Children and Adolescents with Obsessive-Compulsive Disorder: Comorbidity and Quality of Life

The overall aim of the present thesis was to investigate important aspects of childhood obsessive–compulsive disorder (OCD) such as comorbidity and quality of life (QoL). Frequency and continuity of autistic symptoms from preschool age to later childhood in children with OCD were explored as a contribution to the ongoing nosological debate on whether there is an empirical base for summarizing conditions such as OCD, Tourette’s syndrome, eating disorders and autism spectrum disorders as parts of a so-called obsessive– compulsive spectrum. The establishment of proper outcome measures for the evaluation of treatment interventions has been a concern in the field (Pallanti et al., 2002). The measurement of symptom reduction only, without any assessment of subjective well-being, has been criticized (Macy et al., 2013). QoL assessment is a well-established outcome measure in somatic as well as in psychiatric treatment studies. However, in contrast to adult OCD, little is known about QoL in children with OCD and next to nothing is known about the role treatment plays in their QoL. To investigate QoL in children with OCD under different conditions (with and without comorbidity, before and after treatment) is relevant because of the paucity of studies concerning children. In the first study, comorbidity in terms of autistic traits was assessed in children and adolescents seeking treatment in a Swedish OCD Clinic (Gothenburg) and compared with controls from a general population sample. In the second study, QoL was assessed at baseline, and in the third study, both at baseline and after treatment with cognitive behavioural therapy (CBT) in children and adolescents with OCD enrolled in the Nordic Long-term OCD Treatment Study (NordLOTS) and compared with the general population. The NordLOTS is a Nordic multicentre study in which OCD treatment units for children and adolescents collaborated on common procedures for assessment, treatment and outcome evaluation (Thomsen et al., 2013). A manual for CBT with exposure and response prevention was established (Weidle et al., 2014). The QoL study included in this thesis comprised a sample of 135 children and adolescents, 7–17 years of age, with moderate to severe OCD according to the criteria of the Diagnostic and Statistical Manual of Mental Disorders (4th edition, text rev.) (DSM-IV-TR) (2000), including nine individuals with Asperger’s syndrome/high-functioning autism. QoL was assessed at baseline and after treatment with 14 sessions of CBT by self-report and caregiver proxy reports on the Questionnaire for Measuring Health-related Quality of Life in Children and Adolescents (KINDL-R) and compared with an age- and gender-matched sample from the general population. Social competence and school functioning were assessed with the Child Behaviour Checklist, comorbidity with the Kiddie Schedule for Affective Disorders and Schizophrenia (Present and Lifetime Version), severity of OCD with the Children’s Yale–Brown Obsessive Compulsive Scale and the families’ involvement with the child’s OCD symptoms with the Family Accommodation Scale. In addition, the significance of potential factors such as onset and duration of symptoms regarding QoL change were explored. Autism spectrum disorder (ASD) symptoms occurred in about one-fifth of children with OCD and were much more common than in the general population. However, the majority of OCD patients did not have these traits, indicating that ASD and OCD co-occur in a subgroup of cases rather than in OCD as a whole. In general, ASD symptoms reported in children with OCD did not show a strong enough relationship between OCD and ASD to support a classification of ASD as a part of an obsessive–compulsive spectrum group. However, a subgroup of paediatric OCD patients had significant subclinical ASD symptom levels. This should be considered when tailoring individual treatment interventions. QoL and social competence were markedly reduced in children with OCD, both in self-reports and in parents’ reports, compared with the general population. Children with higher comorbidity had lower QoL in parents’ proxy reports. After treatment, QoL ratings in treatment responders were in the same range as in the general population, while non-responders rated no change in QoL. Comorbidity, family accommodation and psychosocial functioning were not associated with changes in QoL after treatment. To the best of our knowledge, this is the largest QoL study of paediatric patients with OCD and the first one based on the assessment of OCD and comorbid disorders by standardized semi-structured diagnostic interviews, comparing patients with matched controls from the general population. It is also the first study assessing QoL changes after treatment in paediatric OCD. QoL assessment with the KINDL-R supported outcome measures for symptom reduction used in the study to define treatment outcomes. Based on our findings, we suggest employing QoL assessment in order to have a more comprehensive understanding of childhood OCD

Feasibility, Acceptability, and Effectiveness of Enhanced Cognitive Behavioral Therapy (eCBT) for Children and Adolescents With Obsessive-Compulsive Disorder: Protocol for an Open Trial and Therapeutic Intervention

Background: Although the evidence base of cognitive behavioral therapy (CBT) for pediatric obsessive-compulsive disorder (OCD) has been broadly established, the treatment is hampered by limited access, poor compliance, and nonresponse. New technologies offer the opportunity to improve the accessibility, user friendliness, and effectiveness of traditional office-based CBT. By employing an integrated and age-appropriate technologically enhanced treatment package, we aim to execute a more focused and attractive application of CBT principles to increase the treatment effect for pediatric OCD. Objective: The aim of this open study is to explore the acceptability, feasibility, and effectiveness of a newly developed enhanced CBT (eCBT) package for pediatric OCD. Methods: This study is an open trial using a historical control design conducted at the outpatient clinic of the Department of Child and Adolescent Psychiatry at St. Olavs University Hospital (Trondheim) or at BUP Klinikk (Aalesund). Participants are 30 children (age 7-17 years) with a primary Diagnostic and Statistical Manual of Mental Disorders (DSM)-5 diagnosis of OCD, and their parents. All participants receive eCBT. eCBT consists of the usual evidence-based CBT for pediatric OCD in an “enhanced” format. Enhancements include videoconferencing sessions (supervision and guided exposure exercises at home) in addition to face-to-face sessions; an app system of interconnected apps for the child, the parents, and the therapist; psychoeducative videos; and frequent online self-assessments with direct feedback to patients and the therapist. Primary outcome measures are the Children’s Yale-Brown Obsessive Compulsive Scale (CY-BOCS) (effectiveness), the Client Satisfaction Questionnaire-8 (acceptability), and treatment drop out (feasibility). Assessments are conducted pretreatment, posttreatment, and at 3- and 6-month follow-ups. A 12-month follow-up assessment is envisioned. The treatment outcome (CY-BOCS) will be compared to traditional face-to-face CBT (data collected in the Nordic Long-term OCD Treatment Study). Results: Ethical approval has been obtained (2016/716/REK nord). Inclusion started on September 04, 2017. Data collection is ongoing. Conclusions: This study is the first step in testing the acceptability, feasibility, and preliminary effectiveness of eCBT. In case of positive results, future steps include improving the eCBT treatment package based on feedback from service users, examining cost-effectiveness in a randomized controlled trial, and making the package available to clinicians and other service providers treating OCD in children and adolescents.publishedVersio

Secondary Outcomes of Enhanced Cognitive Behavioral Therapy (eCBT) for Children and Adolescents with Obsessive-Compulsive Disorder

Background: Obsessive-compulsive disorder (OCD) is a debilitating mental health condition usually presenting with a high degree of comorbid symptoms in the majority of cases. Although face-to-face cognitive-behavioral therapy (CBT) is considered the therapeutic golden standard for pediatric OCD, its accessibility, availability, and consistency in delivery are still limited. To address some of these challenges, an enhanced CBT (eCBT) package was created and introduced. This study explored eCBT’s broad-based impact on OCD-related comorbid symptoms, functional impairment, quality of life and family accommodation among youth with OCD. Methods: This open trial involved 25 pediatric patients with OCD (7−17 years), assessed between January 2018 to February 2020. All patients received eCBT for 14 weeks. Secondary outcomes were assessed at baseline, post-treatment, and 3-, 6-, and 12-month follow-up co-occurring symptoms were evaluated using the Strengths and Difficulties Questionnaire (SDQ), Screen for Child Anxiety-Related Emotional Disorders (SCARED), and Mood and Feelings Questionnaire (MFQ). Quality of life was measured using the KINDL-R, functional impairment through the Child Obsessive-Compulsive Impact Scale Revised (COIS-R), and family accommodation by the Family Accommodation Scale (FAS). Linear mixed-effects models were applied to analyze treatment effects. Results: Results indicated a significant decrease in OCD-related comorbid symptoms post-treatment, with SDQ mean reduce of 3.73 (SE = 1.10, child) and 4.14 (SE = 1.19, parent), SCARED mean reduce of 10.45 (SE = 2.52, child) and 8.40 (SE = 2.82, parent), MFQ mean reduce of 3.23 (SE = 1.11, child) and 2.69 (SE = 1.18, parent). Family accommodation declined with clinician scored FAS mean reduction of 13.25 (SE = 2.31). Quality-of-Life improved significantly post-treatment, with KINDL mean increase of 8.15 (SE = 2.87, children), and 10.54 (SE = 3.07, parents). These positive improvements were further amplified at the 3-month follow-up and remained consistent at the 12-month follow-up. Conclusion: A significant reduction was observed in all secondary outcomes employed and OCD-related functional impairments from baseline to post-treatment, which was maintained through 12-month follow-up. These results imply that after receiving eCBT, children and adolescents experienced substantial decrease in the negative impacts of OCD-related symptoms on their daily life, including home, school, and social interactions.publishedVersio

Biomarker support for ADHD diagnosis based on Event Related Potentials and scores from an attention test

ADHD is a heterogeneous neurodevelopmental disorder associated with dysfunctions in several brain systems. Objective markers of brain dysfunction for clinical assessment are lacking. Many studies applying electroencephalography (EEG) and neuropsychological tests find significant differences between ADHD and controls, but the effect sizes (ES) are often too small for diagnostic purposes. This study aimed to compute a diagnostic index for ADHD by combining behavioral test scores from a cued visual go/no-go task and Event Related Potentials (ERPs). Sixty-one children (age 9–12 years) diagnosed with ADHD and 69 age- and gender-matched typically developing children (TDC) underwent EEG-recording while tested on a go/no-go task. Based on comparisons of ERP group-means and task-performance, variables that differed significantly between the groups with at least moderate ES were converted to a five points percentile scale and multiplied by the ES of the variable. The sum-scores of the variables constituted the diagnostic index. The index discriminated significantly between patients and TDC with a large ES. This index was applied to an independent sample (20 ADHD, 21 TDC), distinguishing the groups with an even larger ES. The diagnostic index described has the potential to support assessment. Further research establishing diagnostic indexes for differential diagnoses is needed.publishedVersionThis article is available under the Creative Commons CC-BY-NC-ND license and permits non-commercial use of the work as published, without adaptation or alteration provided the work is fully attributed

Body Dysmorphic Symptoms in Youth with Obsessive-compulsive Disorder: Prevalence, Clinical Correlates, and Cognitive Behavioral Therapy Outcome

The aims of the study were to estimate the prevalence of body dysmorphic symptoms in a sample of children and adolescents with obsessive-compulsive disorder, possible clinical correlates and whether BDD symptoms predict poorer treatment outcomes after cognitive behavioral therapy. The study included 269 children and adolescents with OCD, aged 7–17 years, from Denmark, Sweden, and Norway, who were treated with 14 weekly sessions of manualized, exposure-based CBT. Twenty-one patients (7.8%) had BDD symptoms. BDD symptoms were associated with older age (p = 0.003) and a higher prevalence of comorbid anxiety disorders (p = 0.025). In addition, patients with BDD symptoms endorsed a greater number of OCD symptoms than did those without BDD symptoms. Having symptoms of BDD did not affect the CBT outcome on OCD. The results of the study suggest that CBT for OCD is equally effective for those with and without comorbid BDD symptoms.acceptedVersio

Remission and Relapse Across Three Years in Pediatric Obsessive-Compulsive Disorder Following Evidence-Based Treatments

Objective: To examine relapse rates following remission in a 3-year follow-up study in pediatric patients with obsessive-compulsive disorder (OCD) treated with cognitive–behavioral therapy (CBT) in a first step, and either continued CBT or sertraline (randomized selection) in a second step. Method: Participants (N ¼ 269) fulfilled DSM-IV OCD criteria with a mean severity on the Children’s Yale–Brown Obsessive Compulsive Scale (CY-BOCS) of 24.6 (SD ¼ 5.1) and were included in analyses according to intent-to-treat principles. CBT used manualized exposure and response prevention (ERP) during both steps 1 and 2, and step 2 sertraline medication used flexible dosing. The follow-up schedules were timed to 6, 12, 24, and 36 months following step 1 CBT. Remission was defined as a CY-BOCS score 10 and relapse as an elevated CY-BOCS score 16 in those who had remitted. Results: A good third of our patients were in stable and full remission at all examinations (n ¼ 98, 36.4%). Further, some in remission following treatment (n ¼ 36, 13.4%) had mild OCD at some examinations. Relapses during follow-up were not uncommon (n ¼ 28, 10.4%), but in many patients these improved again (n ¼ 10, 3.7%) and were in remission at the final 3-year follow-up. Furthermore, a considerable proportion (n ¼ 50, 18.6%) of the patients were initial non-remitters to the treatment but achieved remission at some point during the follow-up. In addition, 11.5% (n ¼ 31) had persistent OCD but reached remission by the last follow-up. Finally, a smaller segment of our sample (9.7%, n ¼ 26), did not attain remission at any point during the study. Conclusion: Our outcome paints a more promising picture of pediatric OCD long-term outcome than previous studies have done. However, both relapse rates and the presence of initial non-remitters and persistent OCD show that treatments need improvement, particularly for those who respond slowly, partially, or not at all. The lack of a general psychiatric interview at follow-up is a marked limitation. Clinical trial registration information: Nordic Long-term Obsessive compulsive disorder (OCD) Treatment Study; https://www.isrctn.com; ISRCTN66385119 Key words: obsessive-compulsive disorder; cognitive-behavioral therapy; serotonin re-uptake inhibitor; stepped care; relapseRemission and Relapse Across Three Years in Pediatric Obsessive-Compulsive Disorder Following Evidence-Based TreatmentspublishedVersio

eCBT Versus Standard Individual CBT for Paediatric Obsessive–Compulsive Disorder

Open access funding provided by NTNU Norwegian University of Science and Technology (incl St. Olavs Hospital - Trondheim University Hospital). The Liaison Committee for Education, Research and Innovation in Central Norway supported this work (Samarbeidsorganet mellom Helse Midt-Norge RHF og NTNU). Publisher Copyright: © 2022, The Author(s).Obsessive–compulsive disorder (OCD) is characterized by recurring obsessions and compulsions often with severe impairment affecting 1–3% of children and adolescents. Cognitive behavioural therapy (CBT) is the therapeutic golden standard for paediatric OCD. However, face-to-face CBT is limited by accessibility, availability, and quality of delivery. Enhanced CBT (eCBT) a combination of face-to-face sessions at the clinic and treatment at home via webcam and a supportive app system aims to address some of these barriers. In this pilot study, we compared eCBT outcomes of 25 paediatric patients with OCD benchmarked against traditional face-to-face CBT (n = 269) from the Nordic Long-term OCD Treatment Study, the largest paediatric OCD CBT study to date. Pairwise comparisons showed no difference between eCBT and NordLOTS treatment outcomes. Mean estimate difference was 2.5 in favour of eCBT (95% CI − 0.3 to 5.3). eCBT compared to NordLOTS showed no significant differences between response and remission rates, suggesting similar effectiveness.Peer reviewe

Sexual obsessions in children and adolescents : Prevalence, clinical correlates, response to cognitive-behavior therapy and long-term follow up

No funding was received for this study. Publisher Copyright: © 2022 The AuthorsSexual obsessions occur in pediatric and adult OCD including thoughts about sexual acts with family members, sexually inappropriate behavior, or homosexual orientation. They may remain undiagnosed because of embarrassment to report thoughts that are perceived as unacceptable. Prevalence studies of sexual obsessions in pediatric populations are rare. The present study investigated prevalence of sexual obsessions and treatment outcome compared to youth with OCD without sexual obsessions in a large sample. Sexual obsessions and OCD severity were assessed with the Children's Yale-Brown Obsessive- Compulsive Scale in all 269 participants of the Nordic Longterm OCD Treatment study (mean age 12.8 years, 48.7% boys) at baseline, after treatment and three years follow-up. Treatment consisted in individual manualized CBT with exposure and response prevention. Patients with and without sexual obsessions were compared on clinical characteristics and treatment outcomes. Sexual obsessions were reported by 18%, those with sexual obsessions were slightly older (13.5 versus 12.7 years). Both groups had no difference in treatment outcome, suggesting that if addressed, the response to CBT is similar in sexual, as in other obsessions. Clinicians need to be aware that children may need help to disclose and to identify these thoughts as obsessions to address them in treatment.Peer reviewe

Long- term remission status in pediatric obsessive-compulsive disorder : Evaluating the predictive value of symptom severity after treatment

Funding Information: This work was supported by the Tryg Foundation [grant number 122892] and the Department of Child and Adolescent Psychiatry, Aarhus University Hospital, Psychiatry. Publisher Copyright: © 2022 The Author(s)It is unknown if long-term remission for pediatric obsessive-compulsive disorder (OCD) patients is associated with post-treatment OCD symptom severity. The aim of the present study was to evaluate if post-treatment symptom severity cut-offs can discriminate remitters from non-remitters in pediatric OCD patients during three years of follow-up. All participants (N = 269) from the Nordic Long-term OCD Treatment Study (NordLOTS) undergoing stepped-care treatment were included. Patients were rated with the Clinical Global Impression – Severity Scale (CGI-S) one (n = 186), two (n = 167), and three years (n = 166) after first-line cognitive-behavioral therapy. Post-treatment symptom severity scores as well as percentage reductions during treatment evaluated with the Children's Yale-Brown Obsessive-Compulsive Scale (CY-BOCS) were analyzed using receiver operating characteristics according to the CGI-S remission scores (< 2) at follow-up. Post-treatment CY-BOCS severity scores acceptably discriminated remitters from non-remitters at one-year follow-up, but poorly for the two- and three-year follow-up. Severity percentage reduction during treatment did not discriminate remission status acceptably at any follow-up point. Post-treatment OCD symptom severity status seems to have little discriminative value for long-term remission status in pediatric patients. Further research is warranted to detect post-treatment factors of prognostic value.Peer reviewe

Internet-based psychotherapy in children with obsessive-compulsive disorder (OCD): protocol of a randomized controlled trial

Background: Obsessive-compulsive disorder (OCD) in children can lead to a huge burden on the concerned patients and their family members. While successful state-of-the art cognitive behavioral interventions exist, there is still a lack of available experts for treatment at home, where most symptoms manifest. Internet-based cognitive behavioral therapy (iCBT) could overcome these restrictions; however, studies about iCBT in children with OCD are rare and mostly target computerized self-help resources and only email contact with the therapist. Therefore, we intended to build up and to evaluate an iCBT approach for children with OCD, replacing successful elements of traditional in-office face-to-face CBT, with face-to-face teleconferences, online materials, and apps. Methods: With the help of a pilot feasibility study, we developed the iCBT consisting of 14 teleconference sessions with the child and parents. The sessions are supported by an app assessing daily and weekly symptoms and treatment course completed by children and parents. Additionally, we obtain heart rate and activity scores from the child via wristbands during several days and exposure sessions. Using a waiting list randomized control trial design, we aim to treat and analyze 20 children with OCD immediately after a diagnostic session whereas the control group of another set of 20 OCD patients will be treated after waiting period of 16 weeks. We will recruit 30 patients in each group to take account for potential dropouts. Outcomes for the treatment group are evaluated before randomization (baseline, t0), 16 weeks (end of treatment, t1), 32 weeks (follow-up 1, t2), and 48 weeks after randomization (follow-up 2, t3). For the waiting list group, outcomes are measured before the first randomization (baseline), at 16 weeks (waiting list period), 32 weeks (end of treatment), 48 weeks after the first randomization (follow-up I), and 64 weeks after the first randomization (follow-up II). Discussion: Based on our experience of feasibility during the pilot study, we were able to develop the iCBT approach and the current study will investigate treatment effectiveness. Building up an iCBT approach, resembling traditional in-office face-to-face therapy, may ensure the achievement of well-known therapy effect factors, the acceptance in both patients and clinicians, and the wide distribution within the health system. Trial registration: ClinicalTrials.gov NCT05037344 . Registered May 2019, last release August 13th, 2021