Precision Implementation: An Approach to Mechanism Testing in Implementation Research

Advancing mechanism-focused research in implementation science is a priority given its potential to improve tailoring and efficiency of implementation strategies. Experimental therapeutics, or experimental medicine, offers an approach for mechanism testing that has been promoted by the NIH Science of Behavior Change and endorsed by the National Institute for Mental Health. This approach has been applied across the translational spectrum - with initial applications to biological research and more recent applications to psychosocial treatment development research. We describe further advancement of experimental therapeutics along the translational spectrum and describe how it is ideally suited to inform precision experimental tests of implementation strategy mechanisms, which we term precision implementation. Such an approach to mechanism testing will allow for identification of causal dose-response relationships between implementation strategies, presumed mechanisms, and implementation outcomes. We discuss the tension between the scientific rigor required to conduct mechanism-focused research using experimental therapeutics and the "real world" conditions in which implementation research takes place. We provide a series of example studies that show "beginning to end" application of this framework in research focused on provider implementation of an evidence-based intervention in routine clinical care settings.

Systematic Review and Meta-analysis: An Empirical Approach to Defining Treatment Response and Remission in Pediatric Obsessive-Compulsive Disorder

OBJECTIVE

A lack of universal definitions for response and remission in pediatric obsessive-compulsive disorder (OCD) has hampered the comparability of results across trials. To address this problem, we conducted an individual participant data diagnostic test accuracy meta-analysis to evaluate the discriminative ability of the Children's Yale-Brown Obsessive-Compulsive Scale (CY-BOCS) in determining response and remission. We also aimed to generate empirically derived cutoffs on the CY-BOCS for these outcomes.

METHOD

A systematic review of PubMed, PsycINFO, Embase and CENTRAL identified 5,401 references; 42 randomized controlled clinical trials were considered eligible, and 21 provided data for inclusion (N = 1,234). Scores of ≤2 in the Clinical Global Impressions Improvement and Severity scales were chosen to define response and remission, respectively. A 2-stage, random-effects meta-analysis model was established. The area under the curve (AUC) and the Youden Index were computed to indicate the discriminative ability of the CY-BOCS and to guide for the optimal cutoff, respectively.

RESULTS

The CY-BOCS had sufficient discriminative ability to determine response (AUC = 0.89) and remission (AUC = 0.92). The optimal cutoff for response was a ≥35% reduction from baseline to posttreatment (sensitivity = 83.9, 95% CI = 83.7-84.1; specificity = 81.7, 95% CI = 81.5-81.9). The optimal cutoff for remission was a posttreatment raw score of ≤12 (sensitivity = 82.0, 95% CI = 81.8-82.2; specificity = 84.6, 95% CI = 84.4-84.8).

CONCLUSION

Meta-analysis identified empirically optimal cutoffs on the CY-BOCS to determine response and remission in pediatric OCD randomized controlled clinical trials. Systematic adoption of standardized operational definitions for response and remission will improve comparability across trials for pediatric OCD.

Expanding the reach of evidence-based mental health interventions to private practice: Qualitative assessment using a policy ecology framework

Background

Evidence-based interventions (EBIs) for mental health disorders are underutilized in routine clinical practice. Exposure therapy for anxiety disorders is one particularly difficult-to-implement EBI that has robust empirical support. Previous research has examined EBI implementation determinants in publicly funded mental health settings, but few studies have examined EBI implementation determinants in private practice settings. Private practice clinicians likely face unique barriers to implementation, including setting-specific contextual barriers to EBI use. The policy ecology framework considers broad systemic determinants, including organizational, regulatory, social, and political contexts, which are likely relevant to EBI implementation in private practice settings but have not been examined in prior research.

Methods

Qualitative interviews were conducted to assess private practice clinicians' perceptions of EBI implementation determinants using the policy ecology framework. Clinicians were asked about implementing mental health EBIs broadly and exposure therapy specifically. Mixed methods analyses compared responses from clinicians working in solo vs. group private practice and clinicians who reported high vs. low organizational support for exposure therapy.

Results

Responses highlight several barriers and facilitators to EBI implementation in private practice. Examples include determinants related to organizational support (e.g., colleagues using EBIs), payer restrictions (e.g., lack of reimbursement for longer sessions), fiscal incentives (e.g., payment for attending training), and consumer demand for EBIs. There were notable differences in barriers faced by clinicians who work in group private practices compared to those working in solo practices. Solo private practice clinicians described ways in which their practice setting limits their degree of colleague support (e.g., for consultation or exposure therapy planning), while also allowing for flexibility (e.g., in their schedules and practice location) that may not be available to clinicians in group practice.

Conclusions

Using the policy ecology framework provides a broad understanding of contextual factors that impact private practice clinicians' use of EBIs, including exposure therapy. Findings point to potential implementation strategies that may address barriers that are unique to clinicians working in private practice.

Improving Delivery Behaviors During Exposure for Pediatric OCD: A Multiple Baseline Training Trial With Community Therapists

This study tested whether a new training tool, the Exposure Guide (EG), improved in-session therapist behaviors (i.e., indicators of quality) that have been associated with youth outcomes in prior clinical trials of exposure therapy. Six therapists at a community mental health agency (CMHA) provided exposure therapy for 8 youth with obsessive-compulsive disorder (OCD). Using a nonconcurrent multiple baseline design with random assignment to baseline lengths of 6 to 16 weeks, therapists received gold-standard exposure therapy training with weekly consultation (baseline phase) followed by addition of EG training and feedback (intervention phase). The primary outcome was therapist behavior during in-session exposures, observed weekly using a validated coding system. Therapist behavior was evaluated in relation to a priori benchmarks derived from clinical trials. Additional outcomes included training feasibility/acceptability, therapist response to case vignettes and beliefs about exposure, and independent evaluator-rated clinical outcomes. Three therapists reached behavior benchmarks only during the EG (intervention) phase. Two therapists met benchmarks during the baseline phase; one of these subsequently moved away from benchmarks but met them again after starting the EG phase. Across all therapists, the percentage of weeks meeting benchmarks was significantly higher during the EG phase (86.4%) vs. the baseline phase (53.2%). Youth participants experienced significant improvement in OCD symptoms and global illness severity from pre- to posttreatment. Results provide initial evidence that adding the EG to gold-standard training can change in-session therapist behaviors in a CMHA setting.

Therapist Behavior During Exposure Tasks Predicts Habituation and Clinical Outcome in Three Randomized Controlled Trials for Pediatric OCD

This study measured therapist behaviors in relation to subsequent habituation within exposure tasks, and also tested their direct and indirect relationships (via habituation) with clinical outcomes of exposure therapy. We observed 459 videotaped exposure tasks with 111 participants in three clinical trials for pediatric obsessive-compulsive disorder (POTS trials). Within exposure tasks, therapist behaviors and patient fear were coded continuously. Outcomes were habituation and posttreatment change in symptom severity, global improvement, and treatment response. More therapist behaviors that encourage approach-and less use of accommodation, unrelated talk, and externalizing language-predicted greater subsequent habituation during individual exposure tasks (exposure-level), and also predicted improved patient clinical outcomes via higher "total dose" of habituation across treatment (patient-level indirect effect). For six of seven therapist behaviors analyzed, the relationship with subsequent habituation within exposure differed by patient fear (low, moderate, or high) at the time the behavior was used. Two therapist behaviors had direct effects in the opposite direction expected; more unrelated talk and less intensifying were associated with greater patient symptom reduction. Results shed light on the "black box" of in-session exposure activities and point to specific therapist behaviors that may be important for clinical outcomes. These behaviors might be best understood in the context of changing patient fear during exposure tasks. Future studies should test whether therapist behaviors can be experimentally manipulated to produce improvement in clinical outcomes.

Cognitive performance of youth with primary generalized anxiety disorder versus primary obsessive-compulsive disorder

BACKGROUND

Despite gains made in the study of childhood anxiety, differential diagnosis remains challenging because of indistinct boundaries between disorders and high comorbidity. This is certainly true for generalized anxiety disorder (GAD) and obsessive-compulsive disorder (OCD) as they share multiple cognitive processes (e.g., rumination, intolerance of uncertainty, and increased attention to threat). Disentangling such cognitive characteristics and, subsequently, underlying mechanisms could serve to inform assessment and treatment practices, and improve prognoses.

METHODS

The current study sought to compare the cognitive performance (working memory, visuospatial memory, planning ability/efficiency, and cognitive flexibility), indexed by the Cambridge Neuropsychological Automated Battery (CANTAB) among three nonoverlapping groups of youth: (1) those diagnosed with OCD (n = 28), (2) those diagnosed with GAD, not OCD (n = 34), and (3) typically-developing controls (TDC) (n = 65).

RESULTS

Results showed that OCD and GAD youth demonstrated neurocognitive deficits in planning ability/efficiency, cognitive flexibility, and visual processing when compared to TDC, with potential diagnostic specificity such that youth with GAD or OCD had unique deficits compared to TDC and to one another. Specifically, youth with OCD demonstrated significantly impaired planning ability compared to youth in the GAD and TDS groups, whereas youth with GAD demonstrated greater cognitive inflexibility and delayed visual processing compared to youth in the OCD and TDC groups.

CONCLUSIONS

Future studies should expand upon these findings with more comprehensive assessment of cognitive functioning by including self- and parent-report forms, and neuroimaging to link behavioral findings with subjective ratings and neurocircuitry. Altogether, data can then inform future assessment and treatment targets.

Measuring fear change within exposures: Functionally-defined habituation predicts outcome in three randomized controlled trials for pediatric OCD

OBJECTIVE

This study measured a variety of within-exposure fear changes and tested the relationship of each with treatment outcomes in exposure therapy.

METHOD

We coded 459 videotaped exposure tasks from 111 participants in 3 clinical trials for pediatric obsessive-compulsive disorder (OCD; POTS trials). Within exposures, fear level was observed continuously and alongside exposure process. Fear change metrics of interest were selected for relevance to mechanistic theory. Fear decreases were classified by function; nonhabituation decreases were associated with observed nonlearning processes (e.g., avoidance), whereas habituation decreases appeared to result from an internal and indirect process. Outcomes were posttreatment change in symptom severity, global improvement, and treatment response.

RESULTS

Greater cumulative habituation across treatment was associated with larger reductions in symptom severity, greater global improvement, and increased odds of treatment response. Fear activation, fear variability, and nonhabituation fear decreases did not predict any outcomes. Exploratory analyses examined fear changes during habituation and nonhabituation exposures; higher peak fear during nonhabituation exposures was associated with attenuated global improvement.

CONCLUSIONS

Habituation is conceptually consistent with multiple mechanistic theories and should continue to be investigated as a practical marker of initial extinction learning and possible moderator of the relationship between fear activation and outcome. Results support the importance of functional and frequent fear measurement during exposures, and discussion considers implications of these findings for future studies aiming to understand learning during exposure and improve exposure delivery. (PsycINFO Database Record

Secondary outcomes from the pediatric obsessive compulsive disorder treatment study II

The Pediatric Obsessive-Compulsive Disorder Treatment Study II (POTS II) investigated the benefit of serotonin reuptake inhibitor (SRI) augmentation with cognitive behavioral therapy (CBT). Primary outcomes focused on OCD symptom change and indicated benefit associated with a full course of CBT. Given that the majority of youth with OCD suffer from significant comorbid symptoms and impaired quality of life, the current study examined POTS II data for effects on secondary outcomes. Participants were 124 youth ages 7-17 years with a primary diagnosis of OCD who were partial responders to an adequate SRI trial. Participants were randomized to medication management, medication management plus instructions in cognitive behavioral therapy (CBT), or medication management plus full CBT. Acute effects on non-OCD anxiety, depression, inattention, hyperactivity, and quality of life were examined across treatment conditions. Improvement across treatment was observed for non-OCD anxiety, inattention, hyperactivity, and quality of life. Changes were generally significantly greater in the group receiving full CBT. Child-rated depression was not found to change. OCD-focused treatment lead to improvement in other areas of psychopathology and functioning. For youth who are partial responders to SRI monotherapy, augmentation with full CBT may yield the greatest benefit on these secondary outcomes.

CLINICAL TRIALS REGISTRATION

Treatment of Pediatric OCD for SRI Partial Responders, Clinicaltrials.gov Identifier: NCT00074815, http://clinicaltrials.gov/show/NCT00074815.

Internet-delivered, family-based treatment for early-onset OCD: A pilot randomized trial

OBJECTIVE

Despite advances in supported treatments for early onset obsessive-compulsive disorder (OCD), progress has been constrained by regionally limited expertise in pediatric OCD. Videoteleconferencing (VTC) methods have proved useful for extending the reach of services for older individuals, but no randomized clinical trials (RCTs) have evaluated VTC for treating early onset OCD.

METHOD

RCT comparing VTC-delivered family based cognitive-behavioral therapy (FB-CBT) versus clinic-based FB-CBT in the treatment of children ages 4-8 with OCD (N = 22). Pretreatment, posttreatment, and 6-month follow-up assessments included mother-/therapist-reports and independent evaluations masked to treatment condition. Primary analyses focused on treatment retention, engagement and satisfaction. Hierarchical linear modeling preliminarily evaluated the effects of time, treatment condition, and their interactions. "Excellent response" was defined as a 1 or 2 on the Clinical Global Impressions-Improvement Scale.

RESULTS

Treatment retention, engagement, alliance and satisfaction were high across conditions. Symptom trajectories and family accommodation across both conditions showed outcomes improving from baseline to posttreatment, and continuing through follow-up. At posttreatment, 72.7% of Internet cases and 60% of Clinic cases showed "excellent response," and at follow-up 80% of Internet cases and 66.7% of Clinic cases showed "excellent response." Significant condition differences were not found across outcomes.

CONCLUSIONS

VTC methods may offer solutions to overcoming traditional barriers to care for early onset OCD by extending the reach of real-time expert services regardless of children's geographic proximity to quality care. (PsycINFO Database Record

Family-Based Treatment of Pediatric Obsessive-Compulsive Disorder: Clinical Considerations and Application

Pediatric obsessive-compulsive disorder (OCD) can be effectively treated with family-based intervention by expanding and enhancing family members' behavioral repertoire to more effectively manage OCD symptoms and affected family interactions. This article provides an overview and practical understanding of the implementation of family-based treatment of pediatric OCD. Special attention is given to relevant contextual family processes that influence symptom presentation, current empirical support for family-based treatment, and the clinical application of family-based cognitive-behavioral therapy. Case vignettes illustrate important clinical considerations for providers.

Sensory over-responsivity in a sample of children seeking treatment for anxiety

OBJECTIVE

Sensory over-responsivity (SOR) refers to an exaggerated, intense, or prolonged behavioral response to ordinary sensory stimuli. The relationship of SOR to psychiatric disorders remains poorly understood. The current study examined the SOR construct within typically developing children with clinically significant anxiety, including the prevalence and course of SOR symptoms and relationship between SOR symptoms, demographic factors, and psychopathology.

METHOD

Children presenting at an anxiety specialty clinic (n = 88) completed a psychiatric diagnostic assessment, which included parent-report measures of SOR, anxiety, obsessive-compulsive disorder (OCD), and global behavior and child-report measures of anxiety, depression, and OCD.

RESULTS

Sensory over-responsivity symptoms were very common: 93.2% were bothered by at least 1 tactile or auditory sensation, and the mean number of bothersome sensations was 9.2 (SD = 7.4). SOR symptoms were reported to be "moderately bothersome" on average and to onset at an early age. Sensory Over-Responsivity Inventory (SensOR) scores did not differ by psychiatric disorder diagnosis, but SensOR scores significantly correlated with measures of OCD and depression. Higher SensOR scores were associated with greater global impairment.

CONCLUSION

A high rate of SOR symptom occurrence was observed in this sample of children seeking anxiety treatment, suggesting that SOR may not be entirely independent of anxiety and may be closely associated with OCD. Future research on the validity and nosology of SOR using psychiatric samples is warranted.

Is There a Relationship Between Tic Frequency and Physiological Arousal? Examination in a Sample of Children With Co-Occurring Tic and Anxiety Disorders

Stress is the contextual variable most commonly implicated in tic exacerbations. However, research examining associations between tics, stressors, and the biological stress response has yielded mixed results. This study examined whether tics occur at a greater frequency during discrete periods of heightened physiological arousal. Children with co-occurring tic and anxiety disorders (n = 8) completed two stress-induction tasks (discussion of family conflict, public speech). Observational (tic frequencies) and physiological (heart rate [HR]) data were synchronized using The Observer XT, and tic frequencies were compared across periods of high and low HR. Tic frequencies across the entire experiment did not increase during periods of higher HR. During the speech task, tic frequencies were significantly lower during periods of higher HR. Results suggest that tic exacerbations may not be associated with heightened physiological arousal and highlight the need for further tic research using integrated measurement of behavioral and biological processes.

Internet-delivered, family-based treatment for early-onset OCD: a preliminary case series

Given the burdens of early-onset obsessive-compulsive disorder (OCD), limitations in the broad availability and accessibility of evidence-based care for affected youth present serious public health concerns. The growing potential for technological innovations to transform care for the most traditionally remote and underserved families holds enormous promise. This article presents the rationale, key considerations, and a preliminary case series for a promising behavioral telehealth innovation in the evidence-based treatment of early-onset OCD. We developed an Internet-based format for the delivery of family-based treatment for early-onset OCD directly to families in their homes, regardless of their geographic proximity to a mental health facility. Videoteleconferencing (VTC) methods were used to deliver real-time cognitive-behavioral therapy centering on exposure and response prevention to affected families. Participants in the preliminary case series included 5 children between the ages of 4 and 8 (M Age = 6.5) who received the Internet-delivered treatment format. All youth completed a full treatment course, all showed OCD symptom improvements and global severity improvements from pre- to posttreatment, all showed at least partial diagnostic response, and 60% no longer met diagnostic criteria for OCD at posttreatment. No participants got worse, and all mothers characterized the quality of services received as "excellent." The present work adds to a growing literature supporting the potential of VTC and related computer technology for meaningfully expanding the reach of supported treatments for OCD and lays the foundation for subsequent controlled evaluations to evaluate matters of efficacy and engagement relative to standard in-office evidence-based care.

CBT Specific Process in Exposure-Based Treatments: Initial Examination in a Pediatric OCD Sample

Cognitive-Behavioral theory and empirical support suggest that optimal activation of fear is a critical component for successful exposure treatment. Using this theory, we developed coding methodology for measuring CBT-specific process during exposure. We piloted this methodology in a sample of young children (N = 18) who previously received CBT as part of a randomized controlled trial. Results supported the preliminary reliability and predictive validity of coding variables with 12 week and 3 month treatment outcome data, generally showing results consistent with CBT theory. However, given our limited and restricted sample, additional testing is warranted. Measurement of CBT-specific process using this methodology may have implications for understanding mechanism of change in exposure-based treatments and for improving dissemination efforts through identification of therapist behaviors associated with improved outcome.

Cognitive behavior therapy augmentation of pharmacotherapy in pediatric obsessive-compulsive disorder: the Pediatric OCD Treatment Study II (POTS II) randomized controlled trial

CONTEXT

The extant literature on the treatment of pediatric obsessive-compulsive disorder (OCD) indicates that partial response to serotonin reuptake inhibitors (SRIs) is the norm and that augmentation with short-term OCD-specific cognitive behavior therapy (CBT) may provide additional benefit.

OBJECTIVE

To examine the effects of augmenting SRIs with CBT or a brief form of CBT, instructions in CBT delivered in the context of medication management.

DESIGN, SETTING, AND PARTICIPANTS

A 12-week randomized controlled trial conducted at 3 academic medical centers between 2004 and 2009, involving 124 pediatric outpatients between the ages of 7 and 17 years with OCD as a primary diagnosis and a Children's Yale-Brown Obsessive Compulsive Scale score of 16 or higher despite an adequate SRI trial.

INTERVENTIONS

Participants were randomly assigned to 1 of 3 treatment strategies that included 7 sessions over 12 weeks: 42 in the medication management only, 42 in the medication management plus instructions in CBT, and 42 in the medication management plus CBT; the last included 14 concurrent CBT sessions.

MAIN OUTCOME MEASURES

Whether patients responded positively to treatment by improving their baseline obsessive-compulsive scale score by 30% or more and demonstrating a change in their continuous scores over 12 weeks.

RESULTS

The medication management plus CBT strategy was superior to the other 2 strategies on all outcome measures. In the primary intention-to-treat analysis, 68.6% (95% CI, 53.9%-83.3%) in the plus CBT group were considered responders, which was significantly better than the 34.0% (95% CI, 18.0%-50.0%) in the plus instructions in CBT group, and 30.0% (95% CI, 14.9%-45.1%) in the medication management only group. The results were similar in pairwise comparisons with the plus CBT strategy being superior to the other 2 strategies (P < .01 for both). The plus instructions in CBT strategy was not statistically superior to medication management only (P = .72). The number needed-to-treat analysis with the plus CBT vs medication management only in order to see 1 additional patient at week 12, on average, was estimated as 3; for the plus CBT vs the plus instructions in CBT strategy, the number needed to treat was also estimated as 3; for the plus instructions in CBT vs medication management only the number needed to treat was estimated as 25.

CONCLUSIONS

Among patients aged 7 to 17 years with OCD and partial response to SRI use, the addition of CBT to medication management compared with medication management alone resulted in a significantly greater response rate, whereas augmentation of medication management with the addition of instructions in CBT did not.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT00074815.

Predictors of parental accommodation in pediatric obsessive-compulsive disorder: findings from the Pediatric Obsessive-Compulsive Disorder Treatment Study (POTS) trial

OBJECTIVE

Few studies have examined predictors of parental accommodation (assessed with the Family Accommodation Scale-Parent Report) among families of children with obsessive-compulsive disorder (OCD). No studies have examined this phenomenon using empirically derived subscales of the Family Accommodation Scale-Parent Report (i.e., Caregiver Involvement, Avoidance of Triggers).

METHOD

Ninety-six youths (and their families) were included in the present study. Parents were asked to complete the Family Accommodation Scale-Parent Report. Families also completed several additional measurements assessing child- and parent-level variables of interest. Regression analyses were used to examine potential predictors of accommodation.

RESULTS

Results support prior research suggesting that accommodation is ubiquitous among the families of children with OCD. Analyses revealed that several child-level (i.e., compulsion severity, oppositional behavior, and frequency of washing symptoms) and one parent-level (i.e., symptoms of anxiety) predictors work jointly to provide significant predictive models of parental accommodation.

CONCLUSIONS

Clinicians and researchers should be aware of the impact of specific child- and parent-level variables on family accommodation in pediatric OCD and in turn their implications for treatment compliance, adherence, and, by extension, outcome. Study limitations warrant replication and extension of these findings; in particular, researchers may seek to obtain a better understanding of how the various facets of parental accommodation may differentially affect treatment.

Behavior therapy for pediatric trichotillomania: Exploring the effects of age on treatment outcome

BACKGROUND

A randomized controlled trial examining the efficacy of behavior therapy for pediatric trichotillomania was recently completed with 24 participants ranging in age from 7 - 17. The broad age range raised a question about whether young children, older children, and adolescents would respond similarly to intervention. In particular, it is unclear whether the younger children have the cognitive capacity to understand concepts like "urges" and whether they are able to introspect enough to be able to benefit from awareness training, which is a key aspect of behavior therapy for trichotillomania.

METHODS

Participants were randomly assigned to receive either behavior therapy (N = 12) or minimal attention control (N = 12), which was included to control for repeated assessments and the passage of time. Primary outcome measures were the independent evaluator-rated NIMH-Trichotillomania Severity Scale, a semi-structured interview often used in trichotillomania treatment trials, and a post-treatment clinical global impression improvement rating (CGI-I).

RESULTS

The correlation between age and change in symptom severity for all patients treated in the trial was small and not statistically significant. A 2 (group: behavioral therapy, minimal attention control) x 2 (time: week 0, 8) x 2 (children < 9 yrs., children > 10) ANOVA with independent evaluator-rated symptom severity scores as the continuous dependent variable also detected no main effects for age or for any interactions involving age. In light of the small sample size, the mean symptom severity scores at weeks 0 and 8 for younger and older patients randomized to behavioral therapy were also plotted. Visual inspection of these data indicated that although the groups appeared to have started at similar levels of severity for children /= 10; the week 8 data show that the three younger children did at least as well as if not slightly better than the nine older children and adolescents.

CONCLUSIONS

Behavior therapy for pediatric trichotillomania appears to be efficacious even in young children. The developmental and clinical implications of these findings will be discussed.

TRIAL REGISTRATION

Clinicaltrials.gov NCT00043563.

Symptom profiles in pediatric obsessive-compulsive disorder (OCD): the effects of comorbid grooming conditions

This study sought to examine possible differences in phenomenological features and/or symptom severity of children diagnosed with obsessive-compulsive disorder (OCD) and a comorbid grooming condition (i.e., skin picking and trichotillomania). A total of 202 children receiving a primary diagnosis of OCD were classified into two distinct groups: (1) OCD alone (n=154) and (2) OCD plus a comorbid grooming condition (OCD+grooming; n=48). Analyses revealed that those children presenting with a comorbid grooming condition demonstrated different symptom profiles than those with OCD alone. In addition, parents of these children were more likely to report the presence of tactile/sensory sensitivity than those in the OCD alone group. However, no differences were found with respect to symptom severity via self-report (e.g., OCI) or semi-structured interview (e.g., CY-BOCS). Possible clinical and treatment implications, future areas of research, and limitations to the present study are discussed.

Examining the Psychometric Properties of the Family Accommodation Scale-Parent-Report (FAS-PR)

Growing research has examined parental accommodation among the families of children with obsessive-compulsive disorder (OCD). However, these studies have utilized a parent-report (PR) version of a measure, the Family Accommodation Scale (FAS) that has never received proper psychometric validation. In turn, previously derived subscales have been developed via clinical rather than empirical evidence. This study aims to conduct a comprehensive psychometric analysis of the FAS-PR utilizing data collected from 96 youths with OCD. Exploratory factors analysis was conducted and revealed a 12-item scale yielding two separate, yet related subscales, Avoidance of Triggers (AT) and Involvement in Compulsions (IC). Subsequent analyses revealed good internal consistency and convergent and discriminant validity. These findings suggest that future research should seek to examine factors that may impact various facets to accommodation as well as the role these facets plays in predicting treatment outcome. Limitations are discussed.

The Pediatric Obsessive-Compulsive Disorder Treatment Study II: rationale, design and methods

This paper presents the rationale, design, and methods of the Pediatric Obsessive-Compulsive Disorder Treatment Study II (POTS II), which investigates two different cognitive-behavior therapy (CBT) augmentation approaches in children and adolescents who have experienced a partial response to pharmacotherapy with a serotonin reuptake inhibitor for OCD. The two CBT approaches test a "single doctor" versus "dual doctor" model of service delivery. A specific goal was to develop and test an easily disseminated protocol whereby child psychiatrists would provide instructions in core CBT procedures recommended for pediatric OCD (e.g., hierarchy development, in vivo exposure homework) during routine medical management of OCD (I-CBT). The conventional "dual doctor" CBT protocol consists of 14 visits over 12 weeks involving: (1) psychoeducation, (2), cognitive training, (3) mapping OCD, and (4) exposure with response prevention (EX/RP). I-CBT is a 7-session version of CBT that does not include imaginal exposure or therapist-assisted EX/RP. In this study, we compared 12 weeks of medication management (MM) provided by a study psychiatrist (MM only) with two types of CBT augmentation: (1) the dual doctor model (MM+CBT); and (2) the single doctor model (MM+I-CBT). The design balanced elements of an efficacy study (e.g., random assignment, independent ratings) with effectiveness research aims (e.g., differences in specific SRI medications, dosages, treatment providers). The study is wrapping up recruitment of 140 youth ages 7-17 with a primary diagnosis of OCD. Independent evaluators (IEs) rated participants at weeks 0,4,8, and 12 during acute treatment and at 3,6, and 12 month follow-up visits.

TRIAL REGISTRATION

NCT00074815.

Phenomenology of Early Childhood Onset Obsessive Compulsive Disorder

This paper describes the phenomenological features of early childhood onset obsessive compulsive disorder (OCD; defined as children meeting DSM-IV criteria for OCD with age of onset <8 years). Fifty-eight children (ages 4-8) were included in the sample. OCD and comorbid diagnoses were determined by structured interview, and OCD severity was measured using the Children's Yale-Brown Obsessive Compulsive Scale (CY-BOCS). Mean age of OCD onset was almost five, and mean age of presentation was between 6 and 7. Mean symptom severity was in the moderately severe range. Comorbidity and family history of OCD were common. Contamination and aggressive/catastrophic obsessions and washing and checking compulsions were endorsed most frequently. Results indicate that early childhood onset OCD may have a lower boy to girl ratio and lower rates of depressive disorders, but may be similar to later childhood onset OCD in terms of OCD symptom presentation and severity.

Juvenile-onset OCD: clinical features in children, adolescents and adults

OBJECTIVE

To examine clinical correlates of juvenile-onset OCD across the lifespan.

METHOD

Data collected at the intake interview from 257 consecutive participants with juvenile-onset OCD (20 children, 44 adolescents and 193 adults) in a naturalistic study of the clinical course of OCD were examined. Participants and parents of juvenile participants completed a structured diagnostic interview, rater-administered severity measures and self-report questionnaires.

RESULTS

Children and adolescents (i.e. juveniles) shared similar features with the exception of age at onset and OCD symptom expression. Clinically meaningful differences between juvenile and adult participants were also found. Compared with adults, juveniles were more likely to be male, recall an earlier age at OCD onset and have different lifetime comorbidity patterns.

CONCLUSION

Juvenile-onset OCD symptom expression is remarkably similar across the lifespan. However, findings also suggest clinically meaningful differences between juveniles and adults. Future work using a prospective design will improve our understanding of course patterns of juvenile-onset OCD.

Early childhood OCD: preliminary findings from a family-based cognitive-behavioral approach

OBJECTIVE

To examine the relative efficacy of family-based cognitive-behavioral therapy (CBT) versus family-based relaxation treatment (RT) for young children ages 5 to 8 years with obsessive-compulsive disorder (OCD).

METHOD

Forty-two young children with primary OCD were randomized to receive 12 sessions of family-based CBT or family-based RT. Assessments were conducted before and after treatment by independent raters blind to treatment assignment. Primary outcomes included scores on the Children's Yale-Brown Obsessive Compulsive Scale and Clinical Global Impressions-Improvement.

RESULTS

For the intent-to-treat sample, CBT was associated with a moderate treatment effect (d = 0.53), although there was not a significant difference between the groups at conventional levels. For the completer sample, CBT had a large effect (d = 0.85), and there was a significant group difference favoring CBT. In the intent-to-treat sample, 50% of children in the CBT group achieved remission as compared to 20% in the RT group. In the completer sample, 69% of children in the CBT group achieved a clinical remission compared to 20% in the RT group.

CONCLUSIONS

Results indicate that children with early-onset OCD benefit from a treatment approach tailored to their developmental needs and family context. CBT was effective in reducing OCD symptoms and in helping a large number of children achieve a clinical remission.

Cognitive behavioral treatment for young children with obsessive-compulsive disorder

Obsessive-compulsive disorder (OCD) is a distressing and functionally impairing disorder that can emerge as early as age 4. Cognitive behavior therapy (CBT) for OCD in youth shows great promise for amelioration of symptoms and associated functional impairment. However, the empirical evidence base for the efficacy of CBT in youth has some significant limitations, particularly as related to treating the very young child with OCD. This report includes a quantitative review of existing child CBT studies to evaluate evidence for the efficacy of CBT for OCD. It identifies gaps in the literature that, when addressed, would enhance the understanding of effective treatment in pediatric OCD. Finally, it presents a proposed research agenda for addressing the unique concerns of the young child with OCD.

Obsessive-compulsive disorder

Compulsions are meant to relieve anxiety or to prevent a dreaded event. An adolescent or adult may recognize that the ritual is unreasonable or excessive, but that is not necessarily true for the young child. Children and adolescents will attempt to hide their rituals, although with more severe symptoms, this is not usually possible. To meet the diagnostic criteria for the disorder, the person must experience distress, spend more than 1 hour a day in either obsessions or compulsions, or experience significant interference in his/her life. This article reviews the phenomenology, causes, treatment, and outcome of children and adolescents with obsessive-compulsive disorder.

Family-based treatment of early-onset obsessive-compulsive disorder

Despite a meaningful common core of symptoms observed across the life span, there are particularly unique features of early-onset (prepubertal) obsessive-compulsive disorder (OCD) that make consideration of early presentation different from adolescent or adult onset and that may have important implications for treatment. This article will first review the unique features of early-onset OCD, focusing particular attention to the developmental and familial context of these children's symptoms. The literature on behavioral family interventions for other childhood disorders, specifically anxiety, as well as that on family processes (e.g., parent-child interactions) in families of children with OCD will be reviewed. The pediatric OCD cognitive-behavioral therapy (CBT) literature (CBT alone and CBT plus medication) will also be reviewed, focusing on current evidence-based treatment guidelines. Finally, a model of family-based treatment for young children with OCD and some preliminary pilot data will be presented.

A preliminary examination of treatment for posttraumatic stress disorder in chronic pain patients: a case study

Manualized treatments have become popular, despite concern about their use when comorbid diagnoses are present. In this report, the efficacy of manualized posttraumatic stress disorder (PTSD) treatment was examined in the presence of chronic pain. Additionally, the effect of PTSD treatment on chronic pain and additional psychiatric diagnoses was explored. Six female patients with both PTSD and chronic pain following motor vehicle accidents were treated for PTSD using a multiple baseline design. The results indicate that manualized treatment for PTSD was effective in reducing PTSD symptoms in these patients. Although there were no changes in subjective pain, there were pain-related functional improvements and reductions in other psychiatric diagnoses for the majority of patients.

Specificity of Stroop interference in patients with pain and PTSD

The authors investigated processing of threat words in motor vehicle accident survivors using a modified Stroop procedure. Three samples were included: 28 participants with comorbid posttraumatic stress disorder (PTSD) and pain, 26 participants with pain without PTSD, and 21 participants without pain or any psychiatric conditions. Four word categories were used: (a) accident words, (b) pain words, (c) positive words, and (d) neutral words. This study examined whether processing biases would occur to accident words only in participants with PTSD or if these biases would also be noted in the No PTSD/Pain sample. Additionally, this study examined whether processing biases would be noted to pain words in the 2 pain samples, irrespective of PTSD. Overall, color naming was significantly slower in the PTSD/Pain group in comparison with the other groups. As well, the PTSD/Pain sample showed significant response delays to both accident and pain-related words, whereas patients with No PTSD/Pain showed delays to pain stimuli only.

Specificity of Stroop interference in patients with pain and PTSD

The authors investigated processing of threat words in motor vehicle accident survivors using a modified Stroop procedure. Three samples were included: 28 participants with comorbid posttraumatic stress disorder (PTSD) and pain, 26 participants with pain without PTSD, and 21 participants without pain or any psychiatric conditions. Four word categories were used: (a) accident words, (b) pain words, (c) positive words, and (d) neutral words. This study examined whether processing biases would occur to accident words only in participants with PTSD or if these biases would also be noted in the No PTSD/Pain sample. Additionally, this study examined whether processing biases would be noted to pain words in the 2 pain samples, irrespective of PTSD. Overall, color naming was significantly slower in the PTSD/Pain group in comparison with the other groups. As well, the PTSD/Pain sample showed significant response delays to both accident and pain-related words, whereas patients with No PTSD/Pain showed delays to pain stimuli only.

Cognitive interference for trauma cues in sexually abused adolescent girls with posttraumatic stress disorder

Investigated cognitive processing of fear-relevant information in sexually abused adolescent girls with posttraumatic stress disorder (PTSD) using a modified Stroop procedure (MSP). Participants were 20 sexually abused girls with PTSD, 13 sexually abused girls without PTSD, and 20 nonvictimized girls who served as controls, 11 to 17 years old. Word conditions included abuse-related threat, developmentally relevant (related to the experience of sexual abuse, e.g., trust, secrecy, and intimacy), general threat, positive, and neutral. Girls with PTSD were expected to show cognitive interference for trauma-related words as well as for developmentally relevant words, relative to adolescents without PTSD. Overall color naming was significantly slower in the PTSD group than in the nonabused controls. Contrary to expectation, all participants demonstrated cognitive interference for trauma-related words. Relevant theoretical and methodological issues are highlighted.

Rush to judgment? Child protective services and allegations of sexual abuse

Two hundred and ninety-three randomly selected cases from a child protection service agency in a large western New York county were examined to test the hypothesis that sexual abuse allegations are investigated and processed more intensively than cases alleging other types of maltreatment. Contrary to the hypothesis, allegations of sexual abuse were substantiated at a lower rate, not investigated more intensively, and not offered more services than were other cases.

Weight loss after extended gastric bypass

BACKGROUND

Gastric bypass (GBP) is the most effective method for controlling morbid obesity. Previously we showed that extending the length of the Roux limb increased weight loss. We have done over 400 obesity operations during the past 20 years. The current study consists of patients from the last 10 years of our experience and compares short to extended Roux-en-Y GBP.

METHODS

Data from all patients operated at the Ottawa General Obesity Clinic were entered into a database on an ongoing basis, and those from the past 10 years were analyzed. All patients had standardized preoperative investigations and postoperative follow-up. Details of these and of the operative technique are provided in the manuscript.

RESULTS

The preoperative weight and BMI were 129 +/- 2 kg, and 46 +/- 2 kg/m2, respectively. The mean weight loss prior to surgery was -2 +/- 21 kg. The results were classified, by percentage weight loss as: 'excellent' = > 35%; 'good' = 25-34%; 'poor' = 15-24%; and 'failure' = < 15%. Sixty-five patients (69%) were available for 2-year follow-up. At this time, mean percentage weight loss was 34 +/- 2 versus 40 +/- 1 for the short Roux (45-135 cm) and long Roux (180-225 cm) groups, respectively (P < 0.01). There were no deaths, leaks, splenectomies or intra-abdominal infections. The incidence of hernia and/or reoperation for bowel obstruction was 35/121 or 29%. The overall incidence of diarrhea was 16/121 (13%) and 6/121 (5%) at 12 and 24 months. Quality of life is significantly impaired in at least three of these patients, all with extended limbs. Major vitamin deficiencies, alterations in liver functions, or other metabolic complications did not occur.

CONCLUSIONS

Gastric bypass is the procedure of choice for morbid obesity. Weight loss is marginally improved in proportion to the length of the Roux limb but at a risk of diarrhea, which occasionally may not manifest itself for 8 to 12 months. It is important that methods be devised to correct follow-up, incisional hernias and diarrhea.

Child age and caseworker attention in child protective services investigations

Infants and toddlers are at increased risk for severe/fatal abuse, often at the hands of male perpetrators. This paper examined whether child maltreatment cases involving younger children receive more casework services, overall caseworker activity (e.g., home visits, phone contacts), and are more likely to be substantiated, particularly if a male perpetrator is involved. The randomly selected sample consisted of 293 child abuse and neglect reports in a large county in Western New York in 1993. Hierarchical regression analyses showed that younger children generally receive more overall services and caseworker activity, and that while age makes a significant contribution after the decision has been made to substantiate a case, it does not have the same effect on the initial decision of whether or not to substantiate. Gender of the perpetrator did not reliably predict caseworker attention.

Lengthening the Roux-Y Limb Increases Weight Loss after Gastric Bypass: a preliminary report

We compared two variants of gastric bypass which have been used at our hospital since 1984. Initially all patients had a standard 45 cm Roux-Y anastomosed to a 30 cc gastric pouch. Subsequently we increased the length of the Roux-Y from 45 to 90 cm. In all patients the jejunum was divided 15-20 cm from the ligament of Treitz. There were six males, and 49 females with a mean age of 35 years. All were at least twice their ideal weights (range 91.5 to 179, X = 127.6). Percentage follow-up ranged from 100% at three months to 13% at 66 months for both the standard and lengthened Roux-Y groups. There were no major technical or metabolic complications. Doubling the length of the standard Roux-Y limb increased the percentage excess weight lost by approximately 6% without diarrhea or other apparent metabolic, sequelae.

Feeding jejunostomy: a safe adjunct to laparotomy

It is well established that a feeding jejunostomy is an invaluable adjuvant for use in critically ill and malnourished patients. What is not well known are the complications of inserting these tubes. Some surgeons are reluctant to insert feeding tubes unless the indications are very clear. From their experience with the insertion of 133 feeding jejunostomy tubes during a 3-year period, the authors conclude that the complications associated with the insertion of such tubes are few and that the procedure is justified even if the tube is never used.

Comparison of Marlex and Gore-tex to repair abdominal wall defects in the rat

Marlex and Gore-tex, two prosthetic materials used to close abdominal wounds, were compared with respect to strength and adhesion formation. A 2.5 X 3.5-cm full-thickness area of abdominal wall was excised in 32 CD rats. The defect was repaired using identically sized patches of Marlex or 1-mm Gore-tex, determined by alternate assignment, and sutured with continuous 4-0 Gore-tex. Adhesion formation was graded at necropsy and recorded photographically in each animal. The mean adhesion index (none = 0, maximal = 4) was 1.37 +/- 0.12 and 2.62 +/- 0.12 (mean +/- SEM) for Gore-tex and Marlex groups respectively (p less than 0.005, unpaired t-test). A template was used to fashion 2-cm coronal strips of abdominal wall for tensile-strength testing. The relative strengths were 2.67 +/- 0.14 and 3.02 +/- 0.16 kg/cm (mean +/- SEM) for the Gore-tex and Marlex groups respectively (NS). Histologically, there were more epithelioid giant cells and less collagen formation in the Gore-tex group. Abdominal wall reconstruction with Gore-tex resulted in wound strength equal to that of Marlex and fewer adhesions. Gore-tex is preferred when prosthetic material and viscera are in close proximity.

The use of endoscopy after gastric partitioning for morbid obesity

Fiberoptic endoscopy is an important diagnostic modality for evaluating the patient with upper gastrointestinal tract symptoms following gastric restrictive operations. The specific indications for endoscopy after obesity surgery include stoma evaluation in patients who fail to lose adequate weight; stomal stenosis; esophagitis; surveillance of the excluded pouch; and suspicion of a marginal ulcer after gastric bypass.

Nonoperative management of stomal stenosis after gastroplasty for morbid obesity

Over a period of six years, 33 of 172 (19 per cent) patients who had gastric partitioning had stomal stenosis develop which was defined as an inability to drink fluids or swallow saliva, or both. All were managed conservatively in the hospital or on an outpatient basis. This consisted of total parenteral nutrition and endoscopy to evaluate the stoma with or without dilation; Eder-Puestow dilaters and long term jejunostomy feeding were used. Thirteen of these patients were dilated a total of 36 times. Three required three to six dilations each, up to the maximum size (45F). There were no complications. Twenty-nine required repletion by combined parenteral and enteral nutrition. Three required jejunostomy insertion as a separate procedure. Patients were observed for six to 60 months. Thirty-two did well. Gastrogastrostomy was required in one patient with a stenosis after the second gastroplasty. Three patients who were dilated regained over 20 per cent of their ideal weight.

Serum alanine aminotransferase to aspartate aminotransferase ratio and degree of fatty liver in morbidly obese patients

We evaluated the change in serum alanine aminotransferase (ALT; EC 2.6.1.2) to serum aspartate aminotransferase (AST; EC 2.6.1.; ALT/AST) ratio with the degree of fatty liver in morbidly obese patients. A total of 31 patients were included in the study. Fatty liver was graded as 0 to 4+. The mean and SD of AST and ALT were not significantly different between groups of patients with various grades of fatty liver. There was, however, a significant correlation between the ALT/AST ratio and the degree of fatty infiltration of the liver. This, we believe, implies damage mainly to the plasma membrane allowing loss of cytoplasmic enzymes rather than loss of mitochondrial enzymes.

Prevention of superficial phlebitis during peripheral parenteral nutrition

Fifty-four patients receiving peripheral parenteral nutrition consisting of 3.5 percent amino acids in a 5 percent dextrose solution were randomly assigned in a double-blind fashion to receive this solution with or without an antiphlebitic mixture (1000 IU heparin, 5 mg hydrocortisone, and 1.8 mEq sodium hydroxide as a buffer). The addition of antiphlebitic mixture resulted in a marked and highly significant reduction in the incidence of phlebitis and a prolongation of the number of phlebitis-free hours during infusion of peripheral parenteral nutrition (p less than 0.005).

Long-term follow-up of concomitant band ligation and sclerotherapy for internal hemorrhoids

From 1978 to 1983, 111 patients with symptomatic internal hemorrhoids were treated as outpatients by a modification of the Barron ligation technique. Each ligated hemorrhoid was injected with a sclerosant. Follow-up, available for 94 of the patients, ranged from 2 to 60 months (mean 18 months). Presenting symptoms were bleeding in 75 (80%) of the 94 patients, pain in 46 (49%), pruritus in 22 (23%) and prolapse in 24 (26%). Results were excellent in 51 (54%) patients, good in 20 (21%) and fair in 9 (10%). Fourteen (15%) patients had unsatisfactory results; only 4 of these required hemorrhoidectomy. The other 10 had residual symptoms but did not require further treatment. Nine patients had minor complications, which included pain lasting 24 to 72 hours in seven, bleeding in one and syncope in one. The addition of sclerotherapy to traditional band ligation for the management of internal hemorrhoids has the advantages of exciting a greater inflammatory reaction between the mucosa and submucosa and preventing premature slipping of the band. The authors conclude that this method of therapy is effective for symptomatic hemorrhoids and that surgical hemorrhoidectomy is seldom indicated.