Bernhard Weidle

Response to atomoxetine in boys with high-functioning autism spectrum disorders and attention deficit/hyperactivity disorder

Aim:  To study the efficacy and tolerability of atomoxetine in high‐functioning boys with autism spectrum disorders (ASD) and comorbid attention deficit/hyperactivity disorder (AD/HD).

The Nordic long-term OCD treatment study (NordLOTS): rationale, design, and methods

BackgroundThis paper describes and discusses the methodology of the Nordic long-term OCD-treatment study (NordLOTS). The purpose of this effectiveness study was to study treatment outcome of CBT, to identify CBT non- or partial responders and to investigate whether an increased number of CBT-sessions or sertraline treatment gives the best outcome; to identify treatment refractory patients and to investigate the outcome of aripiprazole augmentation; to study the outcome over a three year period for each responder including the risk of relapse, and finally to study predictors, moderators and mediators of treatment response.MethodsStep 1 was an open and uncontrolled clinical trial with CBT, step 2 was a controlled, randomised non-blinded study of CBT non-responders from step 1. Patients were randomized to receive either sertraline plus CBT-support or continued and modified CBT. In step 3 patients who did not respond to either CBT or sertraline were treated with aripiprazole augmentation to sertraline.ConclusionsThis multicenter trial covering three Scandinavian countries is going to be the largest CBT-study for paediatric OCD to date. It is not funded by industry and tries in the short and long-term to answer the question whether further CBT or SSRI is better in CBT non-responders.

Tics Moderate Sertraline, but Not Cognitive-Behavior Therapy Response in Pediatric Obsessive-Compulsive Disorder Patients Who Do Not Respond to Cognitive-Behavior Therapy.

Abstract Objective: The purpose of this study was to investigate whether the presence of tic disorder is negatively associated with sertraline (SRT) outcomes, but not with continued cognitive-behavioral therapy (CBT), in a sample of youth who were unresponsive to an initial full course of CBT. Methods: In the Nordic Long-Term OCD Study, children and adolescents with OCD who were rated as nonresponders to 14 weeks of open-label CBT were randomized to continued CBT (n=28) or SRT treatment (n=22) for an additional 16 weeks of treatment. We investigated whether the presence or absence of comorbid tic disorder moderated treatment outcomes on the Childrens Yale-Brown Obsessive Compulsive Scale (CY-BOCS). Results: Twelve out of 50 (24.0%) participants were diagnosed with comorbid tic disorder, with 7 receiving continued CBT and 5 receiving SRT, respectively. In patients without tic disorder, results showed no significant between-group differences on average CY-BOCS scores. However, in patients with comorbid tic disorder, those who received SRT had significantly lower average CY-BOCS scores than those who received continued CBT. Conclusions: Children and adolescents with OCD and comorbid tic disorder, who are nonresponders to an initial 14 week course of CBT, may benefit more from a serotonin reuptake inhibitor (SRI) than from continued CBT.

Obsessive-compulsive symptom dimensions: Association with comorbidity profiles and cognitive-behavioral therapy outcome in pediatric obsessive-compulsive disorder

Our aims were to examine: (1) classes of comorbid disorders in a sample of children and adolescents with Obsessive-Compulsive Disorder (OCD), (2) how these classes relate to obsessive-compulsive symptom dimensions, and (3) the extent to which obsessive-compulsive symptom dimensions predict Cognitive-Behavioral Therapy (CBT) outcome. Participants (N = 269) were assessed with the Kiddie Schedule for Affective Disorders and Schizophrenia (K-SADS-PL) and the Childrens Yale-Brown Obsessive-Compulsive Scale (CY-BOCS). Latent Class Analysis (LCA) was used to identify comorbidity classes. Regression analyses were used to evaluate symptom dimensions as predictors of treatment outcome and their relation to comorbidity classes. Comorbidity was included in the treatment outcome analyses as it can affect outcome. Comorbidity was best categorized by a three-class model and each class was distinctively correlated with the OCD symptom dimensions. Higher scores on the symmetry/hoarding factor increased the chance of responding to CBT by an odds ratio of 1.56 (p = 0.020) when controlled for age, gender, and comorbidity class. The harm/sexual factor (p = 0.675) and contamination/cleaning factor (p = 0.122) did not predict CBT outcome. Three clinically relevant comorbidity subgroups in pediatric OCD were identified. Patients who exhibited higher levels of symmetry/hoarding dimension were more prone to respond to CBT.

Essential Child and Adolescent Psychiatry and Substance Use Disorders for the Nonpsychiatrist

This chapter provides an overview of common child and adolescent psychiatric disorders from the perspective of general pediatric practice. The introduction discusses goals of diagnostic classification and the usefulness and disadvantages of our current classification systems. The chapter outlines the essentials of the following eight conditions: attention-deficit hyperactivity disorder (ADHD), conduct disorder, mood disorders, anxiety disorders and obsessive-compulsive disorder, tic disorders, autism spectrum disorder, schizophrenia spectrum and other psychotic disorders, and substance use disorders. Case vignettes illustrate the clinical presentation of the disorders. For each condition, the chapter discusses diagnostic work-up, including specific assessment tools, and summarizes evidence-based treatment strategies, especially psychoeducation, psychotherapy, and psychopharmacology.

Psychoeducation for Children, Parents, and Family Members About Obsessive-Compulsive Disorder and Cognitive Behavior Therapy

Abstract In this chapter we illustrate how to provide psychoeducation about cognitive behavior therapy (CBT) for pediatric obsessive–compulsive disorder (OCD). We present practical suggestions on how to present this information to children, adolescents, and other family members in a developmentally appropriate way. The chapter covers how to communicate both basic information about OCD as well as an integrative understanding of different theoretical models of OCD. We include a step-by-step approach in how to accomplish relevant educative goals to prepare the grounds for delivering CBT and engage in exposure exercises related to CBT for the clinician. We include detailed and practical-oriented discussions on how to convey psychoeducation about treatment rationale, especially for exposure and response prevention. Finally, we discuss challenging issues which are commonly associated with poorer CBT outcome, such as poor motivation, poor insight, limited cognitive capacity, or comorbid disorders with the aim to adjust psychoeducation in order to improve outcome.

Medication Management of Childhood OCD

Abstract Drug treatment in pediatric OCD has been used for close to 40 years, and the evidence for the efficacy of serotonin reuptake inhibiting (SRI) drugs that has been accumulated is substantial. Starting out with placebo-controlled studies it was established that patients on SRI (e.g., clomipramine, sertraline, fluoxetine, or fluvoxamine) did decrease OCD symptoms with a moderate effect size. However, in direct head-to-head comparisons CBT is superior to SRI and is more robust across different comparisons. For example, does CBT in combination with SSRI work well in SSRI nonresponders, while CBT and sertraline do as well in CBT nonresponders (in a trial of average duration) and sertraline treatment does not enhance good CBT. We argue that CBT should be the first-line treatment in OCD and that SSRI should be reserved for those who do not respond to expertly delivered and possibly extended CBT (i.e., 16–24 sessions). The teams working with pediatric OCD patients should as well consider if pharmacological treatment may be needed for comorbid problems that may interfere with CBT (e.g., treatment for ADHD, severe aggression, etc.)

How can technology enhance cognitive behavioral therapy: The case of pediatric obsessive compulsive disorder

Many children with mental health disorders do not receive adequate treatment due to the uneven dissemination of resources, and other barriers to treatment. In the case of pediatric obsessive compulsive disorder treatment progress is also hindered by partial or non-response to treatment in addition to poor compliance. This debate paper focuses on new technologies as a potential vehicle to address the challenges faced by traditional treatment, with special reference to cognitive behavioral therapy for pediatric obsessive compulsive disorder. We discuss the achievements and challenges that previous studies have faced, debate ways to overcome them, and we offer specific suggestions for further research in the area.

Treatment of a Child With Obsessive‐Compulsive Disorder With Limited Motivation: Course and Outcome of Cognitive‐Behavior Therapy

Motivation is a key ingredient in the successful treatment of pediatric obsessive-compulsive disorder (OCD). As a first-line treatment, cognitive-behavior therapy (CBT) requires extensive client engagement, including participating in exposures and doing homework tasks. A lack of motivation to comply with these tasks may seriously affect treatment outcome. This case study identifies factors interfering with motivation and illustrates motivational strategies to enhance compliance of a child with OCD. The patient was an 11-year-old boy with severe OCD and symptoms of oppositional defiant disorder (ODD). He had extensive OCD-related avoidance behavior but denied the presence of symptoms or did not acknowledge them as a problem. In this article, we discuss the different techniques used to enhance motivation, which subsequently led to a favorable outcome.

Sertraline Treatment of Nonresponders to Extended Cognitive-Behavior Therapy in Pediatric Obsessive-Compulsive Disorder.

OBJECTIVE The purpose of this study was to investigate the effect of sertraline (SRT) in children and adolescents with obsessive-compulsive disorder (OCD) who did not respond to two consecutive courses of cognitive-behavior therapy (CBT). METHODS Observational study with 11 participants (males, n=6), 7-17 years of age with Diagnostic and Statistical Manual of Mental Disorders, 4th ed. (DSM-IV) primary OCD. All had received 14 plus 10 sessions of CBT over the course of 218-532 days (mean=342.2, SD=85.5). Outcome measures were mean reduction of the Childrens Yale-Brown Obsessive Compulsive Scale (CY-BOCS) total score and adequate clinical response (CY-BOCS<16). All participants received SRT (maximum dose 200 mg/day). The study was a part of the Nordic Long-Term OCD Treatment Study (NordLOTS). RESULTS Participants were treated with SRT over 72-300 days (mean=164.2, SD=68.3). The mean CY-BOCS score was reduced from 21.5 (SD=2.6) to 17.5 (SD=3.3). Only three participants obtained adequate clinical response (27.2%), and only two obtained >25% CY-BOCS total score reduction (close to 50%). CONCLUSIONS A clinical response in approximately one third of the participants suggests that SRT treatment might be beneficial to a minority of patients who have consistently failed CBT.