Benefits of cognitive-behavioural therapy for children and youth with obsessive-compulsive disorder: re-examination of the evidence

Clinical expression and treatment response among children with comorbid obsessive compulsive disorder and attention-deficit/hyperactivity disorder

BACKGROUND

Paediatric obsessive-compulsive disorder (OCD) is highly comorbid with other psychological disorders, including attention deficit/hyperactivity disorder (ADHD). Preliminary evidence suggests that youth with comorbid OCD and ADHD may experience greater impairments than children with other comorbidities; however, there is limited research examining the clinical expression and treatment response of these youth.

METHODS

Youth (7 to 17 years) with a primary diagnosis of OCD and comorbid ADHD (n = 40) were compared a sample of age and gender matched youth with OCD and other comorbidity (without ADHD, n = 40). The study investigated symptoms, severity, functioning, comorbidity, family accommodation, in addition to parental psychopathology and rearing styles. Treatment response was investigated at post-treatment and six-month follow-up.

RESULTS

Youth with comorbid OCD and ADHD had fewer sexual obsessions, higher rates of comorbidity, poorer executive functioning and higher family impairment. Families of comorbid youth engaged in significantly more accommodation and reported more negative rearing. Finally, comorbid youth were significantly less likely to be responders or remitters at post-treatment.

LIMITATIONS AND CONCLUSIONS

Limitations include the cross-sectional design, relatively small clinical sample, and lack of an experimental control group of youth with ADHD without OCD. Current approaches to treatment may be improved for youth with comorbid OCD and ADHD by addressing cooccurring anxiety, behavioural difficulties, and maladaptive family accommodation and rearing. Moreover, given pronounced deficits in executive function, these youth may require a stronger initial dose of CBT to achieve an adequate response.

Systematic Review and Meta-Analysis: Cognitive-Behavioral Therapy for Obsessive-Compulsive Disorder in Children and Adolescents

OBJECTIVE

To assess benefits and harms of cognitive-behavioral therapy (CBT) versus no intervention or versus other interventions for pediatric obsessive-compulsive disorder (OCD).

METHOD

We searched for randomized clinical trials of CBT for pediatric OCD. Primary outcomes were OCD severity, serious adverse events, and level of functioning. Secondary outcomes were quality of life and adverse events. Remission from OCD was included as an exploratory outcome. We assessed risk of bias and evaluated the certainty of the evidence with the Grading of Recommendations Assessment, Development and Evaluation (GRADE).

RESULTS

Nine trials (N = 645) were included comparing CBT with no intervention and 3 trials (N = 146) comparing CBT with selective serotonin reuptake inhibitors (SSRIs). Compared with no intervention, CBT decreased OCD severity (mean difference [MD] = -8.51, 95% CI = -10.84 to -6.18, p < .00001, low certainty), improved level of functioning (patient-rated: standardized MD [SMD] = -0.90, 95% CI = -1.19 to -0.62, p < .00001, very low certainty; parent-rated: SMD = -0.68, 95% CI = -1.12 to -0.23, p = .003, very low certainty), had similar proportions of participants with adverse events (risk ratio = 1.06, 95% CI = 0.93-1.22, p = .39, GRADE: low certainty), and was associated with reduced risk of still having OCD (risk ratio = 0.50, 95% CI = 0.37-0.67, p < .00001, very low certainty). We had insufficient data to assess the effect of CBT versus no intervention on serious adverse events and quality of life. Compared with SSRIs, CBT led to similar decreases in OCD severity (MD = -0.75, 95% CI = -3.79 to 2.29, p = .63, GRADE: very low certainty), and was associated with similar risk of still having OCD (risk ratio = 0.85, 95% CI = 0.66-1.09, p = .20, very low certainty). We had insufficient data to assess the effect of CBT versus SSRIs on serious adverse events, level of functioning, quality of life, and adverse events.

CONCLUSION

CBT may be more effective than no intervention and comparable to SSRIs for pediatric OCD, but we are very uncertain about the effect estimates.

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.

A META-ANALYSIS OF COGNITIVE BEHAVIOR THERAPY AND MEDICATION FOR CHILD OBSESSIVE-COMPULSIVE DISORDER: MODERATORS OF TREATMENT EFFICACY, RESPONSE, AND REMISSION

BACKGROUND

Individual randomized controlled trials (RCTs) have demonstrated the efficacy of cognitive behavioral therapy (CBT) and serotonin reuptake inhibitors (SRIs) for the treatment of youth with obsessive-compulsive disorder (OCD). Although meta-analyses have confirmed these results, there has been minimal examination of treatment moderators or an examination of treatment response and symptom/diagnostic remission for these two treatment types. The present report examined the treatment efficacy, treatment response, and symptom/diagnostic remission for youth with OCD receiving either CBT or SRIs relative to comparison conditions, and examined treatment moderators.

METHOD

A comprehensive literature search identified 20 RCTs that met inclusion criteria, and produced a sample size of 507 CBT participants and 789 SRI participants.

RESULTS

Random effects meta-analyses of CBT trials found large treatment effects for treatment efficacy (g = 1.21), treatment response (relative risk [RR] = 3.93), and symptom/diagnostic remission (RR = 5.40). Greater co-occurring anxiety disorders, therapeutic contact, and lower treatment attrition were associated with greater CBT effects. The number needed to treat (NNT) was three for treatment response and symptom/diagnostic remission. Random effects meta-analyses of SRI trials found a moderate treatment effect for treatment efficacy (g = 0.50), treatment response (RR = 1.80), and symptom/diagnostic remission (RR = 2.06). Greater methodological quality was associated with a lower treatment response for SRI trials. The NNT was five for treatment response and symptom/diagnostic remission.

CONCLUSIONS

Findings demonstrate the treatment effects for CBT and SRIs across three important outcome metrics, and provide evidence for moderators of CBT across trials.

Psychological Treatment of Obsessive-Compulsive Disorder in Children and Adolescents: a Meta-Analysis

Although several meta-analyses have investigated the efficacy of psychological treatments for pediatric obsessive-compulsive disorder (OCD), there is not yet a consensus on the most efficacious treatment components. A meta-analysis was carried out to examine the efficacy of the different treatment techniques used in the psychological interventions of pediatric OCD. An exhaustive literature search from 1983 to February 2014 enabled us to locate 46 published articles that applied some kind of cognitive-behavioral therapy (CBT). For each group the effect size was the standardized pretest-posttest mean change, and it was calculated for obsessive-compulsive symptoms and for other outcome measures. The results clearly showed large effect sizes for CBT in reducing obsessive-compulsive symptoms and, to a lesser extent, other outcome measures (d+ = 1.860; 95% CI: 1.639; 2.081). The most promising treatments are those based on multicomponent programs comprising ERP, cognitive strategies, and relapse prevention. The analysis of other potential moderator variables and the implications for clinical practice are discussed.

Dissemination of Evidence-Based Treatment for Pediatric Obsessive-Compulsive Disorder in the Southern Region of Brazil: Challenges and Future Directions

Pediatric obsessive-compulsive disorder (OCD) is a prevalent condition that responds well to specialized treatment including cognitive behavioral therapy (CBT) or serotonin reuptake inhibitors or their combination. In Brazil, the dissemination of evidence-based treatment for pediatric OCD is hindered because of the peculiarities of the health system. The presence of a multitiered health system (public, insured, and private) with insufficient investment in public mental health and relative inaccessibility of insured/private care for most of the Brazilian population make the implementation of specialized OCD treatment centers largely unavailable in Brazil. Furthermore, lack of appropriate training in child mental health, CBT, and evidence-based approaches to OCD in current psychiatry and psychology training programs further impede improvement in diagnosis and treatment. The challenges faced in the current system in Brazil will be discussed and also strategies and programs that are currently being implemented in the south of Brazil to help address the gaps in treatment for pediatric patients with OCD.

Differential efficacy of cognitive-behavioral therapy and pharmacological treatments for pediatric obsessive-compulsive disorder: a meta-analysis

The aim of this paper is to present a meta-analysis about the differential efficacy of cognitive-behavioral therapy (CBT), pharmacological and combined treatment for pediatric obsessive-compulsive disorder (OCD). The literature research and the application of the inclusion criteria enabled us to locate 18 studies, yielding a total of 24 independent comparisons between a treated (10 pharmacological, 11 CBT, and 3 combined interventions) and a control group. All types of interventions were efficacious in reducing obsessive-compulsive symptoms, with effect sizes adjusted by the type of control group of d=1.203 for CBT, d=0.745 for pharmacological treatments, and d=1.704 for mixed treatments. Depression, anxiety and other secondary responses were also improved, especially with CBT interventions. The analysis of moderator variables showed that the CBT protocol and the total of intervention hours exhibited a significant influence on the effect size. Within pharmacological treatment, clomipramine (d=1.305) was more efficacious than selective serotonin reuptake inhibitors (d=0.644), but its adverse effects were more severe. Finally, the clinical implications of the results are discussed.

A cross-sectional study of insight and family accommodation in pediatric obsessive-compulsive disorder

BACKGROUND

Factors predicting treatment outcome in pediatric patients with obsessive-compulsive disorder (OCD) include disease severity, functional impairment, comorbid disorders, insight, and family accommodation (FA). Treatment of pediatric OCD is often only partly successful as some of these predictors are not targeted with conventional therapy. Among these, insight and FA were identified to be modifiable predictors of special relevance to pediatric OCD. Despite their clinical relevance, insight and FA remain understudied in youth with OCD. This study examined the clinical correlates of insight and FA and determined whether FA mediates the relationship between symptom severity and functional impairment in pediatric OCD.

METHODS

This was a cross-sectional, outpatient study. Thirty-five treatment-naive children and adolescentswith DSM-IV diagnosis of OCD (mean age: 13.11 ± 3.16; 54.3% males) were included. Standard questionnaires were administered for assessing the study variables. Insight and comorbidities were assessed based on clinician's interview. Subjects were categorized as belonging to a high insight or a low insight group, and the differences between these two groups were analyzed using ANOVA. Pearson's correlation coefficients were calculated for the remaining variables of interest. Mediation analysis was carried out using structural equation modeling.

RESULTS

Relative to those in the high insight group, subjects in the low insight group were younger, had more severe disease and symptoms, and were accommodated to a greater extent by their families. In addition, comorbid depression was more frequent in subjects belonging to the low insight group. Family accommodation was positively related to disease severity, symptom severity, and functional impairment. Family accommodation totally mediated the relationship between symptom severity and functional impairment.

CONCLUSIONS

Results support the differences in the diagnostic criteria between adult and pediatric patients with OCD with respect to the requirement of insight. Subjects with low insight displayed clinical characteristics of increased severity compared with their high insight counterparts, suggesting that subjects with low insight may require multimodal approach to treatment. Family accommodation was found to mediate the relationship between symptom severity and functional impairment; the use of family-based approaches to cognitive behavioral therapy, with one of the aims of reducing/mitigating FA, may provide better treatment outcomes in pediatric OCD.

Behavioural and cognitive behavioural therapy for obsessive compulsive disorder in children and adolescents

BACKGROUND

While behavioural or cognitive-behavioural therapy (BT/CBT) is recommended as the psychotherapeutic treatment of choice for children and adolescents with obsessive-compulsive disorder (OCD), the application of BT/CBT to paediatric OCD may not be straightforward.

OBJECTIVES

This review examines the overall efficacy of BT/CBT for paediatric OCD, its relative efficacy against psychopharmacology and whether there are benefits in using BT/CBT combined with medication.

SEARCH STRATEGY

We searched CCDANCTR-Studies and CCDANCTR-References (searched on 5/8/2005), MEDLINE, EMBASE, PsycINFO, the reference lists of all selected studies and handsearched journals specifically related to behavioural treatment of OCD.

SELECTION CRITERIA

Included studies were randomised controlled trials or quasi-randomised trials with participants who were 18 years of age or younger and had a diagnosis of OCD, established by clinical assessment or standardised diagnostic interview. Reviewed studies included the standard behavioural or cognitive-behavioural techniques, either alone or in combination, compared with wait-list or pill placebo.

DATA COLLECTION AND ANALYSIS

The quality of selected studies was assessed by two independent reviewers. The primary outcomes comprised of endpoint scores on the gold standard clinical outcome measure of OCD symptoms, distress and interference (CY-BOCS) and endpoint OCD status.

MAIN RESULTS

Four studies with 222 participants were considered eligible for inclusion and for data extraction. Two studies showed significantly better post-treatment functioning and reduced risk of continuing with OCD at post-treatment for the BT/CBT group compared to placebo or wait-list comparisons. We suggested that the POTS 2004 result, equal to a difference of about eight points on the CY-BOCS, represented the best available estimate for the efficacy of BT/CBT relative to no treatment. (WMD -7.50; 95% CI -11.55, -3.45). Pooled evidence from two trials indicated that the efficacy of BT/CBT and medication did not differ significantly (WMD -3.87; 95% CI -8.15, 0.41). There was evidence of the benefit of combined BT/CBT and medication compared to medication alone (WMD -4.55; 95% CI -7.40, -1.70), but not relative to BT/CBT alone (WMD -2.80; 95% CI -7.55, 1.95). The rates of drop out suggested BT/CBT is an acceptable treatment to child and adolescent patients and their families.

AUTHORS' CONCLUSIONS

Although only based on a small number of studies, behavioural or cognitive-behaviour therapy appears to be a promising treatment for OCD in children and adolescents. It can lead to better outcomes when combined with medication compared to medication alone. Additional trials are needed to confirm these findings. In the interim, consideration should be given to the ways in which BT/CBT might be made more widely available as a treatment for OCD in children and adolescents.