Chelsea M. Ale

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 Childrens 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.

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.

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.

Case Examples of Enhancing Pediatric OCD Treatment With a Smartphone Application

These case examples depict the use of a smartphone application, Mayo Clinic Anxiety Coach, to enhance the treatment of pediatric obsessive-compulsive disorder (OCD). The presented cases highlight the use of Anxiety Coach as a stand-alone intervention for mild OCD symptoms and as an adjunct to treatment for severe OCD complicated by geographical barriers. Each case includes a description of treatment, patient use of the application, objective assessment of clinical symptoms, and a qualitative interview with the families. Both patients responded well to treatment and had a positive experience with Anxiety Coach. The application encouraged the families to complete exposures between sessions and allowed a detailed examination of the patients’ engagement in homework assignments. Potential uses of smartphone applications to address challenges facing treatment of, and research on, OCD are discussed.

The Role of Co-Occurring Disruptive Behavior in the Clinical Presentation of Children and Adolescents with Anxiety in the Context of Autism Spectrum Disorders

This study explored the impact of disruptive behavior disorder (DBD) comorbidity on theoretically relevant correlates among 87 children and adolescents with autism spectrum disorders (ASD) and clinically significant anxiety. Relative to youth with ASD and anxiety alone, participants with ASD, anxiety, and DBD: (a) presented with significantly more severe anxiety symptoms per clinician-, parent-, and self-report; (b) were more likely to be prescribed antipsychotic medication but were no more likely to receive additional psychosocial and educational interventions; and (c) experienced significantly greater functional impairment and family interference. These results suggest that co-occurring DBD in the context of ASD and anxiety confers greater risk for heightened symptom severity and functional impairment, and may be linked with increased prescription of antipsychotic medication.

A baseline controlled examination of a 5-day intensive treatment for pediatric obsessive-compulsive disorder

This study extends support for a 5-day intensive exposure and response prevention (ERP) treatment protocol for pediatric obsessive compulsive disorder (OCD). Twenty-two children with OCD received ERP treatment twice daily for 5 days. The treatment also emphasized teaching children and parents how to conduct ERP independently after they returned home. Symptoms were assessed at four time-points: Baseline, 4 weeks later at pre-treatment, one week after the intensive treatment 5-day treatment, and at 3 month follow-up. Changes on the primary outcome measure, clinician severity ratings on the Anxiety Disorders Interview Schedule for Children, and secondary measures, indicated that OCD symptoms remained stable from the evaluation to baseline and improved significantly from baseline to follow-up. Moreover, parental accommodation of OCD decreased significantly from baseline to post-treatment and from post-treatment to follow-up. These data suggest that the 5-day intervention demonstrates efficacy in reducing OCD symptoms and may initiate change in parent accommodation that continues to improve after the family returns home.

The feasibility of improving CBT for childhood anxiety disorders through a dismantling study.

This preliminary randomized controlled trial (RCT) examines the feasibility of dismantling cognitive behavioral therapy (CBT) for childhood anxiety disorders. Fourteen children (10 girls) ages 7 to 14 (m = 10.2) with social phobia, generalized anxiety disorder, separation anxiety disorder, or panic disorder were randomized to receive 6 sessions of either a) the pre-exposure anxiety management strategies presented in traditional CBT, or b) parent-coached exposure therapy. The sample was selected from a treatment seeking population and is representative of children in clinical settings. Examination of fidelity ratings, dropouts, and satisfaction ratings indicated that the interventions were distinguishable, safe, and tolerable. The overall sample improved significantly with pre-post effect sizes generally in the large range for both conditions. Between-group effect sizes indicating greater improvement with parent-coached exposure therapy were moderate or large for ten of 12 variables (i.e., 0.53 to 1.52). Re-evaluation after three months of open treatment suggested that the intervention emphasizing exposure early maintained its superiority while requiring fewer appointments.

Development of Child- and Parent-Report Measures of Behavioral Avoidance Related to Childhood Anxiety Disorders

The current report describes 3 studies conducted to develop 8-item child- and parent-report measures to further the understanding of the role of behavioral avoidance in the development, maintenance, and treatment of childhood anxiety disorders. Participants included both clinical (N=463; ages 8 to 12) and community (N=421; ages 7 to 18) samples of children and their parents from primarily Caucasian intact families. Follow-up data were collected from 104 families in the community sample. Overall, the measures were internally consistent and related to anxiety, distress, and alternative measures of avoidance in both samples. Parent report of childrens behavioral avoidance evidenced the strongest psychometric properties, differentiated among clinical and community populations, and most importantly, predicted childrens anxiety at least 8 months later over and above initial anxiety ratings. Moreover, decreases in avoidance were associated with successful exposure therapy. These results are consistent with the role of behavioral avoidance in the development of anxiety and provide an efficient tool for assessing the role of avoidance in clinical and research settings.

Family-Based Behavioral Treatment of Pediatric Compulsive Hoarding A Case Example

Although compulsive hoarding may pose health, social, and developmental impairment for children, there are few phenomenological and treatment studies to guide assessment and treatment. Current evidence-based questions the link between hoarding and obsessive compulsive disorder (OCD) and the effectiveness of cognitive behavioral therapy protocols for OCD to adequately address the unique challenges of poor insight, poor emotion regulation, and increased family accommodation in children with compulsive hoarding. This case study seeks to illustrate a family-based behavioral approach to outpatient treatment of compulsive hoarding with a 9-year-old girl (pseudonym Lily). Treatment included psychoeducation, exposure to discarding items, exposure to acquiring cues, and parent behavior management techniques.

Two Cases of Early Childhood Selective Mutism Variations and Treatment Complexities

Selective Mutism (SM) is a highly impairing disorder which typically presents upon entry to school and affects approximately 0.7% of children. Despite its impact on social and academic development, it is a difficult disorder to treat and there is a small evidence base for behavioral treatment. Preliminary evidence suggests that behavioral treatment focused on exposure to social interactions, social skill building, and involvement of caregivers in treatment may be promising. This article presents two cases of early childhood SM to demonstrate the importance of tailored treatment implementation to meet the individual needs of each family and help children resume typical social development.