The Role of the Family in Childhood Obsessive–Compulsive Disorder

While obsessive–compulsive disorder is widely recognized to have a strong genetic component, psychosocial factors are also acknowledged to be important. The primary focus of this paper is on familial factors associated with OCD in children and adolescents. It explores the family context as a possible risk factor in the development and maintenance of the disorder, including parental modeling, expressed emotion, parenting style, and family accommodation of the child's symptoms. The involvement of the family in the treatment of the disorder is also reviewed. Finally, future directions for research investigating familial factors in childhood OCD are presented.     

A review of the treatment for refractory obsessive-compulsive disorder: from medicine to deep brain stimulation

This article provides an overview of the etiology, epidemiology, and first-line treatment options for obsessive-compulsive disorder (OCD). The subject of treatment-resistant and treatment-refractory OCD is then discussed, including a definition of these often-debated terms, and the latest treatment options delineated. This includes a review of the latest research concerning the pharmacological agents that have been studied as monotherapy or augmenting agents for the treatment of OCD, the use of experimental medications and procedures, treatment with reversible, minimally invasive procedures, such as vagal nerve stimulation and transcranial magnetic stimulation, invasive but the potentially reversible deep brain stimulation, and irreversible lesioning with ablative psychosurgery. A discussion of the role of psychotherapy in the treatment of OCD is also included.     

The structure of childhood obsessions and compulsions: dimensions in an outpatient sample

While obsessive-compulsive disorder (OCD) is defined as a unitary condition, prior research has identified meaningful and distinct symptom dimensions in adult samples. In contrast, there have been no investigations of symptom dimensions in samples of children diagnosed with OCD. The present study sought to address this gap. Children diagnosed with OCD (n = 137) were administered the Children's Yale-Brown Obsessive-Compulsive Scale symptom checklist and severity index. Symptoms were analyzed using principal components analysis. As with adult samples, four factors were identified from the checklist. However, these four factors (compulsions, sexual/aggressive obsessions, superstitions, and hoarding/ordering/somatic concerns) were different in content from adult studies. Further, several symptoms significantly contributed to more than one dimension. Each dimension was significantly correlated with scores from the severity index, with the exception of the obsession score with the hoarding/ordering/somatic concerns factor. Results suggest that there are distinct dimensions of symptoms in childhood OCD, but that these dimensions do not correspond to those identified in adults. Instead, it appears that some factors share variance, and the dimensions themselves are separated based upon developmental trajectories. The dimensions examined may be useful in future treatment studies using pharmacological and/or behavioral interventions.     

Quetiapine augmentation of selective serotonin reuptake inhibitors in treatment-resistant obsessive-compulsive disorder: a six-month follow-up case series

Obsessive-compulsive disorder (OCD) is a relatively common, often chronic and disabling disorder with high rates of partial and/or absent response to standard, recommended treatments, such as selective serotonin reuptake inhibitors (SSRIs) and psychotherapy. This article presents the cases of four patients suffering from OCD and comorbid mood or anxiety disorders, who were treated with SSRIs at adequate doses for at least 12 weeks, showing a partial response. Quetiapine treatment was added to SSRIs at a dose of 25 mg/day and titrated up to 200 mg/day. Patients were followed up for 6 months. After 12 weeks, all the patients were classified as "much improved" on the Clinical Global Impression-Improvement scale and showed a Yale-Brown Obsessive-Compulsive Scale score reduction > or =35%. After 6 months of follow-up, all the patients maintained the same level of improvement. Although quetiapine augmentation to SSRIs has shown mixed results in published controlled trials in the acute treatment (12 weeks) of patients with treatment-resistant OCD, this case series indicates that patients who benefit from this pharmacologic regimen in the acute phase tend to maintain such an improvement. Larger follow-up studies are warranted to confirm our findings.     

Cognitive-behavioral psychotherapy for pediatric obsessive-compulsive disorder

Discusses the cognitive-behavioral psychotherapy for pediatric obsessive-compulsive disorder (OCD). Over the past 15 years, cognitive-behavioral psychotherapy has emerged as the psychosocial treatment of choice for OCD across lifespan. Unlike other psychotherapies that have been applied usually unsuccessfully to OCD, cognitive-behavioral treatment (CBT) presents a logically consistent and compelling relationship between the disorder, the treatment, and the specified outcome. Nevertheless, despite a consensus that CBT is usually helpful, clinicians routinely complain that patients will not comply with behavioral treatments and parents routinely complain that clinicians are poorly trained in CBT, with the result that many if not most children and adolescents are denied access to effective psychosocial treatment. This unfortunate situation may be avoidable, given an increased understanding regarding the implementation of CBT in children and adolescents with OCD. To this end, we review the principles and the practical aspects of the cognitive-behavioral treatment of OCD in youth, move on to discuss empirical studies supporting the use of CBT in the pediatric age group, and conclude by discussing directions for future research.     

Phenomenology of Early Childhood Onset Obsessive Compulsive Disorder

This paper describes the phenomenological features of early childhood onset obsessive compulsive disorder (OCD; defined as children meeting DSM-IV criteria for OCD with age of onset <8 years). Fifty-eight children (ages 4–8) were included in the sample. OCD and comorbid diagnoses were determined by structured interview, and OCD severity was measured using the Children’s Yale-Brown Obsessive Compulsive Scale (CY-BOCS). Mean age of OCD onset was almost five, and mean age of presentation was between 6 and 7. Mean symptom severity was in the moderately severe range. Comorbidity and family history of OCD were common. Contamination and aggressive/catastrophic obsessions and washing and checking compulsions were endorsed most frequently. Results indicate that early childhood onset OCD may have a lower boy to girl ratio and lower rates of depressive disorders, but may be similar to later childhood onset OCD in terms of OCD symptom presentation and severity.     

Obsessive-compulsive disorder in children and adolescents: Clinical syndrome and treatment

Abstract

Obsessive-compulsive disorder (OCD) in children and adolescents has been relatively neglected by clinicians and researchers. We aim to show that childhood OCD is a serious condition that requires early identification and treatment. The DSM-III-R criteria for OCD are presented along with recent findings on psychopathology. Clinical management of childhood OCD is a challenging and difficult task for mental health professionals. We briefly describe and evaluate advances in behavioural treatment — mainly in vivo exposure and response prevention. Also the adjunctive use of anti-depressant medication is examined. Whilst these clinical innovations are promising, further controlled evaluations are necessary before the efficacy of behaviour therapy can be confidently asserted     

Summer Camp Program for Children With Obsessive–Compulsive Disorder: Description and Preliminary Observations

Summer camp programming has a rich history of promoting childhood development. In the care of children with specific childhood psychiatric disorders, the incorporation of targeted cognitive-behavioral principles provides an opportunity to marry targeted evidence-based practices with broader development, in particular social, emotional, and fine- and gross-motor development. This union is synergistic, providing the practitioner with an opportunity to employ cognitive-behavioral practices in an environment that may overcome common barriers to effective interventions outside the scope of the targeted illness. In this paper, the authors describe the preliminary findings concerning a weeklong, 25-hour summer camp program targeting childhood obsessive–compulsive disorder (OCD). Nine children ages 9–12 years participated in this pilot program. Child and parent feedback alike suggested strong treatment acceptability and efficacy in targeting both core symptoms of OCD as well as associated developmental deficits. The camp’s implementation of exposure and response prevention enables an opportunity to report on the capability of employing these strategies in a summer camp setting. In conjunction with an evidence-based treatment program for childhood OCD, a summer camp program specifically targeted for children with OCD presents a valuable tool for improving child welfare and reducing functional impairments.     

Cool and Hot Aspects of Executive Function in Childhood Obsessive-Compulsive Disorder

Aspects of executive functioning (EF) have been put forward as endophenotypes in obsessive- compulsive disorder (OCD) and meta-analyses support EF underperformance in adult samples. Childhood-onset OCD has been suggested to constitute a separate neurodevelopmental subtype of the disorder but studies on neuropsychological functioning in childhood OCD are limited. The aim of the present study was to investigate performance-based EF in pediatric OCD using observed and latent variable analyses. A case-control design was applied including 50 unmedicated children and adolescents with OCD aged 7–17 years of which 70% were female, 50 pairwise age and gender matched non-psychiatric controls (NP) and 38 children and adolescents with mixed anxiety disorders (MA). Participants underwent structured diagnostic interviews and assessment with a battery encompassing cool EF tasks of working memory, set shifting, inhibition, and planning, and hot EF tasks of decision making and dot probe paradigm affective interference. First, groups were compared on observed variables with multilevel mixed-effects linear regression and analysis of variance. Then the latent structure of cool EF was tested with confirmatory factor analysis (CFA) and groups were compared on the CFA scores. No significant differences between groups appeared on individual cool EF tasks. On the hot EF tasks the OCD group displayed significant interference effects on the dot probe paradigm OCD-specific stimuli relative to NP, but not compared to MA and no group differences emerged for decision making. In the CFA a one-factor solution showed best fit, but the groups did not differ significantly on the resulting latent variable. The present study does not support cool or hot EF impairments in childhood OCD.     

认知行为疗法治疗儿童青少年强迫症的应用研究

强迫症已经被认为是儿童青少年常见的心理障碍之一。强迫症的认知行为模型在成人研究中得到了大量的实证支持,但这个模型在儿童青少年群体中研究相对较少。认知行为疗法被广泛认为是治疗儿童青少年强迫症的有效心理治疗方案,但对于认知行为治疗儿童青少年强迫症的实证研究还有待进一步深入。     

An examination of the cognitive processes involved in childhood obsessive-compulsive disorder

The cognitive theory of obsessive-compulsive disorder (OCD) is the most widely accepted account of the aetiology and maintenance of this disorder in adults. This paper investigated whether cognitive processes were evident in a sample of children with a primary diagnosis of OCD. Using an idiographic approach, as proposed by the Obsessive-Compulsive Cognitions Working Group, this paper assessed cognitive appraisals of responsibility, probability, severity, thought-action fusion, self-doubt and cognitive control. Ratings of these cognitive appraisals were obtained across a sample of children with OCD, and were compared with ratings from a clinical control group of anxious children and a non-clinic control group. It was hypothesised that consistent with the cognitive theory of OCD, children in the OCD group would display higher estimations of these cognitive processes in comparison to anxious and non-clinic children. Results of this investigation provide preliminary support for a cognitive conceptualisation of OCD during childhood. OCD children reported significantly higher ratings of responsibility, severity, thought action fusion and less cognitive control in comparison to non-clinic children. OCD children could also be clearly differentiated from anxious children on ratings of cognitive control. Implications of this investigation are discussed and directions for future research are highlighted.     

Community treatment of severe, refractory obsessive-compulsive disorder

Despite the existence of effective psychological and pharmacological interventions for obsessive-compulsive disorder (OCD), there are a large proportion of individuals for whom intervention is not effective. The study reports on the results of a community treatment service for individuals with treatment-refractory OCD who have not benefitted from previous cognitive behavioural or pharmacological treatment by community mental health services. A total of 205 individuals accepted for treatment by a specialist community OCD treatment service in London were provided with a combination of behavioural, cognitive, and pharmacological treatment within a specialist OCD service, with 158 completing treatment. Treatment was associated with significant reduction in clinician-rated and self-reported OCD symptoms after 12 weeks, with further reductions in OCD symptoms over a subsequent 12-week period. A significant reduction in symptoms of depression was also observed after 12 and 24 weeks. Approximately 40% of individuals treated experienced clinically significant improvement in their symptoms, with approximately 10% deemed to have recovered by the end of treatment. Our results add to previous research into refractory OCD, and provide support for the existence of specialist community treatment services which may provide assistance to individuals who have not responded to previous treatment.     

The Children’s Yale-Brown Obsessive Compulsive Scale: Reliability and Validity for Use Among 5 to 8 Year Olds with Obsessive-Compulsive Disorder

The Children’s Yale-Brown Obsessive Compulsive Scale (CY-BOCS) is the instrument of choice for assessing symptom severity in older children (i.e., 8–18 years) diagnosed with obsessive-compulsive disorder (OCD). The reliability and validity of this measure for use among younger children (i.e., 5–8 years of age), however, has never been examined. The primary aim of this study was to examine this scale’s use among those presenting with early childhood OCD. Forty-two children with OCD between the ages of 4 and 8 years of age were recruited as part of a larger treatment outcome study, and the reliability and validity of the CY-BOCS was examined. Results revealed questionable reliability for the measure’s 5-item Obsessions subscale but good reliability (i.e., internal consistency, temporal stability) for the 5-item Compulsions subscale and 10-item total scale. Results also revealed that the CY-BOCS total scale demonstrated mixed discriminant validity but strong convergent validity and sensitive to change. Collectively, the 10-item, CY-BOCS total score yields a reliable and valid scale for the assessment of symptom severity in early childhood OCD. However, we urge caution in use of the Obsessions subscale in isolation for either clinical or research purposes. Limitations and future areas of research are discussed including the potential benefit of developing a measure of OCD-related symptom severity specifically for younger children with greater attention to developmental differences among children within this population.     

Associations between miscellaneous symptoms and symptom dimensions: an examination of pediatric obsessive-compulsive disorder

Obsessive-compulsive disorder (OCD) in children and adults is a heterogeneous disorder associated with significant psychosocial impairment. Although factor analytic studies have identified symptom dimensions, these analyses do not capture the varied miscellaneous symptoms that fail to load on a specific dimension despite being functionally related. The present study sought to extend the findings of previous research in adults to a sample of youth with OCD (n=131). Logistic regression analyses were used to examine the predictive value of each of the four symptom factors (contamination symptoms, obsessions and checking, symmetry and ordering, and hoarding) to the miscellaneous OCD symptoms. The vast majority of miscellaneous symptoms (17 of the 18 symptoms) were associated with one or more symptoms factors (i.e., contamination symptoms, obsessions and checking, symmetry, and ordering). Hoarding was not related to any miscellaneous symptom. In addition to improving our understanding about the clinical presentation of pediatric OCD, findings also have important assessment (e.g., understanding which miscellaneous symptoms relate to certain dimensions) and treatment implications (e.g., hierarchy development).     

Symptom patterns in children and adolescents with obsessive-compulsive disorder (OCD)

OBJECTIVE: Obsessive-compulsive disorder (OCD) defined at the diagnostic level encompasses divergent symptoms. The present study examines symptom patterns in OCD in children and adolescents in order to search for the presence of diagnostic heterogeneity. SUBJECTS AND METHODS: Two hundred and thirteen outpatients with primary OCD participated. The patients' and primary caretakers' responses on the Children's Yale-Brown Obsessive-Compulsive Scale were used to generate severity ratings for 61 OCD symptoms, and cluster analysed them. RESULTS: A five cluster solution was judged to be the most clinically and theoretically relevant model. The clusters were named: (1) "Mental Rituals, Touching & Ordering", (2) "Contamination & Cleaning", (3) "Superstitions", (4) "Obsessions/Checking & Confessing" and (5) "Somatic Concerns". The symptom patterns of the groups differed, and three groups were particularly homogeneous. In addition, there were differences in severity, number of symptoms and age. CONCLUSIONS: OCD in children and adolescents is a heterogeneous disorder and discrepancies vis-à-vis adult studies indicate that childhood OCD may have developmentally specific traits. The sub-groups obtained are likely to have implications for the assessment of OCD symptoms in children, their prognosis and outcome in treatment research.     

An open clinical trial of cognitive-behaviour therapy in children and adolescents with obsessive-compulsive disorder administered in regular outpatient clinics

The aim of the present study was to examine the effectiveness of manual-guided cognitive-behaviour therapy (CBT) for childhood obsessive-compulsive disorder (OCD) administered within three regular, i.e., non-academic, Norwegian outpatient child psychiatric clinics. METHODS: A total of 28 youngsters, aged 8-17 with primary OCD entered the study. Assessment at intake included Norwegian versions of the K-SADS-PL, Children's Yale-Brown Obsessive Compulsive Scale (CY-BOCS), and a measure of OCD-specific functional impairment (Child OCD Impact Scale (COIS)). Therapy consisted of 12 manual-guided sessions with combined individual and family CBT-based interventions and was conducted by psychologists and physicians under training and supervision. Outcome was assessed after treatment and at 3- and 6-month follow-ups by means of the CY-BOCS, the Clinical Global Impression (CGI) and the CGI-Improvement scales, and the COIS. RESULTS: Twenty-four youngsters (86%) completed treatment and were available for the follow-up assessments. Significant improvements were found on all outcome measures after treatment, including a mean symptom reduction on the CY-BOCS of 60.6%, increasing to 68.8% at the 6-month follow-up. Estimates of within-group effect sizes showed strong effects of treatment. CONCLUSION: The results of the present study suggest that manual-guided CBT for childhood OCD can be successfully implemented in non-academic community child psychiatric settings with outcomes in accordance with previous findings from highly specialised university clinics.     

Issues surrounding the cognitive neuroscience of obsessive-compulsive disorder

Obsessive-compulsive disorder (OCD) has been studied extensively in recent years, with increased emphasis on understanding OCD’s biological substrates. There has been significant progress in documenting abnormal brain function in OCD patients, particularly in the orbitofrontal cortex, basal ganglia, and thalamus. Similar progress has broadened our understanding of the cognitive and behavioral manifestations of the disorder, including deficits in set shifting, hyperattention, and visuospatial construction abilities. Unfortunately, these results have not been replicated consistently. This report comprises a review of previous attempts to characterize the neurobiology and neuropsychology of OCD, and a discussion of several factors in OCD research that can help to explain previous inconsistencies.     

First-Line Treatment for Pediatric Obsessive–Compulsive Disorder

Pediatric obsessive–compulsive disorder (OCD) is a common psychiatric disorder that impairs children’s functioning in home, school, and community settings. Once thought to be an untreatable or treatment refractory disorder, evidence-based treatments now exist for pediatric OCD. Various psychological treatment approaches for pediatric OCD have been investigated and research supports the use of cognitive-behavioral therapy (CBT) with exposure and response prevention (E/RP) and combined CBT/E/RP with serotonin reuptake inhibitor pharmacotherapy. This paper reviews these approaches and highlights the prominent role of CBT/E/RP as a first-line treatment for pediatric OCD.     

The Children's Yale-Brown Obsessive-Compulsive Scale: item structure in an outpatient setting

The Children's Yale-Brown Obsessive-Compulsive Scale (CY-BOCS) is one of the most popular measures of symptom severity for childhood obsessive-compulsive disorder (OCD). This study describes the factor structure of the CY-BOCS. A total of 233 children diagnosed with OCD were evaluated with the CY-BOCS. The results indicated that 2 alternate 2-factor solutions (obsessions and compulsions; severity and disturbance) fit the data set best. The results also suggested that items assessing resistance to obsessions and compulsions provide unreliable evaluations of these symptoms in children with OCD. Recommendations for modifications to the CY-BOCS as well as clinical applications and for future research with the measure are made.