Group family-based cognitive behavioral therapy for pediatric obsessive compulsive disorder: Global outcomes and predictors of improvement

Parent Management Training Augmentation to Address Coercive and Disruptive Behavior in Cognitive-Behavioral Therapy for Pediatric Obsessive-Compulsive Disorder

Coercive and disruptive behaviors commonly interfere with cognitive-behavioral therapy (CBT) trials among youths with obsessive-compulsive disorder (OCD). Although evidence supports parent management training (PMT) for reducing disruptive behavior, no group-based PMT interventions exist for OCD-related disruptive behaviors. We studied feasibility and effectiveness of group-based adjunctive PMT among non-randomized, OCD-affected families receiving family-based group CBT. Linear mixed models estimated treatment effects across OCD-related and parenting outcomes at post-treatment and 1-month follow-up. Treatment response for 37 families receiving CBT + PMT (M_age = 13.90) was compared to 80 families receiving only CBT (M_age = 13.93). CBT + PMT was highly accepted by families. Families who received CBT + PMT had improved disruptive behaviors, parental distress tolerance, and other OCD-related outcomes. OCD-related outcomes did not significantly differ between groups. Results support CBT + PMT as effective treatment for pediatric OCD that may not provide incremental benefits beyond CBT alone. Future research should determine feasible and effective ways to incorporate key PMT components into CBT-based interventions.

Co-occurring OCD and Panic Disorder: A Review of Their Etiology and Treatment

Estimated rates of co-occurrence between obsessive and compulsive disorder (OCD) and panic disorder (PD) are notable, but vary considerably, with rates from epidemiological and clinical studies ranging from 1.8% to 22% (Rector et al., 2017). We reviewed the current empirical literature on the etiology, treatment, diagnostic assessment, and differential diagnosis of co-occurring OCD/PD. Best practices for cognitive-behavioral treatment, including identifying and addressing treatment barriers are also addressed. Although it is acknowledged in current literature that co-occurring OCD and PD levels may be clinically significant, there remains a need to thoroughly examine the possible consequences and future research directions of this overlap. Future research must continue to elucidate the biological and environmental causes of OCD/PD co-occurrence.

Cognitive-Behavioral Therapy for Obsessive-Compulsive Disorder: 2021 Update

In this update of a previous review, the authors discuss cognitive-behavioral therapy (CBT) with exposure and response prevention for obsessive-compulsive disorder (OCD). This efficacious modality avoids side effects common to psychotropic medication and reduces risk of relapse once treatment has ended. Psychotherapy involves identification and ranking of stimuli that provoke obsessions, exposure to these stimuli while preventing compulsions, and cognitive restructuring. The family of the OCD patient plays a significant role in treatment. This article includes expanded research on family-focused CBT and treatment of pediatric OCD. The family's accommodation and emotional response to a patient's symptoms may interfere with therapy and perpetuate the disorder. The treatment of pediatric OCD involves the same considerations. However, the form of obsessions and compulsions may differ and therapeutic techniques are modified to make them age appropriate.

Longitudinal trajectory and predictors of change in family accommodation during exposure therapy for pediatric OCD

Family accommodation (FA) is key in the maintenance of OCD. However, most studies are cross-sectional, and have not identified long-term trajectories and correlates of FA changes over treatment. This study investigated changes in clinician-rated FA over 10 sessions of cognitive behavioral therapy (CBT) for 142 children with OCD, as well as several key predictors/correlates: (a) clinician-rated OCD symptom severity, (b) child- and parent-rated functional impairment, (c) parent-rated treatment expectancies, and (d) child- and parent-rated therapeutic alliance. Multi-level models indicated that FA changed significantly during treatment, with gains maintained over 6-months. Baseline clinician-rated OCD severity did not predict changes in FA. Significant interactions indicated that children with higher child- and parent-rated impairment exhibited greater FA improvements over treatment (versus children with lower impairment). Child- and parent-rated therapeutic alliance and parent-rated expectancies did not predict FA changes. Finally, FA mediated the relationship between OCD severity and parent- (but not child-) rated impairment. Reverse mediation models were also significant. Findings indicate that CBT can successfully reduce FA (a) even if children experience high OCD severity and interference in school, relationships, and family life, and (b) regardless of non-specific factors like treatment expectancies and alliance. FA reductions are an important mechanism mediating treatment response.

Predictors of Parental Accommodation and Response Treatment in Young Children With Obsessive-Compulsive Disorder

Background: Cognitive-behavioral family-based treatment (CBFT) is the treatment standard in very young children with obsessive-compulsive disorder (OCD), which includes the same core components of cognitive-behavioral therapy (CBT) with significant family involvement. Although the latter reports high rates of remission, some children do not improve with treatments. Therefore, it is necessary to identify possible moderating variables such as comorbidity, severity of disorder, years of onset, parental anxiety, and parental accommodation. This study has two main aims: (1) to propose a predictive model on family accommodation (father and mother), taking into account variables related to the children (severity of obsessive-compulsive responses, internalizing and externalizing symptoms, and comorbidity) and with the parents before intervention (worry, accommodation of one parental member over the other) and (2) to examine the mediating role of externalizing symptoms and mother's accommodation in the relation between initial severity and improvement of severity of obsessive-compulsive responses in children aged 5-8 years. Methods: Participants comprised 56 children with OCD [mean = 6.61 (SD = 0.76)] and their parents; 79% of the sample was men. Treatment was implemented by two clinicians specialized in OCD (>15 years of experience). Clinicians were trained to administer CBT protocol in the same way. They were doctors of clinical psychology and researchers at the OCD. Results: Mother's accommodation was associated with child variables (Child Behavior Checklist-Externalizing and Initial Severity, Children's Yale-Brown Obsessive-Compulsive Scale). Father's accommodation could be explained by parent variables (mother's accommodation and worry). Simple mediation model tested using the SPSS macro PROCESS supported the relation of the initial severity of symptoms with that following intervention, through the simple indirect effect of externalizing symptoms of the child. Conclusions: Comorbidities with externalizing symptoms, father's worry, and mother's accommodation were variables that should be controlled in treatment of pediatric OCD.

Effects of Treatment Setting on Outcomes of Flexibly-Dosed Intensive Cognitive Behavioral Therapy for Pediatric OCD: A Randomized Controlled Pilot Trial

Introduction: Optimizing individual outcomes of cognitive-behavioral therapy (CBT) remains a priority. Methods: Youth were randomized to receive intensive CBT at a hospital clinic (n = 14) or within their home (n = 12). Youth completed 3 × 3 h sessions (Phase I) and up to four additional 3-h sessions as desired/needed (Phase II). An independent evaluator assessed youth after Phase I, Phase II (when applicable), and at 1- and 6-months post-treatment. A range of OCD-related (e.g., severity, impairment) and secondary (e.g., quality of life, comorbid symptoms) outcomes were assessed. Results: Families' satisfaction with the treatment program was high. Of study completers (n = 22), five youth (23%) utilized no Phase II sessions and 9 (41%) utilized all four (Median Phase II sessions: 2.5). Large improvements in OCD-related outcomes and small-to-moderate benefits across secondary domains were observed. Statistically-significant differences in primary outcomes were not observed between settings; however, minor benefits for home-based treatment were observed (e.g., maintenance of gains, youth comfort with treatment). Discussion: Intensive CBT is an efficacious treatment for pediatric OCD. Families opted for differing doses based on their needs. Home-based treatment, while not substantially superior to hospital care, may offer some value, particularly when desired/relevant. Clinical Trial Registration: www.ClinicalTrials.gov; https://clinicaltrials.gov/ct2/show/NCT03672565, identifier: NCT03672565.

Mindfulness-based skills training group for parents of obsessive-compulsive disorder-affected children: A caregiver-focused intervention

BACKGROUND AND PURPOSE

Parents of children with obsessive-compulsive disorder (OCD) report significant emotional and socio-occupational impacts. There is, however, currently insufficient support for these parents. This study examined a mindfulness-based intervention for parents of OCD-affected children, investigating its feasibility and impact on parental ability to tolerate their child's OCD-related distress, in addition to exploring potential indirect effects.

MATERIALS AND METHODS

Parents of OCD-affected children (n = 39) completed an eight-week baseline observation period followed by eight, weekly manualized mindfulness-based intervention group sessions. Measures of parental tolerance of child distress, dispositional mindfulness, family accommodation, family functioning, and OCD symptom severity were collected.

RESULTS

In comparison to the baseline observation period, parental tolerance of child distress and dispositional mindfulness significantly improved following mindfulness training. No other temporal differences were observed. Parents reported high satisfaction.

CONCLUSION

Mindfulness-based skills training for parents of OCD-affected youth appears to be feasible and to significantly increase tolerance related to the child's distress.

CLINICAL TRIAL REGISTRATION NUMBER

NCT03212703.

Avoidance, Insight, Impairment Recognition Concordance, and Cognitive-Behavioral Therapy Outcomes in Pediatric Obsessive-Compulsive Disorder

OBJECTIVE

Insight and avoidance are commonly discussed factors in obsessive-compulsive disorder (OCD) that have demonstrated associations with increased severity as well as reduced treatment response in adults, but these factors have not been sufficiently examined in pediatric OCD. This study examined the impacts of avoidance, insight, and impairment recognition concordance on cognitive-behavioral therapy (CBT) outcomes as well as impacts of CBT on insight and avoidance in a large sample of youths affected by OCD.

METHOD

Data from 573 OCD-affected youths enrolled in CBT trials were aggregated. Children's Yale-Brown Obsessive-Compulsive Scale items measured treatment response, insight, and avoidance. Standardized differences between child and parent ratings of impairment were used to calculate impairment recognition concordance. Binary logistic regression was used to identify variables associated with treatment response.

RESULTS

Greater avoidance, limited child recognition of impairment, older age, and lower baseline severity predicted reduced likelihood of treatment response, but insight did not. Both insight and avoidance improved significantly following CBT. Response rates were lower when posttreatment insight and avoidance were worse.

CONCLUSION

Contrasting with prevailing belief, poor insight does not appear to limit CBT response potential in pediatric OCD. Avoidance and impairment recognition are understudied CBT response predictors and warrant further consideration in pediatric OCD. Clinicians should attend to these factors to optimize outcomes for children affected by this common, debilitating illness.

Does Family Accommodation Predict Outcome of Concentrated Exposure and Response Prevention for Adolescents?

Findings suggest that increased levels of family accommodation are associated with a poorer treatment outcome in obsessive-compulsive disorder (OCD). A concentrated treatment format, the Bergen 4-day treatment (B4DT), has previously demonstrated promising results in the treatment of adolescents with OCD. The present paper examined changes in family accommodation and investigated whether family accommodation predicted outcome, in a sample of 63 adolescents (age range 11-18) participating in the B4DT. There were significant reductions on CY-BOCS and FAS from pre- to post-treatment and from pre-treatment to follow-up (p < 0.001), with large within-group effect sizes on both measures. Pre-treatment levels of symptom severity or family accommodation was not found to predict outcome at post-treatment or at follow-up. Less OCD-related functional impairment at pre-treatment predicted a better outcome at both post-treatment and follow-up. The findings suggest that the B4DT significantly reduces OCD-symptoms regardless of pre-treatment levels of family accommodation or OCD severity.

Family involvement and treatment for young children with Obsessive-Compulsive Disorder: Randomized control study

Background/Objective

The aim of this paper was to evaluate the diferential efficacy of cognitive behavioral family treatment in children under 8 years of age with Obsessive-Compulsive Disorder (OCD) in the reduction of obsessive-compulsive responses and secondary outcomes in three treatment conditions: (a) Treatment of parents and child, (b) Treatment of mother and child, and (c) Treatment of mother.

Method

Forty-four children with obsessive-compulsive disorder, aged 5.2-7.9 years old and their parents, were randomized to one of three groups in a 1:1:1 ratio. Seventy-five percent was male and 100% Caucasian (White-European). Treatment involved 12 individual sessions of is Cognitive-Behavioral Family-Based Treatment delivered.

Results

The three conditions produced clinical improvements in post-test and follow-up in the primary (symptom severity OCD) and secondary outcomes. The results showed no intergroup differences in variables related to OCD symptom severity, although statistically significant differences were found in groups in Internalizing and Externalizing problem, mother and fathers accomodation.

Conclusions

The most efficient condition was that including a greater number of family members even when there was high family accommodation. The direct involvement of the child in the psychological treatment was important in achieving better results.

Challenges in the diagnosis and treatment of pediatric obsessive-compulsive disorder

Obsessive-compulsive disorder (OCD) affects 1%-3% of children worldwide and has a profound impact on quality of life for patients and families. Although our understanding of the underlying etiology remains limited, data from neuroimaging and genetic studies as well as the efficacy of serotonergic medications suggest the disorder is associated with the fundamental alterations in the function of cortico-striato-thalamocortical circuits. Significant delays to diagnosis are common, ultimately leading to more severe functional impairment with long-term developmental consequences. The clinical assessment requires a detailed history of specific OCD symptoms as well as psychiatric and medical comorbidities. Standardized assessment tools may aid in evaluating and tracking symptom severity and both individual and family functioning. In the majority of children, an interdisciplinary approach that combines cognitive behavioral therapy with a serotonin reuptake inhibitor leads to meaningful symptom improvement, although some patients experience a chronic, episodic course. There are limited data to guide the management of treatment-refractory illness in children, although atypical antipsychotics and glutamate-modulating agents may be used cautiously as augmenting agents. This review outlines a clinical approach to the diagnosis and management of OCD, highlighting associated challenges, and limitations to our current knowledge.

Family accommodation in psychopathology: A synthesized review

Family accommodation describes changes that family members make to their own behavior, to help their relative who is dealing with psychopathology, and to avoid or alleviate distress related to the disorder. Research on family accommodation has expanded greatly in the past few years. The aim of this study was to provide a synthesized review of recent findings on family accommodation in psychopathology. Electronic databases were searched for available, peer-reviewed, English language papers, published between September 2015 and March 2018, cross-referencing psychiatric disorders with accommodation and other family-related terms. Ninety-one papers were identified and reviewed, of which 69 were included. In obsessive-compulsive disorder and anxiety disorders family accommodation has been linked to symptom severity, functional impairment, caregiver burden, and poorer treatment outcomes. Several randomized controlled trials explored the efficacy of treatments aimed at reducing family accommodation. A growing number of studies have reported family accommodation in eating disorders where it is associated with greater symptom severity and caregiver burden. Family accommodation has also been studied in other disorders, including autism spectrum disorders, tic disorders, and posttraumatic stress disorder. Research on family accommodation in psychopathology is advancing steadily, expanding across disorders. The study highlights the importance of addressing family accommodation in the assessment and treatment of various disorders.

Coercive and disruptive behaviors mediate group cognitive-behavioral therapy response in pediatric obsessive-compulsive disorder

PURPOSE

Coercive and disruptive behaviors (CDBs) are commonplace in pediatric obsessive-compulsive disorder (OCD) and are associated with increased disorder impact and reduced treatment response. Prior research suggests that CDBs mediate the cross-sectional relationship between family accommodation and OCD symptom severity; however, the impact of reducing CDBs on other treatment outcomes has yet to be studied.

METHODS

Participants comprised 49 OCD-affected youth (42.9% male, M_age at baseline = 13.7) and their parent(s) who completed a 12-week, group family-based cognitive-behavioral treatment at an OCD specialty clinic. Outcomes included parent-report measures of CDBs, family accommodation, symptom severity, and both child- and family-level impairment. Descriptive, correlation, and regression analyses were followed by tests of indirect effects (mediation).

RESULTS

Changes in all outcome variables had moderate to strong correlations with each other. As hypothesized, CDB decreases predicted positive changes in OCD severity as well as in child and family impairment. Further, whereas improvement in OCD severity predicted changes in child and family impairment, improvements in family accommodation were not directly predictive of any outcomes. Consistent with hypotheses, changes in CDBs mediated relationships between changes in accommodation and child- and family-level impairment, as well as relationships between changes in OCD severity and both levels of impairment. Additional exploratory analyses found that changes in symptom severity significantly mediated relationships between changes in CDBs and both levels of impairments.

CONCLUSIONS

Findings suggest that attention to reducing CDBs is warranted in the treatment of pediatric OCD, and that accommodation reductions lead to meaningful improvements in child and family functioning only when CDBs and/or symptoms are also reduced. Future family-based treatments may benefit from inclusion of components specifically targeting CDBs that occur within the context of accommodating OCD symptoms.

Symptom Insight in Pediatric Obsessive-Compulsive Disorder: Outcomes of an International Aggregated Cross-Sectional Sample

Insight in obsessive-compulsive disorder (OCD) refers to patients' recognition that their obsessions and compulsions are symptoms rather than necessary or natural thoughts and behaviors.¹ It has been estimated that 20% to 45% of youth with OCD exhibit poor or absent insight.^2-4 Identified correlates of poor insight include younger age,^2,3,5,6 increased OCD severity,^2,4,7 impairment,^4,7,8 and family accommodation^2,4; lower intellectual and adaptive functioning³; and greater depressive symptoms.^2,3 Poorer insight has also been associated with reduced response across treatment groups (ie, selective serotonin reuptake inhibitor [SSRI], cognitive behavioral therapy [CBT], combined SSRI plus CBT, or pill placebo).⁹.