Alessandro S. De Nadai

The Effect of Cognitive-Behavioral Therapy Versus Treatment as Usual for Anxiety in Children With Autism Spectrum Disorders: A Randomized, Controlled Trial

OBJECTIVE To examine the efficacy of a modular cognitive-behavioral therapy (CBT) protocol relative to treatment as usual (TAU) among children with high-functioning autism spectrum disorders (ASD) and clinically significant anxiety. METHOD A total of 45 children (7-11 years of age) with high-functioning ASD and clinically significant anxiety were randomized to receive 16 sessions of weekly CBT or TAU for an equivalent duration. After screening, assessments were conducted at baseline, post-treatment, and 3-month follow-up. Raters were blind to treatment condition. RESULTS Youth receiving CBT showed substantial improvement relative to TAU on primary anxiety outcomes. Of 24 children randomized to the CBT arm, 18 (75%) were treatment responders, versus only 3 of 21 children (14%) in the TAU arm. Gains were generally maintained at 3-month follow-up for CBT responders. CONCLUSIONS Relative to usual care, CBT adapted for anxious youth with high-functioning ASD demonstrates large effects in reducing anxiety symptoms. This study contributes to the growing literature supporting adapted CBT approaches for treating anxiety in youth with ASD.

Defining treatment response and remission in obsessive-compulsive disorder: a signal detection analysis of the Children's Yale-Brown Obsessive Compulsive Scale.

OBJECTIVE To examine the optimal Childrens Yale-Brown Obsessive-Compulsive Scale (CY-BOCS) percent reduction cutoffs for predicting treatment response and clinical remission among children and adolescents with obsessive-compulsive disorder (OCD). METHOD Youth with OCD (N = 109; range 7 to 19 years) received 14 sessions of weekly or intensive family-based CBT as part of previously published studies or through the standard clinical flow at our facility. Assessments were conducted before and after treatment and included the CY-BOCS, response and remission status on the Clinical Global Impressions Scale, and the Child Obsessive-Compulsive Impact Scale. RESULTS Maximally efficient CY-BOCS cutoffs were observed at a 25% reduction for treatment response, a 45% to 50% reduction for symptom remission, and a CY-BOCS score of 14 when considering raw scores. OCD-related impairment improved as a function of treatment response and symptom remission. CONCLUSIONS These data indicate that a CY-BOCS reduction of 25% appears to be optimal for determining treatment response, a reduction of 45% to 50% appears to be optimal for detecting symptom remission, and a CY-BOCS raw score of 14 best reflects remission after treatment. Clinical trials should employ a consistent definition of treatment response for cross-study comparability. Clinicians can use these values for treatment planning decisions.

Rage Attacks in Pediatric Obsessive-Compulsive Disorder: Phenomenology and Clinical Correlates.

OBJECTIVE Rage attacks have been documented in youth with varied psychiatric disorders, but few data have been reported on the clinical characteristics and correlates of rage attacks among children with obsessive-compulsive disorder (OCD). METHOD Participants were 86 children (ages 6-16 years) with a primary diagnosis of OCD. Patients and their primary caregiver were administered clinician-rated measures of obsessive-compulsive severity and rage severity. Children completed the Center for Epidemiologic Studies Depression Scale and the Child Sheehan Disability Scale-Child, whereas parents completed the Rage Attacks Questionnaire, Aberrant Behavior Checklist-Irritability Scale, Childrens Affective Lability Scale, and Child Sheehan Disability Scale-Parent. RESULTS Rage was common among youth with OCD and was associated with varied clinical characteristics. Rage severity accounted for functional impairment beyond the influence of obsessive-compulsive symptom severity; however, these relations were explained by the impact of family accommodation. CONCLUSIONS These data suggest that rage attacks are relatively common, have a negative impact on illness presentation, and contribute to functional impairment above and beyond obsessive-compulsive symptom severity. Rage may contribute to family accommodation of symptoms, which may further affect obsessive-compulsive symptom severity and impairment.

Multiple Informant Agreement on the Anxiety Disorders Interview Schedule in Youth with Autism Spectrum Disorders

OBJECTIVE The purpose of this study was to examine child, parent, and clinicians consensus agreement on the Anxiety Disorders Interview Schedule, Child and Parent versions (ADIS-C/P) in a sample of children and adolescents with autism spectrum disorders (ASD). METHOD Youth with ASD (n=85; age range=7-17 years) and their parents were each administered the ADIS-C/P by a trained clinician. Consensus diagnoses were determined in a clinical conference using best estimate procedures that incorporated all available information. RESULTS Children and youth with ASD diagnoses generally showed poor diagnostic agreement with parents and clinical consensus, whereas parents showed good-to-excellent diagnostic agreement with clinical consensus diagnoses. Diagnostic agreement between parents and consensus was moderated by the specific ASD diagnosis. Otherwise, the pattern of relationships did not systematically differ as a function of age or externalizing comorbidity. CONCLUSIONS These data suggest that parent and youth agreement regarding the presence of clinical levels of anxiety is markedly poor among youth with ASD. Additionally, clinicians are likely to base their diagnostic impressions on parent report, placing minimal emphasis on child report.

Refining clinical judgment of treatment outcome in obsessive–compulsive disorder

This research aimed to provide clinicians and investigators with optimal treatment outcome criteria for accurately predicting response and remission in both research studies and clinical practice. Data from 153 adult OCD outpatients (ages 18-79) who had participated in a treatment outcome study were examined. Signal detection analysis was conducted to compare levels of Yale-Brown Obsessive Compulsive Scale (Y-BOCS) symptom percent reductions and post treatment absolute scores with Clinical Global Impression (CGI) ratings of symptom improvement and severity. Optimal cutoff criteria were based on sensitivity, specificity and efficiency and were assessed via the Quality Receiver Operating Characteristic curve. A Y-BOCS reduction of 45% was observed to be the most efficient for predicting response in research trials, whereas a reduction of 35% may be optimal for clinical use. A 55% Y-BOCS reduction was determined to be the optimal cutoff for predicting remission in both clinical and research settings. A Y-BOCS absolute raw score of 12 or less was optimal for predicting remission in a clinical setting and a raw score of 14 or below was most favorable in research trials. This research provides the first empirical contrast of optimal outcome criteria in OCD based on differing ideals of both research and practice.

Defining Treatment Response in Pediatric Tic Disorders: A Signal Detection Analysis of the Yale Global Tic Severity Scale

OBJECTIVE To examine the optimal Yale Global Tic Severity Scale (YGTSS) percent reduction and raw cutoffs for predicting treatment response among children and adolescents with tic disorders. METHOD Youth with a tic disorder (N=108; range=5-17 years) participated in several clinical trials involving varied medications or psychosocial treatment, or received naturalistic care. Assessments were conducted before and after treatment and included the YGTSS and response status on the Clinical Global Impressions-Improvement Scale (CGI-I). RESULTS A 35% reduction on the YGTSS total tic severity score or a YGTSS raw total tic severity score change of 6 or 7 points were the best indicators of clinical treatment response in youth with tic disorders. CONCLUSIONS A YGTSS total tic severity score reduction of 35% or a raw total tic severity score change of 6 or 7 appears optimal for determining treatment response. A consistent definition of treatment response on the YGTSS may facilitate cross-study comparability. Practitioners can use these values for treatment planning decisions (e.g., change medications, etc.).

The relationship between change in therapeutic alliance ratings and improvement in youth symptom severity: Whose ratings matter the most?

This paper presents the psychometric evaluation of brief measures of therapeutic alliance (TA) for youths, clinicians and caregivers and a longitudinal analysis of relationships between changes in TA and changes in youth symptom and functioning severity. Psychometric analyses using methods from Classical Test Theory, Item Response Theory, and Factor Analysis indicate that the measures of TA used in this study offer something new for both practice and research. The measures have variability, sensitivity to change over time, brevity and can be used with multiple parties through parallel forms. The longitudinal analyses, employing hierarchical linear modeling with time-varying covariates, found that TA ratings of the clinician correlated with symptom improvement as rated by the clinician, caregiver and youth. Additional analyses showed that decreases in clinician-rated youth TA was most important in predicting a lower rate of youth improvement. Implications for future research and clinical practice are discussed.

Psychometric Properties of the Obsessive Compulsive Inventory: Child Version in Children and Adolescents with Obsessive–Compulsive Disorder

The psychometric properties of the Obsessive Compulsive Inventory–Child Version (OCI-CV) were examined in ninety-six youth with a primary/co-primary diagnosis of obsessive–compulsive disorder (OCD). A confirmatory factor analysis revealed an acceptable model of fit with factors consisting of doubting/checking, obsessing, hoarding, washing, ordering, and neutralizing. The internal consistency of the OCI-CV total score was good, while internal consistency for subscale scores ranged from poor to good. The OCI-CV was modestly correlated with obsessive–compulsive symptom severity on the Children’s Yale-Brown Obsessive Compulsive Scale (CY-BOCS) Severity Scale, as well as with clinician-reported OCD severity. All OCI-CV subscales significantly correlated with the corresponding CY-BOCS Symptom Checklist dimension. The OCI-CV significantly correlated with child-reported depressive symptoms and OCD-related functional impairment, but was not significantly correlated with parent-reported irritability or clinician-reported overall functioning. Taken together, these data suggest the psychometric properties of the OCI-CV are adequate for assessing obsessive–compulsive symptom presence among youth with OCD.

Agreement between Therapists, Parents, Patients, and Independent Evaluators on Clinical Improvement in Pediatric Obsessive-Compulsive Disorder.

OBJECTIVE Independent evaluators (IE) are used widely in clinical trials to make unbiased determinations of treatment response. By virtue of being kept blind to treatment condition, however, IEs are also kept unaware of many pertinent clinical details that are relevant for decisions about clinical improvement. In this study, agreement among raters (children, parents, therapists, and IEs) about treatment response over the course of a 14-week clinical trial for pediatric obsessive-compulsive disorder (OCD) was examined in order to determine the utility of nonblind clinician and patient ratings of treatment response. METHOD Participants were 71 youth (mean age = 12.2 years; 63.4% female) with a primary diagnosis of OCD and their parents participating in a psychotherapy trial. IEs provided response ratings (Clinicians Global Impressions-Improvement Scale; CGI-I) at Weeks 4, 8, and 14, and therapists, children, and parents completed independent CGI-I ratings at Weeks 2, 4, 8, and 14. RESULTS Nonlinear mixed models revealed differences in rating parties, with therapists and IEs slower to rate treatment improvement compared with children and parents, and growth curve models suggested that therapists and IEs produced generally consistent ratings. In addition, no evidence was found for an Evaluator × Treatment interaction, indicating that raters displayed these differences consistently across both active and placebo conditions. CONCLUSIONS Youth and parents may be able to provide accurate ratings of global improvement; nonblinded treating clinicians (with training in research-oriented assessment) can offer global improvement ratings commensurate with blinded IEs. Findings suggest that alternatives (or additions) to the blinded-IE model may be appropriate for assessing global improvement, especially with the growing emphasis on dissemination and effectiveness trials.

Dysregulation in pediatric obsessive compulsive disorder

Although obsessive compulsive disorder (OCD) and common co-occurring conditions share deficits in self-regulatory abilities, there has been minimal examination of impaired self-regulation (dysregulation) in youth with OCD. This study examined the association of dysregulation with symptom severity, impairment, and treatment outcome in pediatric OCD. Clinicians assessed obsessive-compulsive severity, family accommodation and global severity in 144 youth with OCD. Youth completed self-report severity ratings of anxiety and depressive symptoms. Parents completed the Child Behavior Checklist (CBCL), and both children and parents completed parallel ratings of obsessive-compulsive impairment. Ninety-seven youth received cognitive behavioral therapy (CBT) and were re-assessed after treatment. Dysregulation was assessed using the CBCL-Dysregulation Profile. Before treatment, dysregulated youth exhibited greater obsessive-compulsive symptom severity, depressive mood, family accommodation, and impairment than non-dysregulated youth. The magnitude of dysregulation directly predicted child-rated impairment, parent-rated impairment, and family accommodation, beyond obsessive-compulsive severity. The magnitude of pretreatment dysregulation predicted treatment discontinuation but not treatment response. Obsessive-compulsive symptom severity and dysregulation level significantly decreased after CBT. Dysregulated youth with OCD presented as more clinically severe than their non-dysregulated counterparts, and may require more individualized interventions to reduce dysregulated behavior to prevent CBT attrition. For treatment completers, CBT was associated with a decrease in dysregulation level.