were the focus of treatment, dysregulation predicted an array of non-targeted psychopathology at follow-up. Among youth with a principal anxiety disorder, the effects of CBT (Coping Cat) appear to be robust against broad impairments in self-regulation. However, youth with a pretreatment dysregulation profile likely need follow-up to monitor for the emergence of other disorders.

Obsessive-compulsive symptoms are associated with psychiatric comorbidities, behavioral and clinical problems: a population-based study of Brazilian school children

Pediatric-onset obsessive-compulsive disorder (OCD) is underdiagnosed, and many affected children are untreated. The present study seeks to evaluate the presence and the clinical impact of OCD and obsessive-compulsive symptoms (OCS) in a large sample of school-age children. In Phase I, we performed an initial screening using the Family History Screen (FHS). In Phase II, we identified an "at-risk" sample, as well as a randomly selected group of children. A total of 2,512 children (6-12 years old) were assessed using the FHS, the Development and Well-Being Assessment (DAWBA), the Strengths and Difficulties Questionnaire (SDQ), and the Child Behavior Checklist (CBCL). Data analyses included descriptive and multivariate analytical techniques. 2,512 children (mean age: 8.86 ± 1.84 years; 55.0% male) were categorized into one of the three diagnostic groups: OCD (n = 77), OCS (n = 488), and unaffected controls (n = 1,947). There were no significant socio-demographic differences (age, gender, socioeconomic status) across groups. The OCS group resembled the OCD on overall impairment, including school problems and delinquent behaviors. However, the OCD group did have significantly higher rates of several comorbid psychiatric disorders, including separation anxiety, generalized anxiety, and major depressive disorder, than OCS or unaffected controls. Moreover, the OCD group also scored higher than the SDQ, as well as on each of CBCL items rated by the parent. Our findings suggest that there is a psychopathological continuum between OCS and OCD in school-aged children. The presence of OCS is associated with functional impairment, which needs further investigation in longitudinal studies.

The Dysregulation Profile in middle childhood and adolescence across reporters: factor structure, measurement invariance, and links with self-harm and suicidal ideation

Recently, a phenotype of severe dysregulation, the Dysregulation Profile (DP), has been identified. DP consists of elevated scores on the Anxious/Depressed (AD), Aggressive Behavior (AGG) and Attention Problems (AP) scales of the Child Behavior Checklist (CBCL), Teacher Report Form (TRF), or Youth Self Report (YSR). A drawback in current research is that DP has been conceptualized and operationalized in different manners and research on the factor structure of DP is lacking. Therefore, we examined the factor structure of DP across multiple reporters, measurement invariance across gender, parents, and time, as well as links between DP and self-harm and suicidal ideation. Data from a large community sample were used (N = 697), covering middle childhood (Mage = 7.90, (SD = 1.16) and adolescence (Mage = 13.93, SD = 1.14). Mothers, fathers, teachers, and youth themselves reported on children's emotional and behavioral problems using the CBCL, TRF, and YSR. Results indicated that in middle childhood and in adolescence, a bifactor model with a general factor of Dysregulation alongside three specific factors of AD, AGG, and AP fitted best, compared to a second-order or one-factor model. The model showed good fit for mother, father, teacher, and youth reports and showed invariance across gender, parents and time. Youth, mother, and father reported Dysregulation was uniquely and positively related to adolescent-reported self-harm and suicidal ideation. The DP is best conceptualized as a broad dysregulation syndrome, which exists over and above anxiety/depression, aggression, and attention problems as specific problems. The bifactor model of DP explains the uniqueness and interrelatedness of these behavioral problems and can help explaining shared and non-shared etiology factors. The exclusive link between the general dysregulation factor and adolescents' self-harm and suicidal ideation further established the clinical relevance of the bifactor model.

Family accommodation in obsessive-compulsive and anxiety disorders: a five-year update

Family accommodation describes changes that individuals make to their behavior, to help their relative who is dealing with a psychiatric and/or psychological disorder(s), avoid or alleviate distress related to the disorder. Research on family accommodation has advanced rapidly. In this update we aim to provide a synthesis of findings from the past five years. A search of available, peer-reviewed, English language papers was conducted through PubMed and PsycINFO, cross referencing psychiatric disorders with accommodation and other family-related terms. The resulting 121 papers were individually reviewed and evaluated and the main findings were discussed. Family accommodation is common in obsessive-compulsive disorder (OCD) and in anxiety disorders, and manifests similarly across these disorders. Family accommodation is associated with more severe psychopathology and poorer clinical outcomes. Treatments have begun to focus on the reduction of family accommodation as a primary therapeutic goal and finally, neurobiological underpinnings of family accommodation are beginning to be investigated.

Preliminary study of family accommodation in youth with autism spectrum disorders and anxiety: Incidence, clinical correlates, and behavioral treatment response

Anxiety symptoms are common in youth with autism spectrum disorders (ASD) and directly associated with symptom severity and functional impairment. Family accommodation occurs frequently among individuals with obsessive-compulsive and anxiety disorders; to date, no data exist on the nature and correlates of family accommodation in youth with ASD and anxiety, as well as its relationship to cognitive-behavioral therapy outcome. Forty children with ASD and a comorbid anxiety disorder participated. Clinicians administered measures of ASD and anxiety disorder caseness, anxiety symptom severity, and family accommodation; parents completed questionnaires assessing social responsiveness, internalizing and externalizing behaviors, and functional impairment. A subsample of youth (n = 24) completed a course of cognitive-behavioral therapy. Family accommodation was common and positively correlated with anxiety symptom severity, but not functional impairment, general internalizing symptoms, externalizing behavior, or social responsiveness. Family accommodation decreased following cognitive-behavioral therapy with decreases in family accommodation being associated with decreases in anxiety levels. Treatment responders reported lower family accommodation frequency and lower parent impact relative to non-responders. Clinical implications of this study in assessing and psychotherapeutically treating youth with ASD and comorbid anxiety are discussed.

Comparing family accommodation in pediatric obsessive-compulsive disorder, anxiety disorders, and nonanxious children

BACKGROUND

Family accommodation describes ways in which parents modify their behavior to help a child avoid or alleviate distress caused by emotional disorders. Accommodation is associated with increased symptom severity, lower functioning, and poorer treatment outcomes. Accommodation is prevalent in childhood obsessive-compulsive disorder (OCD) and anxiety disorders (ADs) but no studies have compared accommodation in these groups or compared them to healthy controls to ascertain if accommodation is prevalent in the general population. This study addresses these gaps by comparing patterns of accommodation, factors that maintain accommodation, and its relation to symptom severity in OCD and AD, relative to healthy controls.

METHOD

We directly compared reports of accommodation to childhood OCD (N = 26) and AD (N = 31), and a comparison group of nonanxious (NA) children (N = 30). Mothers completed measures of accommodation (Family Accommodation Scale (FAS)/Family Accommodation Scale-Anxiety (FASA)), anxiety (Screen for Childhood Anxiety Related Emotional Disorders-Parent Report (SCARED-PR)), and OCD (Children's Yale-Brown Obsessive Compulsive Scale (CYBOCS)).

RESULTS

Family accommodation is prevalent among mothers of children with OCD and AD. Few differences were found between the two clinical groups who reported more accommodation (F[2,84] = 23.411, P < .001, partial η(2) = .358), greater distress (F[2,84] = 24.050, P < .001, partial η(2) = .364), and more consequences of not accommodating (F[2,84] = 18.967, P < .001, partial η(2) = .311), than the NA group. Accommodation was associated with severity of anxiety in AD (r = .426, P = .017) and OCD (r = .465, P = .017), but not in the NA group.

CONCLUSIONS

Findings highlight family accommodation as a phenomenon that applies broadly and in a similar manner to children with AD and OCD. Evaluating accommodation provides useful information for clinical care and is an important part of the assessment of children with AD and OCD.

Enhancing exposure therapy for anxiety disorders, obsessive-compulsive disorder and post-traumatic stress disorder

Translating findings from basic science, several compounds have been identified that may enhance therapeutic outcomes and/or expedite treatment gains when administered alongside exposure-based treatments. Four of these compounds (referred to as cognitive enhancers) have been evaluated in the context of randomized controlled trials for anxiety disorders (e.g., specific phobias, panic disorder, social anxiety disorder), obsessive-compulsive disorder and post-traumatic stress disorder. These cognitive enhancers include D-cycloserine, yohimbine hydrochloride, glucocorticoids and cortisol and brain-derived neurotrophic factor. There is consistent evidence that cognitive enhancers can enhance therapeutic outcomes and/or expedite treatment gains across anxiety disorders, obsessive-compulsive disorder and post-traumatic stress disorder. Emerging evidence has highlighted the importance of within-session fear habituation and between-session fear learning, which can either enhance fear extinction or reconsolidate of fear responses. Although findings from these trials are promising, there are several considerations that warrant further evaluation prior to widespread use of cognitive enhancers in exposure-based treatments. Consistent trial design and large sample sizes are important in future studies of cognitive enhancers.