Kristen Benito

Evidence Base Update for Psychosocial Treatments for Pediatric Obsessive-Compulsive Disorder

Pediatric obsessive-compulsive disorder (OCD) is a chronic and impairing condition that often persists into adulthood. Barrett, Farrell, Pina, Peris, and Piacentini (2008), in this journal, provided a detailed review of evidence-based psychosocial treatments for youth with OCD. The current review provides an evidence base update of the pediatric OCD psychosocial treatment literature with particular attention to advances in the field as well as to the methodological challenges inherent in evaluating such findings. Psychosocial treatment studies conducted since the last review are described and evaluated according to methodological rigor and evidence-based classification using the JCCAP evidence-based treatment evaluation criteria (Southam-Gerow & Prinstein, this issue). Findings from this review clearly converge in support of cognitive-behavioral therapy as an effective and appropriate first line treatment for youth with OCD (either alone or in combination with medication). Although no treatment for pediatric OCD has yet to be designated as “well-established,” both individual and individual family-based treatments have been shown to be “probably efficacious.” Moderators and predictors of treatment outcome are discussed as are the areas where we have advanced the field and the areas where we have room to grow. The methodological and clinical challenges inherent in a review of the evidence base are reviewed. Finally, future research directions are outlined.

Family-Based Treatment of Early Childhood Obsessive-Compulsive Disorder The Pediatric Obsessive-Compulsive Disorder Treatment Study for Young Children (POTS Jr)—A Randomized Clinical Trial

IMPORTANCE Cognitive behavior therapy (CBT) has been established as efficacious for obsessive-compulsive disorder (OCD) among older children and adolescents, yet its effect on young children has not been evaluated sufficiently. OBJECTIVE To examine the relative efficacy of family-based CBT (FB-CBT) involving exposure plus response prevention vs an FB relaxation treatment (FB-RT) control condition for children 5 to 8 years of age. DESIGN, SETTING, AND PARTICIPANTS A 14-week randomized clinical trial (Pediatric Obsessive-Compulsive Disorder Treatment Study for Young Children [POTS Jr]) conducted at 3 academic medical centers between 2006 and 2011, involving 127 pediatric outpatients 5 to 8 years of age who received a primary diagnosis of OCD and a Childrens Yale-Brown Obsessive Compulsive Scale total score of 16 or higher. INTERVENTIONS Participants were randomly assigned to 14 weeks of (1) FB-CBT, including exposure plus response prevention, or (2) FB-RT. MAIN OUTCOMES AND MEASURES Responder status defined as an independent evaluator-rated Clinical Global Impression-Improvement scale score of 1 (very much improved) or 2 (much improved) and change in independent evaluator-rated continuous Childrens Yale-Brown Obsessive Compulsive Scale total score. RESULTS Family-based CBT was superior to FB-RT on both primary outcome measures. The percentages of children who were rated as 1 (very much improved) or 2 (much improved) on the Clinical Global Impression-Improvement scale at 14 weeks were 72% for FB-CBT and 41% for FB-RT. The effect size difference between FB-CBT and FB-RT on the Clinical Global Impression-Improvement scale was 0.31 (95% CI, 0.17-0.45). The number needed to treat (NNT) with FB-CBT vs FB-RT was estimated as 3.2 (95% CI, 2.2-5.8). The effect size difference between FB-CBT and FB-RT on the Childrens Yale-Brown Obsessive Compulsive Scale at week 14 was 0.84 (95% CI, 0.62-1.06). CONCLUSIONS AND RELEVANCE A comprehensive FB-CBT program was superior to a relaxation program with a similar format in reducing OCD symptoms and functional impairment in young children (5-8 years of age) with OCD. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT00533806.

Factors associated with practitioners' use of exposure therapy for childhood anxiety disorders

The current study examines factors related to use of exposure therapy by clinicians who treat children with anxiety disorders. A sample of 331 therapists from a variety of backgrounds (i.e., social workers, doctoral psychologists, masters level counselors, and marriage and family therapists) completed a survey regarding use of exposure and other treatment techniques for childhood anxiety disorders, as well as beliefs about exposure and child resiliency. Although the majority of therapists endorsed a CBT orientation (81%) and use of CBT techniques, exposure therapy was rarely endorsed. Holding a PhD in psychology as well as more positive beliefs about exposure and child resiliency were associated with greater use of exposure. The results suggest that exposure-based therapy is rarely offered in community settings and that dissemination should focus on individual evidence-based principles and correcting therapist misconceptions.

Development of the pediatric accommodation scale: reliability and validity of clinician- and parent-report measures.

The present study developed parallel clinician- and parent-rated measures of family accommodation (Pediatric Accommodation Scale, PAS; Pediatric Accommodation Scale-Parent Report; PAS-PR) for youth with a primary anxiety disorder. Both measures assess frequency and impact of family accommodation on youth and families. Studying youth ages 5-17 (N=105 caregiver-youth dyads), results provide evidence for the psychometric properties of the PAS, including internal consistency, inter-rater reliability, and convergent and discriminant validity. The PAS-PR exhibited good internal consistency and convergent validity with the PAS. Nearly all parents (>95%) endorsed some accommodation and accommodation frequency was associated with parent-rated impairment (home and school), and with youth-rated impairment (school only). Greater impact of accommodation on parents was associated with parent self-reported depressive symptoms. Findings support the common occurrence of family accommodation in youth with anxiety disorders, as well as for the use of the PAS and PAS-PR to measure family accommodation in this population.

Assessment of obsessive–compulsive disorder: review and future directions

Careful evaluation of obsessive–compulsive disorder (OCD) is critical owing to its under-recognition, difficulty ascertaining accurate diagnoses and the need for detailed treatment planning. We review current methods for the assessment of OCD in adults, including unstandardized clinical interviews, standardized diagnostic and other clinical interviews, patient- and family-report measures, and brief or web-based screening measures. Depending upon the question of interest, clinicians and researchers may select from these measures to best assess obsessive–compulsive symptoms in multiple settings. Current research regarding the assessment of OCD has focused on the underlying symptom dimensions, suggesting that each symptom dimension may be associated with different etiology and require tailored treatment. In the future, research may show that effective assessment of OCD involves identification of relevant symptom dimensions to facilitate the choice of appropriate treatment.

Therapeutic Process During Exposure: Habituation Model.

The current paper outlines the habituation model of exposure process, which is a behavioral model emphasizing use of individually tailored functional analysis during exposures. This is a model of therapeutic process rather than one meant to explain the mechanism of change underlying exposure-based treatments. Habitation, or a natural decrease in anxiety level in the absence of anxiety-reducing behavior, might be best understood as an intermediate treatment outcome that informs therapeutic process, rather than as a mechanism of change. The habituation model purports that three conditions are necessary for optimal benefit from exposures: 1) fear activation, 2) minimization of anxiety-reducing behaviors, and 3) habituation. We describe prescribed therapist and client behaviors as those that increase or maintain anxiety level during an exposure (and therefore, facilitate habituation), and proscribed therapist and client behaviors as those that decrease anxiety during an exposure (and therefore, impede habituation). We illustrate model-consistent behaviors in the case of Monica, as well as outline the existing research support and call for additional research to further test the tenets of the habituation model as described in this paper.

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.

Characteristics of Young Children with Obsessive–Compulsive Disorder: Baseline Features from the POTS Jr. Sample

Abstract Pediatric obsessive–compulsive disorder (OCD) is a chronic and impairing condition that can emerge early in childhood and persist into adulthood. The primary aim of this paper is to examine the characteristics of a large sample of young children with OCD (age range from 5 to 8). The sample will be described with regard to: demographics, OCD symptoms/severity, family history and parental psychopathology, comorbidity, and global and family functioning. The sample includes 127 youth with a primary diagnosis of OCD who participated in a multi-site, randomized control clinical trial of family-based exposure with response prevention. Key findings include moderate to severe OCD symptoms, high rates of impairment, and significant comorbidity, despite the participants’ young age. Discussion focuses on how the characteristics of young children compare with older youth and with the few other samples of young children with OCD. Considerations regarding generalizability of the sample and limitations of the study are discussed.

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.

Evidence Base Update of Psychosocial Treatments for Pediatric Obsessive-Compulsive Disorder: Evaluating, Improving, and Transporting What Works

Pediatric obsessive-compulsive disorder is a chronic and impairing condition that often persists into adulthood. This review refreshes the state of support for psychosocial treatments and the predictors or moderators that relate to their efficacy and evaluates how the literature has improved since the last update in 2014. A secondary goal is to propose an additional framework for the categorization of studies based on central research questions rather than treatment format. Psychosocial treatment studies conducted since the last review are described and evaluated according to methodological rigor and evidence-based classification using the Journal of Clinical Child and Adolescent Psychology evidence-based treatment evaluation criteria. Findings again converge in support of cognitive-behavioral therapy (CBT) as an effective and appropriate first-line treatment for youth with obsessive-compulsive disorder. Family-focused CBT is now well-established. A number of other treatments including CBT+ D-Cycloserine, CBT+ Sertraline, CBT+ positive family interaction therapy, and technology-based CBT are now probably efficacious. Demographic, clinical, and family factors are consistent predictors of CBT outcome with conflicting findings for neurocognitive predictors. The field has advanced significantly since the last review, but there is still room for improvement. Some of the conclusions that can be drawn may be limited by our evaluation criteria. Future directions are proposed to advance treatment outcome research beyond a focus on which treatments work to exploring factors that account for how and why they work.