The impact of intensive treatment for pediatric anxiety and obsessive-compulsive disorder on daily functioning

The psychosocial and educational burden of obsessive-compulsive disorder in youth

BACKGROUND

Pediatric OCD is associated with functional impairment in multiple environments. However, relatively little is known about the impact of comorbid conditions, as well as OCD severity on psychosocial functioning in this population. Furthermore, most studies did not include a control sample, nor examined differences between children and adolescents. The goal of this investigation was to assess psychosocial functioning and its associations with age, symptom severity, and comorbid conditions in a large well characterized sample of pediatric OCD probands, and controls.

METHODS

Participants included 117 pediatric OCD probands and 147 controls, that underwent a careful diagnostic process, and completed several questionnaires and interviews.

RESULTS

Results revealed significant psychosocial impairments across multiple domains/settings, some of which were affected by symptom severity as well as by conduct related comorbidities and to a lesser extent affective disorders. In addition, different aspects of psychosocial impairments were found between children and adolescents.

CONCLUSION

This study provides high resolution information regarding the types and extent of psychosocial dysfunction in youth with OCD, as well as its relationship with clinical and diagnostic correlates. It is recommended that evaluation and management of OCD in youth in research and clinical settings regularly include qualitative and semi-quantitative assessment of function across these domains.

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.

Reduction of Mental Health-Related Emergency Department Admissions for Youth and Young Adults Following a Remote Intensive Outpatient Program: Quality Improvement Analysis

BACKGROUND

Pediatric mental health emergency department (ED) visits are increasing at 6% to 10% per year, at substantial cost, while 13% of youth with psychiatric hospitalizations are readmitted in the following weeks. Hospitals do not have the resources to meet escalating youth's mental health needs. Intensive outpatient (IOP) programs, which provide multiple hours of care each week, have the power to reduce the number of patients in need of hospitalized care and provide a step-down option for patients discharging from ED's in order to prevent readmissions.

OBJECTIVE

The purpose of this program evaluation was to assess (1) whether youth and young adult ED admission rates decreased following participation in a remote IOP program and (2) whether there were differences in readmission rates between youth and young adults by gender identity, sexual orientation, race, or ethnicity.

METHODS

Data were collected from intake and 3-month postdischarge surveys for 735 clients who attended at least 6 sessions of a remote IOP program for youth and young adults. Patients reported if they had been admitted to an ED within the previous 30 days and the admission reason. Over half (407/707, 57.6%) of clients were adolescents and the rest were young adults (300/707, 42.4%; mean age 18.25, SD 4.94 years). The sample was diverse in gender identity (329/687, 47.9% female; 196/687, 28.5% male; and 65/669, 9.7% nonbinary) and sexual orientation (248/635, 39.1% heterosexual; 137/635, 21.6% bisexual; 80/635, 10.9% pansexual; and 170/635, 26.8% other sexual orientation) and represented several racial (9/481, 1.9% Asian; 48/481, 10% Black; 9/481, 1.9% Indigenous; 380/481, 79% White; and 35/481, 7.2% other) and ethnic identities (112/455, 24.6% Hispanic and 28/455, 6.2% other ethnic identity).

RESULTS

Mental health-related ED admissions significantly decreased between intake and 3 months after discharge, such that 94% (65/69) of clients with a recent history of mental health-related ED admissions at IOP intake reported no mental health-related ED admissions at 3 months after discharge from treatment (χ21=38.8, P<.001). There were no differences in ED admissions at intake or in improvement at 3 months after discharge by age, gender, sexuality, race, or ethnicity.

CONCLUSIONS

This study documents a decrease in ED admissions between intake and 3 months after discharge among both youth and young adults who engage in IOP care following ED visits. The similar outcomes across demographic groups indicate that youth and young adults experience similar decreases after the current tracks of programming. Future research could conduct a full return-on-investment analysis for intensive mental health services for youth and young adults.

The title has been changed to: Understanding Treatment Needs of Youth in a Remote IOP: A Quality Improvement Analysis of Solicited Journals (Preprint)

BACKGROUND

Youth experiencing high-acuity mental health symptoms often require highly restrictive levels of care (ie, inpatient care) that removes them from the relationships and activities essential for healthy development. An alternative treatment gaining evidence in its ability to support this population is the intensive outpatient programming (IOP) model. Understanding the experiences of adolescents and young adults during IOP treatment episodes may enhance clinical responsiveness to changing needs and protect against transfer to inpatient care.

OBJECTIVE

The objective of the analysis reported here was to identify heretofore unrecognized treatment needs of adolescents and young adults attending a remote IOP to help the program make clinical and programmatic decisions that increase its ability to support the recovery of program participants.

METHODS

Treatment experiences are collected weekly via electronic journals as part of ongoing quality improvement efforts. The journals are used by clinicians proximally to help them identify youth in crisis and distally to help them better understand and respond to the needs and experiences of program participants. Journal entries are downloaded each week, reviewed by program staff for evidence of the need for immediate intervention, and later deidentified and shared with quality improvement partners via monthly uploads to a secure folder. A total of 200 entries were chosen based on inclusion criteria that focused primarily on having at least one entry at 3 specified time points across the treatment episode. Overall, 3 coders analyzed the data using open-coding thematic analysis from an essentialist perspective such that the coders sought to represent the data and thus the essential experience of the youth as closely as possible.

RESULTS

Three themes emerged: mental health symptoms, peer relations, and recovery. The mental health symptoms theme was not surprising, given the context within which the journals were completed and the journal instructions asking that they write about how they are feeling. The peer relations and recovery themes provided novel insight, with entries included in the peer relations theme demonstrating the central importance of peer relationships, both within and outside of the therapeutic setting. The entries contained under the recovery theme described experience of recovery in terms of increases in function and self-acceptance versus reductions in clinical symptoms.

CONCLUSIONS

These findings support the conceptualization of this population as youth with both mental health and developmental needs. In addition, these findings suggest that current definitions of recovery may inadvertently miss supporting and documenting treatment gains considered most important to the youth and young adults receiving care. Taken together, youth-serving IOPs may be better positioned to treat youth and assess program impact through the inclusion of functional measures and attention to fundamental tasks of the adolescent and young adult developmental periods.

The Impact of Family Therapy Participation on Youth and Young Adult Engagement and Retention in a Telehealth Intensive Outpatient Program: Quality Improvement Analysis (Preprint)

BACKGROUND

 Early treatment dropout among youths and young adults (28%-75%) puts them at risk for poorer outcomes. Family engagement in treatment is linked to lower dropout and better attendance in outpatient, in-person treatment. However, this has not been studied in intensive or telehealth settings.

OBJECTIVE

 We aimed to examine whether family members' participation in telehealth intensive outpatient (IOP) therapy for mental health disorders in youths and young adults is associated with patient's treatment engagement. A secondary aim was to assess demographic factors associated with family engagement in treatment.

METHODS

 Data were collected from intake surveys, discharge outcome surveys, and administrative data for patients who attended a remote IOP for youths and young adults, nationwide. Data included 1487 patients who completed both intake and discharge surveys and either completed or disengaged from treatment between December 2020 and September 2022. Descriptive statistics were used to characterize the sample's baseline differences in demographics, engagement, and participation in family therapy. Mann-Whitney U and chi-square tests were used to explore differences in engagement and treatment completion between patients with and those without family therapy. Binomial regression was used to explore significant demographic predictors of family therapy participation and treatment completion.

RESULTS

 Patients with family therapy had significantly better engagement and treatment completion outcomes than clients with no family therapy. Youths and young adults with ≥1 family therapy session were significantly more likely to stay in treatment an average of 2 weeks longer (median 11 weeks vs 9 weeks) and to attend a higher percentage of IOP sessions (median 84.38% vs 75.00%). Patients with family therapy were more likely to complete treatment than clients with no family therapy (608/731, 83.2% vs 445/752, 59.2%; P<.001). Different demographic variables were associated with an increased likelihood of participating in family therapy, including younger age (odds ratio 1.3) and identifying as heterosexual (odds ratio 1.4). After controlling for demographic factors, family therapy remained a significant predictor of treatment completion, such that each family therapy session attended was associated with a 1.4-fold increase in the odds of completing treatment (95% CI 1.3-1.4).

CONCLUSIONS

 Youths and young adults whose families participate in any family therapy have lower dropout, greater length of stay, and higher treatment completion than those whose families do not participate in services in a remote IOP program. The findings of this quality improvement analysis are the first to establish a relationship between participation in family therapy and an increased engagement and retention in remote treatment for youths and young patients in IOP programing. Given the established importance of obtaining an adequate dosage of treatment, bolstering family therapy offerings is another tool that could contribute to the provision of care that better meets the needs of youths, young adults, and their families.

Cognitive-Behavioral Therapy for Obsessive-Compulsive Disorder: 2021 Update

In this update of a previous review, the authors discuss cognitive-behavioral therapy (CBT) with exposure and response prevention for obsessive-compulsive disorder (OCD). This efficacious modality avoids side effects common to psychotropic medication and reduces risk of relapse once treatment has ended. Psychotherapy involves identification and ranking of stimuli that provoke obsessions, exposure to these stimuli while preventing compulsions, and cognitive restructuring. The family of the OCD patient plays a significant role in treatment. This article includes expanded research on family-focused CBT and treatment of pediatric OCD. The family's accommodation and emotional response to a patient's symptoms may interfere with therapy and perpetuate the disorder. The treatment of pediatric OCD involves the same considerations. However, the form of obsessions and compulsions may differ and therapeutic techniques are modified to make them age appropriate.

Associations between parental distress and pediatric anxiety and obsessive-compulsive disorder treatment outcomes

This study investigated whether an intensive group-based cognitive-behavioral therapy program with family involvement for children with anxiety disorders and obsessive-compulsive disorder could help reduce parental distress by addressing the larger family system. This study also examined associations between parental distress and parent-reported child outcomes of treatment. Two hundred ninety-nine children and adolescents, ages 6-19, who were patients in the intensive treatment program and their caregivers participated in this intervention-based study. Parents reported significant reductions in their own distress from admission to discharge, and greater reductions in parent-reported distress predicted greater reductions in parents' reports of their children's anxiety symptoms and the degree of child functional impairment. Higher levels of parent-reported parent mental health symptoms at children's admission and at discharge were associated with poorer levels of functioning in children at discharge. Parents' mental health symptoms may play a critical role in children and adolescents' treatment outcomes and therefore may need to be a separate treatment target.