Treatment Of Pediatric Obsessive-compulsive Disorder Research Articles

Treatment of Pediatric Obsessive-Compulsive Disorder: A Review

Recently, research in pediatric obsessive-compulsive disorder (OCD) has expanded to include large family genetic studies, elaboration of phenotypic dimensions, description of co-morbid disorders and their moderating effects on treatment response and outcome, research on immune-based neuropsychiatric causes, randomized controlled trials of selective serotonin reuptake inhibitors (SSRIs), randomized controlled trials of cognitive behavioral therapy (CBT), comparative treatment trials; new approaches in behavior therapy, and increased awareness of newer approaches to treatment. The purpose of this article is to review assessment and treatment strategies to include current advances in research.

An Uncontrolled Examination of a 5-Day Intensive Treatment for Pediatric OCD

This study examined the feasibility of a 5-day intensive treatment for pediatric obsessive-compulsive disorder (OCD). Fifteen children with OCD received a week-long treatment based on exposure and response prevention (ERP). The intervention also emphasized teaching children and parents how to conduct ERP independently at home. All families completed the week-long treatment and symptoms improved significantly as measured by self- and parent-report forms, as well as the Children's Yale-Brown Obsessive-Compulsive Scale, F(2, 22) = 45.67, p < .05. Total CY-BOCS scores decreased significantly from pretreatment ( M = 28.00, SD = 4.24) to posttreatment [ M = 16.00, SD = 6.0, F(1, 11) = 34.38, p < .05] and from posttreatment to 5-month follow-up [ M = 11.5, SD = 7.3; F(1, 11) = 12.94, p < .05]. This level of improvement was consistent with other intensive treatments for pediatric OCD. The study suggests that the 5-day program is a promising treatment for children with OCD who do not have access to local providers.

Recent Developments in the Assessment and Treatment of Pediatric Obsessive-Compulsive Disorder

Although tremendous strides have recently been made in the development of assessment and treatment methods for pediatric obsessive-compulsive disorder (OCD), more accurate methods for diagnosis, more effective treatments, and more refined instruments for monitoring progress during therapy are still needed. The present commentary highlights the papers in this series of articles. The excellent work by the contributors to this special edition highlights critical elements and limitations of the assessment process for OCD, the importance of monitoring symptom changes, and possible augmentation strategies for treatment refractory cases. The findings from these studies will almost certainly impact the management of pediatric OCD and lead to further refinements.

P03-02 - Therapeutic alliance in the cognitive behavioral treatment of pediatric obsessive-compulsive disorder

ObjectivesThe purpose of the current study was to investigate the influence of therapeutic alliance (TA) as a treatment process variable on outcome in cognitive-behavioral therapy (CBT) for pediatric obsessive-compulsive disorder (OCD). Although CBT for pediatric OCD disorder is considered a first-line treatment, not all youth have positive treatment responses, suggesting the need for investigating factors that enhance or reduce treatment effects.MethodsTwenty-five youth aged 7-17 years (M = 13.16, SD = 2.69) with a principal diagnosis of OCD and parents participated in the study. Using a multiple-informant, multiple-time point design, the current study examined the role of TA in family-based CBT for pediatric OCD.ResultsFindings indicated(1)stronger child-rated, parent-rated, and therapist-rated TAs were predictive of better treatment outcome,(2)larger, more positive early alliance shifts (rated by changes in child-rated TA between sessions 1 and 5) were predictive of better treatment outcome.ConclusionsTA was a predictor of subsequent change in OCD symptoms in youth treated with CBT. These findings correspond with alliance-outcome research among youth treated with evidence based therapies for behavior disorders.

Intensive Family-Based Cognitive-Behavioral Therapy for Pediatric Obsessive-Compulsive Disorder: Applications for Treatment of Medication Partial- or Nonresponders

Serotonin reuptake inhibitor medications and cognitive-behavioral therapy (CBT) are both effective treatments for pediatric obsessive-compulsive disorder (OCD). Despite recommendations that youth with OCD be treated with CBT alone or together with serotonin reuptake inhibitor medication, many youth are treated with medication alone or with non-CBT psychotherapy initially. Although effective, symptom remission with medication alone is rare (e.g., only 21.4% of youth achieved remission with sertraline in the Pediatric OCD Treatment Study, 2004) and residual symptoms often remain (e.g., 58% of subjects in the March et al. [1998] sertraline trial were not considered treatment responders). This paper reviews the literature on the efficacy of CBT for pediatric OCD, particularly as it relates to the treatment of youth with prior inadequate response to medication. It also describes an intensive, family-based CBT program for children and adolescents with OCD and support for its efficacy among those with prior partial- or nonresponse to medication. Finally, we present a case study of an adolescent girl with OCD who participated in the intensive treatment program after having limited benefit from medication and non-CBT psychotherapy and experienced a favorable response.

Pharmacotherapy in Paediatric Obsessive-Compulsive Disorder

Pediatric obsessive-compulsive disorder (OCD) can cause substantial impairment in academic, social and family functioning. Even though cognitive-behavioural therapy (CBT) is an effective treatment, the pharmacological option has to be taken into consideration. Effectiveness of serotonin reuptake inhibitors (SRIs) has been supported by several double-blind, placebo-controlled studies. To report the response to pharmacotherapy in children and adolescents with OCD naturalistically followed up and treated with SRIs. From a consecutive series of 257 patients (174 males and 83 females; mean age 13.6+/-2.7 years) diagnosed with OCD following a clinical interview according to DSM-IV criteria, 37 children improved significantly after psychotherapy and were excluded. The remaining 220 patients were included in the study. Eighty-nine patients (40.5%) were managed with SRI monotherapy and 131 with an SRI in combination with another medication. Compared with those who needed polypharmacy, patients managed with SRI monotherapy were younger at the time of the first consultation, had less severe symptoms at baseline, and more frequently presented with co-occurring anxiety and depressive disorders, while patients receiving polypharmacy presented with higher rates of bipolar disorder, tic disorder and disruptive behaviour disorders. 135 patients (61.4%) achieved a positive clinical response and were considered responders. When differences between responders and nonresponders at the end of follow-up were considered, irrespective of the pharmacological treatment (monotherapy or polypharmacy), responders had less severe disease at baseline, were younger at the time of the first consultation, more frequently presented with the contamination/cleaning phenotype and less frequently presented with the hoarding phenotype. Treatment refractoriness was associated with higher rates of conduct disorder and bipolar disorder, and lower rates of generalized anxiety disorder and panic disorder. Forty-three children received therapy with an atypical antipsychotic as an augmenting strategy, and 25 of these children (58.1%) became responders. Responders to augmentation were less severely impaired at baseline, while different subtypes of OCD were similar between responders and nonresponders, as were patterns of co-morbidity. Our study suggests that putative variables associated with response to pharmacological treatment of paediatric OCD can be defined, and can help improve treatment strategies.

The More You Do It, the Easier It Gets: Exposure and Response Prevention for OCD

This manuscript is one in a series of invited papers to this journal. The purpose of the series is to highlight and discuss the similarities and differences between various behavioral and cognitive-behavioral approaches to the treatment of obsessive-compulsive disorder (OCD). The first article in this series (Twohig & Whittal) describes the case of “Caroline” upon which the current manuscript is based. We approach the case from a cognitive-behavioral orientation with exposure and ritual prevention (EX/RP) as the primary therapeutic approach. We highlight the use of EX/RP because of the considerable body of empirical evidence showing that EX/RP is an efficacious treatment for both adult and pediatric OCD. Using the provided case vignette, we outline a rationale for EX/RP and describe how EX/RP might be used to treat Caroline’s OCD. We begin by discussing the theoretical underpinnings for EX/RP and providing a rationale for treatment. We then briefly discuss the rich extant literature supporting EX/RP as an effective treatment for OCD. We then provide a detailed case conceptualization and description of the treatment. We conclude with barriers commonly encountered during EX/RP.

Pediatric obsessive–compulsive disorder: management priorities in primary care

Obsessive-compulsive disorder (OCD) is a severe neuropsychiatric condition with a substantial prevalence in childhood and adolescence. Our understanding of the etiopathogenesis of pediatric OCD continues to grow, along with diagnostic and treatment approaches. The present study attempts to provide a parsimonious review of important studies of pediatric OCD with particular emphasis on studies over the last year. Consistent with many other pediatric conditions, OCD in childhood and adolescence has distinct yet overlapping features with the adult-onset type. It appears that OCD is a multidimensional disorder with substantial comorbidity with other neuropsychiatric disorders that may affect its course and treatment. Although its pathophysiology remains to be fully elucidated, evidence suggests that OCD likely results from a complex interaction between multiple genetic variants and nongenetic factors. Meanwhile, evidence supporting the efficacy of selective serotonin reuptake inhibitors, augmentation strategies affecting other neurotransmitter systems, and cognitive behavioral therapy for the treatment of pediatric OCD continues to emerge. Results from the studies reviewed here reflect the heterogeneity of pediatric OCD. It is clear that clinicians need to consider specific symptoms, comorbid conditions, and the rapidly evolving clinical research when working with children and adolescents with OCD.

Treatment Outcome for Adolescent Obsessive-Compulsive Disorder in a Specialized Hospital Setting

Although few data are available concerning adolescents with obsessive-compulsive disorder (OCD), the existing literature suggests that cognitive-behavioral therapy (CBT) is the first-line treatment of choice for adolescents with mild to moderate OCD. A combination of CBT and serotonin reuptake inhibitors (SRIs) is recommended for more severe forms of OCD, based on the Expert Consensus Guidelines for the Treatment of Obsessive-Compulsive Disorder and the Pediatric OCD Treatment Study (POTS). Despite the effectiveness of CBT, a recent meta-analysis found that 27% of adolescent outpatients fail to show clinically significant improvement following CBT and many also fail to show improvement with pharmacotherapy. One alternative for those who do not improve with outpatient treatment is an intensive inpatient program. Within the last 10 years, two specialty hospitals have created programs that provide intensive CBT milieu treatment with multidisciplinary support (e.g., nursing, psychopharmacology) to treat adolescents with OCD. This naturalistic study describes treatment outcomes in 23 patients who received treatment in one of these programs between 2005 and 2006. Results suggest significant improvements on the majority of outcome measures, with 70% of the patients judged to meet criteria for clinically significant change. Thus, inpatient treatment appears potentially efficacious, although future controlled trials with larger samples are needed.

Editorial: Prevention in the community and treatment in the clinic – two different methodological approaches to determining the evidence‐base for child mental health interventions

Editorial: Prevention in the community and treatment in the clinic – two different methodological approaches to determining the evidence‐base for child mental health interventions

School Psychologists' Views and Management of Obsessive-Compulsive Disorder in Children and Adolescents

Over the past decade, an increasing body of research has been conducted on evidence-based psychological and psychiatric treatment for pediatric obsessive-compulsive disorder (OCD). Despite this improved understanding, however, these treatments are not being performed. This study descriptively examined the practices and views of school psychologists on the management of pediatric OCD. Two hundred twenty-seven clinicians responded to a survey adapted from previous work by Valderhaug, Gotestam, and Larsson. Results suggested that school psychologists preferred cognitive-behavioral, medical, and family/systemic orientations relative to psychodynamic and humanistic approaches. Although respondents reported an adherence to evidence-based treatment, only 7% reported using behavioral exposure. Many respondents reported only moderate treatment success and expressed an overwhelming need for further training in both the assessment and treatment of pediatric OCD. Our results suggest that school psychologists are not adequately trained to assess and provide evidence-based treatment of pediatric OCD.

A School-Based Treatment Model for Pediatric Obsessive-Compulsive Disorder

School psychologists have expertise in the realm of school-based assessment and intervention for behavioral, educational, and psychological difficulties. Recent evidence indicates that many school psychologists lack evidenced based knowledge about assessment and treatment of pediatric Obsessive-Compulsive Disorder (OCD). Pediatric OCD is a relatively common disorder that contributes to substantial impairment in educational and psychosocial domains. Evidence based treatment of pediatric OCD, particularly cognitive-behavioral therapy, has shown to be efficacious. Therefore, the aims of this paper are to provide a review of empirically established treatments for pediatric OCD, and present a school-based problem-solving model that school psychologists can utilize to conceptualize, assess, and treat OCD.

Family-Based Cognitive-Behavioral Therapy for Pediatric Obsessive-Compulsive Disorder: Comparison of Intensive and Weekly Approaches

To examine the relative efficacy of intensive versus weekly cognitive-behavioral therapy (CBT) for children and adolescents with obsessive-compulsive disorder (OCD). Forty children and adolescents with OCD (range 7-17 years) were randomized to receive 14 sessions of weekly or intensive (daily psychotherapy sessions) family-based CBT. Assessments were conducted at three time points: pretreatment, posttreatment, and 3-month follow-up. Raters were initially blind to randomization. Primary outcomes included scores on the Children's Yale-Brown Obsessive-Compulsive Scale, remission status, and ratings on the Clinical Global Impression-Severity and Clinical Global Improvement scales. Secondary outcomes included the Child Obsessive Compulsive Impact Scale-Parent Rated, Children's Depression Inventory, Multidimensional Anxiety Scale for Children, and Family Accommodation Scale. Adjunctive pharmacotherapy was not an exclusion criterion. Intensive CBT was as effective as weekly treatment with some advantages present immediately after treatment. No group differences were found at follow-up, with gains being largely maintained over time. Although no group x time interaction was found for the Children's Yale-Brown Obsessive-Compulsive Scale (F(1,38) = 2.2, p = .15), the intensive group was rated on the Clinical Global Impression-Severity as less ill relative to the weekly group (F(1,38) = 9.4, p < .005). At posttreatment, 75% (15/20) of youths in the intensive group and 50% (10/20) in the weekly group met remission status criteria. Ninety percent (18/20) of youths in the intensive group and 65% (13/20) in the weekly group were considered treatment responders on the Clinical Global Improvement (chi1(2) = 3.6, p = .06). Both intensive and weekly CBT are efficacious treatments for pediatric OCD. Intensive treatment may have slight immediate advantages over weekly CBT, although both modalities have similar outcomes at 3-month follow-up.

Tics Moderate Treatment Outcome with Sertraline but not Cognitive-Behavior Therapy in Pediatric Obsessive-Compulsive Disorder

The presence of a comorbid tic disorder may predict a poorer outcome in the acute treatment of pediatric obsessive-compulsive disorder (OCD). Using data from the National Institute of Mental Health (NIMH)-funded Pediatric OCD Treatment Study (POTS) that compared cognitive-behavior therapy (CBT), medical management with sertraline (SER), and the combination of CBT and SER (COMB), to pill placebo (PBO) in children and adolescents with OCD, we asked whether the presence of a comorbid tic disorder influenced symptom reduction on the Children's Yale-Brown Obsessive Compulsive Scale (CY-BOCS) after 12 weeks of treatment. Fifteen percent (17 of 112) of patients exhibited a comorbid tic disorder. In patients without tics, results replicated previously published intent-to-treat outcomes: COMB > CBT > SER > PBO. In patients with a comorbid tic disorder, SER did not differ from PBO, while COMB remained superior to CBT and CBT remained superior to PBO. In contrast to CBT outcomes, which are not differentially impacted, tic disorders appear to adversely impact the outcome of medication management of pediatric OCD. Children and adolescents with obsessive-compulsive disorder and a comorbid tic disorder should begin treatment with cognitive-behavior therapy alone or the combination of cognitive-behavior therapy plus a serotonin reuptake inhibitor.

Relapse Following Successful Intensive Treatment of Pediatric Obsessive-Compulsive Disorder

This case study describes the use of intensive exposure and response prevention (ERP) for the treatment of pediatric obsessive-compulsive disorder (OCD). The adolescent described in this report lives a long distance from treatment providers with expertise in managing severe OCD symptoms. Thus, he has to travel out of town for effective therapy. The treatment program results in substantial immediate benefits. However, gradual relapse is noted once treatment is over and the patient returns to his home environment. Obstacles to the accessibility of ERP for pediatric OCD, conducting successful treatment, and generalizing and maintaining gains are discussed with the aim of drawing attention to, and facilitating the prevention of, these difficulties. Suggestions for addressing the shortcomings highlighted by this case are presented.

Update on the Treatment of Pediatric Obsessive-Compulsive Disorder

Obsessive-compulsive disorder (OCD) is a debilitating disorder that is prevalent in pediatric populations. Due to the high prevalence and poor prognosis if left untreated, research into the effectiveness and efficacy of psychological and pharmacological treatments has expanded. Accompanying efforts to disseminate such treatments to practitioners has significantly lagged behind, resulting in many children and adolescents diagnosed with OCD not receiving appropriate treatment. This review discusses the current literature on pharmacological and psychological treatments of pediatric OCD, with emphasis on two empirically supported treatment modalities for children and adolescents: Cognitive-Behavioral Therapy (CBT) with exposure and response prevention (E/RP), and pharmacotherapy (serotonin reuptake inhibitors [SRIs] and selective serotonin reuptake inhibitors [SSRIs]). Discussion about the nature of these interventions, clinical challenges, and future areas for study are included. Keywords: obsessive-compulsive disorder (ocd), cognitive-behavioral therapy, pediatric

The effectiveness of treatment for pediatric obsessive-compulsive disorder: A meta-analysis

The last decade has seen a noticeable increase in the number of treatment outcome studies for pediatric obsessive-compulsive disorder (OCD). The present article describes a meta-analysis of this literature with the aim of quantifying treatment effects and examining the extent to which various patient or treatment variables are related to outcome. Results showed that pharmacotherapy with serotonergic antidepressants and cognitive-behavioral therapy involving exposure and response prevention are each effective in reducing OCD symptoms. Cognitive-behavioral therapy produced larger effect sizes and greater rates of clinically significant improvement compared to medication, although there were methodological differences between medication and psychotherapy studies.

Paroxetine Treatment in Children and Adolescents With Obsessive-Compulsive Disorder: A Randomized, Multicenter, Double-Blind, Placebo-Controlled Trial

To assess the efficacy and safety of paroxetine for the treatment of pediatric obsessive-compulsive disorder. Children (7-11 years of age) and adolescents (12-17 years of age) meeting DSM-IV criteria for obsessive-compulsive disorder were randomized to paroxetine (10-50 mg/day) or placebo for 10 weeks. The primary efficacy measure was change from baseline in the Children's Yale-Brown Obsessive-Compulsive Scale (CY-BOCS) total score at week 10 last observation carried forward end point. Safety was assessed primarily through adverse event monitoring. A total of 207 patients were randomized to treatment. Of these, 203 were included in the intention-to-treat population. Adjusted mean changes from baseline at week 10 observation carried forward end point in CY-BOCS total score for patients receiving paroxetine and placebo were -8.78 (SE=0.82) and -5.34 points (SE=0.77), respectively. The adjusted mean difference, -3.45 in favor of paroxetine, was statistically significant (95% confidence interval=-5.60 to -1.29, p=.002). Adverse events were generally mild to moderate in intensity. A total of 10.2% (10/98) of patients in the paroxetine group and 2.9% (3 of 105) in the placebo group discontinued treatment because of adverse events. Paroxetine is an effective and generally well-tolerated treatment for obsessive-compulsive disorder in children and adolescents.

Cognitive-Behavior Therapy, Sertraline, and Their Combination for Children and Adolescents With Obsessive-Compulsive Disorder

The empirical literature on treatment of obsessive-compulsive disorder (OCD) in children and adolescents supports the efficacy of short-term OCD-specific cognitive-behavior therapy (CBT) or medical management with selective serotonin reuptake inhibitors. However, little is known about their relative and combined efficacy. To evaluate the efficacy of CBT alone and medical management with the selective serotonin reuptake inhibitor sertraline alone, or CBT and sertraline combined, as initial treatment for children and adolescents with OCD. The Pediatric OCD Treatment Study, a balanced, masked randomized controlled trial conducted in 3 academic centers in the United States and enrolling a volunteer outpatient sample of 112 patients aged 7 through 17 years with a primary Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition diagnosis of OCD and a Children's Yale-Brown Obsessive-Compulsive Scale (CY-BOCS) score of 16 or higher. Patients were recruited between September 1997 and December 2002. Participants were randomly assigned to receive CBT alone, sertraline alone, combined CBT and sertraline, or pill placebo for 12 weeks. Change in CY-BOCS score over 12 weeks as rated by an independent evaluator masked to treatment status; rate of clinical remission defined as a CY-BOCS score less than or equal to 10. Ninety-seven of 112 patients (87%) completed the full 12 weeks of treatment. Intent-to-treat random regression analyses indicated a statistically significant advantage for CBT alone (P = .003), sertraline alone (P = .007), and combined treatment (P = .001) compared with placebo. Combined treatment also proved superior to CBT alone (P = .008) and to sertraline alone (P = .006), which did not differ from each other. Site differences emerged for CBT and sertraline but not for combined treatment, suggesting that combined treatment is less susceptible to setting-specific variations. The rate of clinical remission for combined treatment was 53.6% (95% confidence interval [CI], 36%-70%); for CBT alone, 39.3% (95% CI, 24%-58%); for sertraline alone, 21.4% (95% CI, 10%-40%); and for placebo, 3.6% (95% CI, 0%-19%). The remission rate for combined treatment did not differ from that for CBT alone (P = .42) but did differ from sertraline alone (P = .03) and from placebo (P<.001). CBT alone did not differ from sertraline alone (P = .24) but did differ from placebo (P = .002), whereas sertraline alone did not (P = .10). The 3 active treatments proved acceptable and well tolerated, with no evidence of treatment-emergent harm to self or to others. Children and adolescents with OCD should begin treatment with the combination of CBT plus a selective serotonin reuptake inhibitor or CBT alone.

The Pediatric Obsessive-Compulsive Disorder Treatment Study: Rationale, Design, and Methods

Obsessive-compulsive disorder (OCD), which has a prevalence of 1 in 200 in children and adolescents, carries with it significant functional morbidity. A growing empirical literature supports the efficacy of short-term treatment with OCD-specific cognitive-behavior therapy (CBT) or medication management with a selective serotonin reuptake inhibitor. These and other studies also identify a substantial probability of partial response and, possibly, differences in durability when treatment is discontinued between medication and CBT. The Pediatric OCD Treatment Study is a multicenter, randomized, masked clinical trial designed to evaluate the relative benefit and durability of four treatments for children and adolescents with OCD: sertraline, CBT, combination of sertraline and CBT, and pill placebo. Stage 1 (12 weeks) is a balanced randomized comparison of these four treatments. Responders at the end of stage 1 advance to 4 months of open follow-up in their assigned arm during which all treatment is discontinued. At the end of stage 2 (if not before), nonresponders to any treatment at the end of stage 1, any patient relapsing in stage 2, and all stage 1 placebo patients receive open treatment that is tailored to the patient's needs. A volunteer sample of 120 subjects between the ages of 7 and 17 inclusive with a primary Diagnostic and Statistical Manual of Mental Disorders (fourth edition) diagnosis of OCD enters the study. All patients, regardless of responder status, return for all scheduled assessments. This report describes the design of the trial, the rationale for the design choices made, and the methods used to carry out the trial.