Else de Haan

Cognitive and behavioral therapies alone versus in combination with fluvoxamine in the treatment of obsessive Compulsive disorder

The purpose of this treatment package design study was to investigate the differential efficacy of cognitive therapy or exposure in vivo with response prevention for obsessive compulsive disorder (OCD) versus the sequential combination with fluvoxamine. Patients with OCD (N = 117) were randomized to one of the following five conditions: a) cognitive therapy for weeks 1 to 16, b) exposure in vivo with response prevention for weeks 1 to 16, c) fluvoxamine for weeks 1 to 16 plus cognitive therapy in weeks 9 to 16, d) fluvoxamine for weeks 1 to 16 plus exposure in vivo with response prevention in weeks 9 to 16, or e) waiting list control condition for weeks 1 to 8 only. Assessments took place before treatment (pretest) and after 8 (midtest), and 16 weeks (posttest). In the first 8 weeks, six treatment sessions were delivered. During weeks 9 to 16, another 10 sessions were given. Thirty-one patients dropped out. Outcome was assessed by patient-, therapist- and assessor-ratings of the Anxiety Discomfort Scale, the Yale-Brown Obsessive Compulsive Scale, and the Padua Inventory-Revised. In contrast with the four treatments, after 8 weeks the waiting list control condition did not result in a significant decrease of symptoms. After 16 weeks of treatment, all four treatment packages were effective on these OCD ratings, but they did not differ among each other in effectiveness. In OCD, the sequential combination of fluvoxamine with cognitive therapy or exposure in vivo with response prevention is not superior to either cognitive therapy or exposure in vivo alone.

Child versus family cognitive-behavioral therapy in clinically anxious youth: An efficacy and partial effectiveness study

OBJECTIVE The efficacy and partial effectiveness of child-focused versus family-focused cognitive-behavioral therapy (CBT) for clinically anxious youths was evaluated, in particular in relation to parental anxiety disorders and childs age. METHOD Clinically referred children with anxiety disorders (N = 128) and their parents were randomly assigned to child or family CBT and evaluated at pretreatment, posttreatment, and 3-month follow-up. Twenty-five families were measured before and after a 2- to 3-month waitlist period. RESULTS None of the waitlisted children recovered from their anxiety disorders. In contrast, 41% of the treated children no longer met criteria for any anxiety disorder after CBT, and 52% demonstrated continued improvement at the 3-month follow-up. Significantly more children were free of anxiety disorders (53%) in the child CBT condition compared with family CBT condition (28%) at posttreatment, whereas at 3-month follow-up, the superior effect of child CBT was no longer significant. Similar results were obtained from the questionnaire measures. Both child and family CBT were less effective if parents had an anxiety disorder themselves. On some of the measures, child CBT was superior if parents had anxiety disorders themselves, whereas family CBT was superior if parents had no anxiety disorders. Finally, younger children had better outcomes than older children, regardless of the treatment condition. CONCLUSIONS Overall, child CBT seems slightly more beneficial than family CBT. Because this study was conducted in a clinical setting with clinically referred children, results indicate partial effectiveness for child CBT.

Paediatric obsessive-compulsive disorder, a neurodevelopmental disorder? Evidence from neuroimaging.

OBJECTIVE To present an overview of neuroimaging data on paediatric obsessive-compulsive disorder (OCD) and discuss implications for further research. METHOD Medline PsycINFO databases and reference lists were searched for relevant articles. All neuroimaging studies up to October 1, 2008 involving children and adolescents with obsessive-compulsive disorder were included. RESULTS Twenty-eight neuroimaging studies using various neuroimaging techniques (CT (2) MRI (15) MRS (8) and SPECT (2) fMRI (2) but no PET or DTI) including a total of 462 paediatric patients were identified. A number of findings indicate a dysfunction of the prefrontal-striatal-thalamic circuit with the involvement of other basal ganglia structures (putamen globus pallidus) and the thalamus in contrast to adult studies which report mainly involvement of the caudate nucleus and orbitofrontal cortex. Several findings point at an aberrant development of the brain in paediatric OCD, patients when compared with healthy controls. CONCLUSION Neuroimaging studies have contributed to our understanding of the neurobiological basis of paediatric OCD. This review provides an agenda for further theory driven research in particular aimed at identifying a critical window of abnormal maturation of prefrontal-striatal-thalamic and limbic circuitry in paediatric OCD patients.

Developmental aspects of error and high-conflict-related brain activity in pediatric obsessive-compulsive disorder: a fMRI study with a Flanker task before and after CBT

BACKGROUND Heightened error and conflict monitoring are considered central mechanisms in obsessive-compulsive disorder (OCD) and are associated with anterior cingulate cortex (ACC) function. Pediatric obsessive-compulsive patients provide an opportunity to investigate the development of this area and its associations with psychopathology. METHODS Repeated measures were carried out using functional magnetic resonance imaging (fMRI) during the performance of an interference task, the arrow version of the Flanker paradigm, before and after cognitive-behavioral treatment of 25 medication-free pediatric obsessive-compulsive patients compared with age- and gender-matched healthy controls. RESULTS During error trials compared to correct trials, pediatric OCD patients and controls showed an interaction effect of Group × Time × Age in the ACC and insula. This effect was mainly driven by an increased activation in older OCD subjects, which was also present after treatment. During high-conflict trials compared with low-conflict trials, a Group × Time × Age interaction effect was found in bilateral insula. This effect was driven by an increase of BOLD (blood oxygen level dependent) signal in older OCD patients before but not after treatment. In addition, a Group × Time interaction effect in dorsomedial prefrontal cortex, premotor region and ACC was found. This effect was driven by an increase of BOLD signal in OCD subjects relative to controls over time. CONCLUSIONS Compared to healthy controls, children and adolescents with OCD show increased activation of the ACC during error responses and in bilateral insular cortex during high-conflict tasks, which is age dependent and which is only partially affected by cognitive-behavioral therapy (CBT). Therefore, we suggest that ACC functioning is a vulnerability marker in pediatric OCD, whereas insular dysfunction may be state dependent.

Cognitive Behavior Therapy for Pediatric Functional Abdominal Pain: A Randomized Controlled Trial

OBJECTIVE: This randomized controlled trial investigated the effectiveness of a 6-session protocolized cognitive behavior therapy (CBT) compared with 6 visits to a pediatrician (intensive medical care; IMC) for the treatment of pediatric functional abdominal pain (FAP). METHODS: One hundred four children aged 7 to 18 were randomized to CBT or IMC. CBT was delivered primarily by trained master’s degree students in psychology; IMC was delivered by pediatricians or pediatric gastroenterologists. Assessments were performed pretreatment, posttreatment, and at 6- and 12-month follow-up. Primary outcomes were level of abdominal pain (AP) as reported on questionnaires and diaries. Secondary outcomes were other gastrointestinal complaints, functional disability, other somatic complaints, anxiety, depression, and quality of life. RESULTS: Both CBT and IMC resulted in a significant decrease in AP (P < .001), but no significant difference was found between the treatments in their effectiveness (P > .05 for all end points). According to the questionnaire-derived data, 1 year after treatment, 60% of children that received CBT had significantly improved or recovered, versus 56.4% of children receiving IMC, which did not significantly differ (P = .47). These percentages were 65.8% versus 62.8% according to the diary-derived data, which also did not significantly differ (P = .14). Additionally, nearly all secondary outcomes improved after treatment. CONCLUSIONS: CBT was equally effective as IMC in reducing AP in children with FAP. More research into the specific working mechanisms of CBT for pediatric FAP is needed.

Costs and Cost-Effectiveness of Family CBT Versus Individual CBT in Clinically Anxious Children

The objective of this study was to investigate the cost-effectiveness of family cognitive-behavioral therapy (CBT) compared with individual CBT in children with anxiety disorders. Clinically anxious children (aged 8—18 years) referred for treatment were randomly assigned to family or individual CBT and were assessed pre-treatment, post treatment, and at 3 months and 1 year after treatment. Cost-effectiveness ratios were calculated expressing the incremental costs per anxiety-free child and the incremental costs per Quality Adjusted Life Year (QALY) for the referred child. Neither societal costs nor effectiveness were significantly different between individual and family CBT. However, the point estimates of the cost-effectiveness ratios resulted in dominance for individual CBT, indicating that individual CBT is more effective and less costly than family CBT. These results were confirmed by bootstrap analyses and cost-effectiveness acceptability curves. Several secondary and sensitivity analyses showed that the results were robust. It can be concluded that family CBT is not a cost-effective treatment for clinically anxious children, compared with individual CBT.

Mediators of cognitive behavioral therapy for anxiety-disordered children and adolescents : cognition, perceived control, and coping

The purpose is to investigate whether a change in putative mediators (negative and positive thoughts, coping strategies, and perceived control over anxious situations) precedes a change in anxiety symptoms in anxiety-disordered children and adolescents receiving cognitive behavioral therapy (CBT). Participants were 145 Dutch children (8–18 years old, M = 12.5 years, 57% girls) with a primary anxiety disorder. Assessments were completed pretreatment, in-treatment, posttreatment, and at 3-month follow-up. Sequential temporal dependencies between putative mediators and parent- and child-reported anxiety symptoms were investigated in AMOS using longitudinal Latent Difference Score Modeling. During treatment an increase of positive thoughts preceded a decrease in child-reported anxiety symptoms. An increase in three coping strategies (direct problem solving, positive cognitive restructuring, and seeking distraction) preceded a decrease in parent-reported anxiety symptoms. A reciprocal effect was found for perceived control: A decrease in parent-reported anxiety symptoms both preceded and followed an increase in perceived control. Using a longitudinal design, a temporal relationship between several putative mediators and CBT-outcome for anxious children was explored. The results suggest that a change in positive thoughts, but not negative thoughts, and several coping strategies precedes a change in symptom reduction and, therefore, at least partly support theoretical models of anxiety upon which the anxiety intervention is based.

Abdominal pain in Dutch schoolchildren: relations with physical and psychological comorbid complaints in children and their parents.

Objectives: Children with functional abdominal pain (FAP) frequently report comorbid complaints such as anxiety and activity limitations. Their parents often experience heightened levels of anxiety, depression, and somatization. The aim of the present study was to investigate whether these comorbid complaints in children and their parents are specific for FAP or can also be found in a community sample. Patients and Methods: Six hundred sixty-five schoolchildren (ages 7–18 years) filled out questionnaires concerning AP, activity limitations, somatic complaints, quality of life, and symptoms of anxiety and depression. A total of 391 of their parents filled out questionnaires concerning parental anxiety, depression, and somatization. Pearson correlations and multiple regression analyses were performed. Results: A total of 56.5% of the children reported AP at least once in a 2-week period. Univariate relations with AP were found for activity limitations (r = 0.392), somatic complaints (r = 0.408), 3 of 5 domains of quality of life (r ranging from −0.120 to −0.209), and symptoms of anxiety and depression (r, respectively, 0.329 and 0.361). Multivariate analyses showed only significant relations for female sex (β = 0.230), younger age (β = −0.077), activity limitations (β = 0.247), somatic complaints (β = 0.170), and depressive symptoms (β = 0.093). Conclusions: Activity limitations, somatic complaints, and depressive symptoms are related to AP in the general population, whereas a reduced quality of life, anxiety, and parental internalizing problems seem specific comorbid complaints for FAP. Future research on parental internalizing problems, quality of life, and anxiety as risk factors for FAP is warranted.

Development and initial validation of the obsessive belief questionnaire‐child version (OBQ‐CV)

Background: Cognitive models of obsessive–compulsive disorder (OCD) propose that beliefs are important in the etiology and maintenance of OCD and that these beliefs develop during childhood [Neal et al., 1991: Psychol Bull 109:400–410; Rachman, 1997: Behav Res Ther 35:793–802; Cronbach, 1951: Psychometrika 16:297–334]. However, the ability to test these predictions has been hampered by the lack of a standardized measure of OCD‐related beliefs for youth. Therefore, this article presents initial data on a youth version of the widely used Obsessive Belief Questionnaire (OBQ) [Bonett, 2002: J Educ Behav Stat 27:335–340]. Methods: Data examining the psychometric properties of the Obsessive Belief Questionnaire‐Child Version (OBQ‐CV) are presented from two pediatric OCD samples: a North American (n=29, aged 9–17 years) and a Dutch sample (n=48, aged 8–18 years). Results: Preliminary findings from both samples support the internal consistency, retest reliability, and convergent validity of the OBQ‐CV. Conclusions: Results of this study suggest that the OBQ‐CV is a promising tool for examining the role of cognitions in pediatric OCD. Development of the OBQ‐CV to augment the existing adult version of the scale creates unique opportunities for investigating the role of cognitions in OCD across the lifespan. Depression and Anxiety, 2010.  © 2010 Wiley‐Liss, Inc.

Cognitive versus Behavior Therapy : Processes of Change in the Treatment of Obsessive-Compulsive Disorder

Background: Behavior therapy [exposure and response prevention (ERP)] and cognitive therapy (CT) have proven effective in the treatment of obsessive-compulsive disorder. Direct comparisons between these treatment modalities have exposed no differences in efficacy. However, very little research has been conducted into the differences between the change processes in ERP and CT. This investigation is a first attempt to study change by measuring scores on a weekly basis rather than at specific stages in the treatment and follow-up. Methods: We used the Yale-Brown Obsessive-Compulsive Scale (Y-BOCS) at weekly intervals to rate and compare the severity of the obsessions and compulsions of 61 completers of either CT or ERP. The aim was to ascertain whether the process of change in CT is different from the process of change in ERP. We expected that ERP would primarily affect behavior, thus reducing compulsions first, while CT would primarily affect thought, thus reducing obsessions first. Results: Firstly, no differences were found between ERP and CT with respect to the change process for obsessions and compulsions. Secondly, it emerged that changes in compulsions predicted all treatment effects better than changes in obsessions. Conclusions: These results suggest that reduction of compulsions is the process through which both ERP and CT affect change.