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.     

Potentials and Limitations of Cognitive Treatments for Obsessive‐Compulsive Disorder

Exposure and response prevention (ERP) is a well‐established treatment for obsessive‐compulsive disorder (OCD). However, it is not completely effective for many patients, and some do not benefit from or tolerate this treatment. Over the past 3 decades there has been growing interest in using cognitive interventions, either as adjuncts or alternatives to exposure‐based treatments such as ERP, to address these shortcomings. Cognitive therapy and cognitive behavior therapy for OCD have both demonstrated greater efficacy than no treatment at all, and appear to have a lower incidence of dropout than ERP. Unfortunately, however, for the average OCD patient, cognitive interventions have not improved treatment efficacy; that is, cognitive interventions, either alone or combined with ERP, are no more effective than ERP alone. Reasons for this disappointing result are considered, and indications for the use of cognitive interventions are discussed. Future research directions are suggested in order to evaluate more fully the merits of, and indications for, cognitive methods for treating OCD.     

Flexible Manualized Treatment for Pediatric Obsessive–Compulsive Disorder: A Case Study

The following case study describes the treatment of an 8 year-old girl with early-onset obsessive compulsive disorder using a manualized cognitive-behavioral therapy with exposure and response prevention (CBT/EPR) protocol, implemented using a “flexibility within fidelity” approach. The case study focuses on how the treatment manual was successfully implemented in a flexible manner to address unique aspects of the case. These unique factors included the child’s extreme shyness at the beginning of treatment (with implications for rapport building), the primarily obsessional presentation of this child’s symptoms, the child’s avoidance of discussing the content of her obsessive thoughts, and secondary depressive symptoms (excessive guilt, frequent crying, and sadness) that contributed to the child’s impairment and distress. Assessment of progress indicated improvement in symptoms after four sessions of cognitive skill building and again in the last five sessions after implementing increased exposure to obsessive thoughts using narrative techniques. The implications for clinicians and student therapists, including the importance of rapport building, developmentally tailoring treatment, and flexibly implementing treatment to address the unique characteristics of the individual patient are discussed.     

Combining Pharmacotherapy with Cognitive‐Behavioral Interventions for Obsessive‐Compulsive Disorder

This paper reviews the evidence‐based literature concerning the efficacy and effectiveness of cognitive behavior therapy (CBT), drug treatment and their combination for obsessive‐compulsive disorder (OCD). After a brief outline of the seminal studies, the state of the art is presented with reference to the consensual recommendations proposed in the last 10 years. Management of OCD rests on potent selective serotonin re‐uptake inhibitors and CBT, used separately, sequentially, or concurrently. A hierarchical model for clinical decision‐making is reported. With greater severity of OCD, it is recommended to add medications. However, the response rate is still too low in many patients, and some patients remain refractory to any kind of treatment. This stresses the importance of joint efforts of psychological and biological teams to develop new treatments.     

Cognitive–Behavior Therapy for Pediatric Trichotillomania

Trichotillomania (TTM) is a chronic disorder in which youth repeatedly pull their hair to the extent that they experience noticeable hair loss as well as clinically significant academic, social, and/or occupational impairment. Prevalence rates of TTM in children are largely unknown, although the onset of TTM primarily occurs in childhood. Modified habit reversal training is the current psychological treatment of choice for TTM in adults and researchers and clinicians have applied this approach to the treatment of pediatric TTM. This article describes cognitive–behavior therapy for pediatric TTM, with an emphasis on the application of standard interventions across the developmental age range. In particular, recent findings on the role of experiential avoidance in TTM and the manner with which the type of hair pulling changes across the developmental age range, recommends the flexible principle-driven application of treatment strategies with careful consideration of the developmental age of youth.     

Interpersonal Functioning in Obsessive–Compulsive Personality Disorder

The core symptoms of obsessive–compulsive personality disorder (OCPD) often lead to interpersonal difficulties. However, little research has explored interpersonal functioning in OCPD. This study examined interpersonal problems, interpersonal sensitivities, empathy, and systemizing, the drive to analyze and derive underlying rules for systems, in a sample of 25 OCPD individuals, 25 individuals with comorbid OCPD and obsessive–compulsive disorder (OCD), and 25 healthy controls. We found that OCPD individuals reported hostile-dominant interpersonal problems and sensitivities with warm-dominant behavior by others, whereas OCPD+OCD individuals reported submissive interpersonal problems and sensitivities with warm-submissive behavior by others. Individuals with OCPD, with and without OCD, reported less empathic perspective taking relative to healthy controls. Finally, we found that OCPD males reported a higher drive to analyze and derive rules for systems than OCPD females. Overall, results suggest that there are interpersonal deficits associated with OCPD and the clinical implications of these deficits are discussed.     

Danger Ideation Reduction Therapy for Obsessive–Compulsive Checking: Preliminary Findings

Danger Ideation Reduction Therapy (DIRT) is a cognitive treatment package developed in the mid-1990s to treat obsessive–compulsive (OC) washing. DIRT is solely directed at decreasing threat expectancies and does not involve direct or indirect exposure. The effectiveness of the DIRT package for OC washers has been examined, and to date a number of publications, including two randomised controlled trials, support its efficacy. Recently, the DIRT package was modified to treat people with the OC checking subtype. In the current study, three adult OC checkers received DIRT in 12 to 14 individual 1-hr sessions conducted by a clinical psychologist. At posttreatment, substantial and clinically significant reductions in scores on a range of standardized outcome measures of obsessive–compulsive disorder symptom severity were apparent for all three participants. Crucially, these improvements were maintained at 4-month follow-up. Although further research is clearly warranted, these preliminary findings suggest that DIRT for checkers may prove as effective as DIRT for OC washers.     

A Comparison of Obsessive–Compulsive Personality Disorder Scales

In this study, we utilized a large undergraduate sample (N = 536), oversampled for the Diagnostic and Statistical Manual of Mental Disorders (4th ed., text revision [DSM–IV–TR]; American Psychiatric Association, 2000) obsessive–compulsive personality disorder (OCPD) pathology, to compare 8 self-report measures of OCPD. No prior study has compared more than 3 measures, and the results indicate that the scales had only moderate convergent validity. We also went beyond the existing literature to compare these scales to 2 external reference points: their relationships with a well-established measure of the five-factor model of personality (FFM) and clinicians' ratings of their coverage of the DSM–IV–TR criterion set. When the FFM was used as a point of comparison, the results suggest important differences among the measures with respect to their divergent representation of conscientiousness, neuroticism, and agreeableness. Additionally, an analysis of the construct coverage indicated that the measures also varied in terms of their representation of particular diagnostic criteria. For example, whereas some scales contained items distributed across the diagnostic criteria, others were concentrated more heavily on particular features of the DSM–IV–TR disorder.     

Understanding Obsessive–Compulsive Disorder: Focus on Decision Making

Current approaches to obsessive-compulsive disorder (OCD) have suggested that neurobiological abnormalities play a crucial role in the etiology and course of this psychiatric illness. In particular, a fronto-subcortical circuit, including the orbitofrontal cortex, basal ganglia and thalamus appears to be involved in the expression of OCD symptoms. Neuropsychological studies have also shown that patients with OCD show deficits in cognitive abilities that are strictly linked to the functioning of the frontal lobe and its related fronto-subcortical structures, such as executive functioning deficits and insufficient cognitive-behavioral flexibility. This article focuses on decision making, an executive ability that plays a crucial role in many real-life situations, whereby individuals choose between pursuing strategies of action that involve only immediate reward and others based on long-term reward. Although the role of decision-making deficits in the evolution of OCD requires further research, the collected findings have significant implications for understanding the clinical and behavioral heterogeneity that characterizes individuals with OCD.     

Clinical Feedback About Empirically Supported Treatments for Obsessive‐Compulsive Disorder

Previous evidence for the treatment of obsessive‐compulsive disorder (OCD) has been derived principally from randomized controlled trials. As such, evidence about the treatment of OCD has unilaterally flowed from researchers to clinicians. Despite often having decades of experience treating OCD, clinicians’ feedback on their clinical observations in using these treatments has not been solicited. The current study contacted clinicians for their clinical observations on empirically supported treatments for OCD to identify commonly used cognitive-behavioral techniques and their limitations in their practices. One hundred eighty-one psychotherapists completed an online survey. The average participant practiced psychotherapy for 15 years, worked in private practice, held a doctorate, and treated an average of 25 clients with OCD in their lifetime. In regard to the most common techniques, behavioral strategies involving exposure to a feared outcome and prevention of a compulsive ritual were the most frequent group of interventions, followed by techniques that attempted to identify and challenge irrational thoughts. However, the majority of participants also reported incorporating mindfulness or acceptance-based methods. Based on therapists’ reports, the most common barriers to the efficacy of cognitive-behavioral interventions included limited premorbid functioning, chaotic lifestyles, controlling and critical families, OCD symptom severity, OCD symptom chronicity, and comorbidities. This study provides insight into common practices and limitations in clinical practice to inform future clinically relevant treatment research.     

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.     

Evidence-Based Assessment in Children and Adolescents with Obsessive–Compulsive Disorder

The assessment of varied psychiatric disorders, including obsessive–compulsive disorder (OCD), is shifting towards the use of evidence-based assessments (EBAs). This shift has fostered the development, validation and adaptation of several measures to rate obsessive–compulsive symptoms and other related problematic areas such as functional impairment or family attitudes among others. The aim of this paper is to present a systematic review of psychometric studies on pediatric OCD-specific measures to classify these according to assessment evidence-based criteria. Selection criteria that determined which studies were included in the review were: (1) analyzing an OCD measure and (2) including participants’ age being 18 years or younger. The literature search procedure was conducted in Medline, PsycINFO, PsycARTICLES, ERIC, Cochrane Library, and Scholar Google databases and enabled us to locate 42 studies which analyzed psychometric properties of 14 OCD measures studied in children and adolescents. Instruments were grouped into the following assessment areas: symptom presence and severity, functional impairment, family functioning and cognitive dimensions of OCD. Psychometric data regarding internal structure, internal consistency, reliability, validity and diagnostic precision were also reported. Further, measures were classified as well-established, approaching well-established and promising assessments in terms of reliability and validity. We concluded that the assessment of OCD in pediatric populations is a growing field that in a short-medium term could provide a wide variety of EBAs for the evaluation obsessive–compulsive symptoms and other OCD-related dimensions. The paper concludes by highlighting directions for future research.     

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.     

Influence of Co‐Morbid Generalized Anxiety Disorder,Panic Disorder and Personality Disorders on the Outcome of Cognitive Behavioural Treatment of Obsessive‐Compulsive Disorder

This study examined co‐morbid generalized anxiety disorder and/or panic disorder and personality disorders as predictors of treatment outcomes in adult outpatients with obsessive‐compulsive disorder. The patients received exposure with response prevention (ERP) treatment with the addition of either elements of cognitive therapy (ERP+CT) or relaxation training (ERP+REL). It was hypothesized that the addition of cognitive interventions would yield better treatment outcomes for patients with co‐morbid generalized anxiety disorder and/or panic disorder. It was also hypothesized that patients with any personality disorder would show less treatment gains in both conditions. Using intention‐to‐treat criteria, patients with generalized anxiety disorder and/or panic disorder co‐morbidity showed less treatment gains at post‐treatment across both treatment conditions. This group showed significantly more treatment gains in the ERP+CT condition at the post‐treatment and the 12‐month follow‐up assessments compared with patients in the ERP+REL condition. However, this was not significant when comparing treatment completers. Patients with a co‐morbid Cluster A or B personality disorder showed significantly less treatment gains in both treatment conditions at the 12‐month follow‐up assessment. Among treatment completers, patients with a Cluster C personality disorder showed significantly better outcomes at the post‐treatment assessment in the ERP+REL treatment condition. These results, clinical implications, and the importance of further investigations are discussed.     

Risking Everything in Obsessive–Compulsive Disorder: An Analogue Decision-Making Study

An experiment examined decision-making processes among nonclinical participants with low or high levels of OCD symptomatology (N?=?303). To better simulate the decision environments that are most likely to be problematic for clients with OCD, we employed decision tasks that incorporated “black swan” options that have a very low probability but involve substantial loss. When faced with a choice between a safer option that involved no risk of loss or a riskier alternative with a very low probability of substantial loss, most participants chose the safer option regardless of OCD symptom level. However, when faced with choices between options that had similar expected values to the previous choices, but where each option had some low risk of a substantial loss, there was a significant shift towards riskier decisions. These effects were stronger when the task involved a contamination based, health-relevant decision task as compared to one with financial outcomes. The results suggest that both low and high symptom OC participants approach decisions involving risk-free options and decisions involving risky alternatives in qualitatively different ways. There was some evidence that measures of impulsivity were better predictors of the shift to risky decision making than OCD symptomatology.

     

Does d-Cycloserine Augmentation of CBT Improve Therapeutic Homework Compliance for Pediatric Obsessive–Compulsive Disorder?

Clinical studies in adults and children with obsessive–compulsive disorder (OCD) have shown that d-cycloserine (DCS) can improve treatment response by enhancing fear extinction learning during exposure-based psychotherapy. Some have hypothesized that improved treatment response is a function of increased compliance and engagement in therapeutic homework tasks, a core component of behavioral treatment. The present study examined the relationship between DCS augmented cognitive-behavioral therapy (CBT) and homework compliance in a double-blind, placebo controlled trial with 30 youth with OCD. All children received 10 CBT sessions, the last seven of which included exposure and response prevention paired with DCS or placebo dosed 1 h before the session started. Results suggested that DCS augmented CBT did not predict improved homework compliance over the course of treatment, relative to the placebo augmented CBT group. However, when groups were collapsed, homework compliance was directly associated with treatment outcome. These findings suggest that while DCS may not increase homework compliance over time, more generally, homework compliance is an integral part of pediatric OCD treatment outcome.     

Obsessional Beliefs and Symptoms of Obsessive–Compulsive Disorder in a Clinical Sample

The aim of the present study was to investigate the relationships among a broad range of obsessive–compulsive disorder (OCD) symptoms and obsessional beliefs in a clinical sample of OCD patients. Ninety-nine treatment-seeking adult OCD patients completed the Obsessive Beliefs Questionnaire and the Obsessive–Compulsive Inventory-Revised. Hierarchical regression analyses, controlling for comorbid symptoms, suggested that washing was predicted by responsibility/threat estimation beliefs. Checking/doubting was not predicted by any obsessional beliefs. Hoarding was predicted by perfectionism/certainty beliefs. Neutralizing was predicted by responsibility/threat estimation beliefs. Obsessing was predicted by importance/control of thoughts and perfectionism/certainty beliefs. Ordering was predicted by perfectionism/certainty beliefs. A principal components analysis of OCD symptom dimensions and accompanying beliefs yielded two components, accounting for 53% of the variance: one, which was labeled “Fear/Threat,” consisted of importance/control of thoughts, obsessing, responsibility/threat estimation, and washing. The second, which was labeled “Incompleteness/Not Just Right,” consisted of neutralizing, perfectionism/certainty, checking/doubting, and hoarding.     

Hierarchical Structure of Dysfunctional Beliefs in Obsessive‐Compulsive Disorder

The Obsessive Beliefs Questionnaire was developed as a comprehensive measure of dysfunctional beliefs, which cognitive models consider to be etiologically related to obsessive‐compulsive disorder. Obsessive Beliefs Questionnaire subscales tend to be highly correlated, which raises the question of whether obsessive‐compulsive‐related beliefs are hierarchically structured, consisting of lower‐order factors loading on 1 or more higher‐order factors. To investigate the nature and relative importance of these factors, a hierarchical factor analysis was conducted (n = 202 obsessive‐compulsive disorder patients), using a Schmid‐Leiman transformation. Results indicated a higher‐order (general factor) and 3 lower‐order factors: (i) responsibility and overestimation of threat, (ii) perfectionism and intolerance of uncertainty and (iii) importance and control of thoughts. The high‐order factor accounted for more variance in Obsessive Beliefs Questionnaire scores (22%) than did the lower‐order factors (6–7%), thereby underscoring the importance of the higher‐order factor. Despite the importance of the higher‐order factor, the lower‐order factors significantly predicted unique variance in measures of obsessive‐compulsive symptoms, including severity ratings of compulsions. These finding suggest that cognitive models of obsessive‐compulsive disorder should take into consideration the hierarchic structure of obsessive‐compulsive‐related beliefs.     

Pragmatic Competency and Obsessive–Compulsive Disorder: A Comparative Assessment with Normal Controls

Unlike such cognitive impairments as autism and schizophrenia, the speech pattern in obsessive–compulsive disorder (OCD) has largely remained underrepresented. We examined the pragmatic competence of OCD-affected individuals under two variant modes: pragmatic recognition and pragmatic production. In the recognition phase, the informants completed a discourse completion test around two speech acts of request and apology (20 high power distance situations). The production phase was carried out through an interview during which the informants’ communication behaviors were rated on the basis of the Orion’s pragmatic language skills checklist (OPLS) subscales. No significant difference was observed between the normal and OCD groups in terms of pragmatic recognition. Moreover, considering the OPLS subscales, although the normal controls significantly outperformed in non-verbal communication and expressive skills, the overall pragmatic production ability of the two groups was statistically alike. The results are discussed in relation to the two competing disorders of autism and social anxiety.