Intensive Family-Based Cognitive-Behavioral Therapy for Pediatric Obsessive-Compulsive Disorder: Applications for Treatment of Medication Partial- or Nonresponders.

Serotonin reuptake inhibitor medications and cognitive-behavioral therapy (CBT) are both effective treatments for pediatric obsessive-compulsive disorder (OCD). Despite recommendations that youth with OCD be treated with CBT alone or together with serotonin reuptake inhibitor medication, many youth are treated with medication alone or with non-CBT psychotherapy initially. Although effective, symptom remission with medication alone is rare (e.g., only 21.4% of youth achieved remission with sertraline in the Pediatric OCD Treatment Study, 2004) and residual symptoms often remain (e.g., 58% of subjects in the March et al. [1998] sertraline trial were not considered treatment responders). This paper reviews the literature on the efficacy of CBT for pediatric OCD, particularly as it relates to the treatment of youth with prior inadequate response to medication. It also describes an intensive, family-based CBT program for children and adolescents with OCD and support for its efficacy among those with prior partial- or nonresponse to medication. Finally, we present a case study of an adolescent girl with OCD who participated in the intensive treatment program after having limited benefit from medication and non-CBT psychotherapy and experienced a favorable response.

Associations between miscellaneous symptoms and symptom dimensions in adults with obsessive-compulsive disorder.

Obsessive-compulsive disorder (OCD) is a debilitating psychiatric condition with a heterogeneous array of obsessions and compulsions. Although factor analytic studies have identified symptom dimensions comprising the clinical presentation of OCD, many frequently reported miscellaneous symptoms are not considered in factor analytic studies because they do not fit conceptually within a particular symptom category, despite being functionally related. In the present study, we examined the associations between miscellaneous symptoms and OCD symptom dimensions in a sample of 111 adults with OCD. Overall, most miscellaneous symptoms were associated with one or more symptom dimensions in previously identified four- (14 of the 22 symptoms) and five-factor models (12 of the 22 symptoms). In both models, Contamination/Cleaning was the only dimension not related to any miscellaneous symptom. The present results provide information about which miscellaneous symptoms may be related to particular symptom dimensions, which will assist in clinical evaluations and help planning behavioral psychotherapy (e.g., hierarchy development).

Clinical features associated with treatment-resistant pediatric obsessive-compulsive disorder.

OBJECTIVE: The objective of the study was to identify clinical and sociodemographic characteristics that may differentiate youth with obsessive-compulsive disorder (OCD) who are resistant to treatment vs those who have a favorable response. METHOD: Participants included 60 outpatients, aged 7-17 years, who were determined to have previously received an adequate trial of a first-line treatment (ie, serotonin reuptake inhibitors, cognitive behavioral therapy). Patients who were treatment-resistant were compared with responders on a number of factors, including severity and nature of OCD symptoms, levels of internalizing and externalizing symptoms, family accommodation of OCD symptoms, and functional impairment. RESULTS: The treatment-resistant group endorsed significantly more obsessions and compulsions, greater levels of internalizing symptoms, higher parental stress related to accommodation, and greater functional impairment than treatment responders. However, relative to treatment-resistant patients, treatment responders reported higher levels of depressive symptoms, perhaps indicating that they were more distressed by their OCD symptoms, as well as greater insight into their symptoms. CONCLUSIONS: This study indicates that youth with more severe symptoms of OCD, higher related parental stress, and greater functional impairment tend to be more resistant to first-line treatments, and that perhaps they may require more intensive or family-based interventions. Treatment responders report more depressive symptoms and insight into their OCD, which may suggest a greater readiness for treatment. Further research likely would help to identify which types of treatment would be most beneficial for individual youth.

Obsessive-compulsive disorder in youth with and without a chronic tic disorder.

The goal of this study was to discriminate subtypes of pediatric obsessive-compulsive disorder (OCD) among youth with and without a comorbid tic disorder. Seventy-four youth (M(age)=9.7+/-2.3 years) with a principal diagnosis of OCD, with (n=46) or without (n=28) a comorbid tic disorder, were assessed with a semi-structured diagnostic interview and the Children's Yale Brown Obsessive-Compulsive Scale (CY-BOCS). The CY-BOCS Symptom Checklist was used to categorize obsessions and compulsions. Group differences were analyzed by t tests, chi(2), and discriminant function analyses. Results suggested that subjects without tics had significantly more contamination obsessions, sexual obsessions, and counting compulsions than youth with comorbid tics. Generally speaking, however, youth with and without tics had similar symptom presentations. These data suggest that pediatric OCD patients with and without comorbid tics may have some aspects of symptom presentation that differ, but generally have more OCD symptoms in common than different. Implications of these findings on clinical presentation and treatment efficacy are highlighted.

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).

Comprehensive primary care for children with special health care needs in rural areas.

OBJECTIVE: Most research on comprehensive primary care interventions for children with chronic health conditions has been conducted in large urban areas, where child health and related services are readily available. The purpose of this study was to evaluate the feasibility and impact of a medical home demonstration project in a more rural part of the country. METHODS: Fifty-one parents of children with special health care needs participated in a pre-/posttreatment assessment of a program designed to enhance comprehensive and coordinated care. Participants were recruited from 3 primary care practices in a central Midwest state and remained in the program for approximately 12 months. RESULTS: Parents reported significant increases in satisfaction with care coordination and access to mental health services after the intervention. They also noted decreases in family needs, caregiver strain, parents' missed work days, children's school absences, and utilization of ambulatory services. Satisfaction with primary care declined slightly but remained in the "very good" range. Families of children with more complex conditions were more likely to report a decrease in needs after intervention, but other factors, such as geographic location or socioeconomic status, were not related to key outcome variables. CONCLUSIONS: Comprehensive care has a positive effect on children with chronic health conditions and their families, including those who live in more rural areas. Additional study is needed to learn more about rural service delivery strategies that promote implementation of this approach in general practice.

Anxiety- and depression-related thoughts in children: development and evaluation of a cognition measure.

This study examined anxiety- and depression-related cognitive content in children. We developed the Children's Thought Questionnaire (CTQ) to include anxious thoughts characterized by threat and uncertainty; depressive thoughts by loss, self-deprecation, and certainty/hopelessness; and positive thoughts by interest, pleasure, and positive self-reference. The CTQ and measures of anxious and depressive symptoms were completed by 193 5th- and 6th-grade children. Exploratory factor analysis of the CTQ revealed that items loaded on 2 factors according to negative and positive valence. However, use of conceptually derived subscales demonstrated specificity, with higher levels of anxious thoughts uniquely predicting greater anxious symptoms and higher depressive thoughts uniquely predicting greater depressive symptoms. Furthermore, positive thoughts were negatively related to depressive symptoms but either unrelated or positively related to anxious symptoms, thus providing support for cognitive specificity.

Primary care supports for children with chronic health conditions: identifying and predicting unmet family needs.

OBJECTIVE: To examine unmet needs among families of children with chronic health conditions treated in primary care settings and to identify predictors of these needs. METHOD: Primary care physicians referred 83 caregivers of children with chronic health conditions. Mothers completed the Family Needs Survey, as well as other measures of child and family functioning. RESULTS: Mothers reported a high prevalence and broad range of unmet family needs. The most frequent area of need was for information about services and ways to promote child health and development. Predictors of total number of family needs included demographic characteristics, ratings of social support, and appraisals of family burden. Predictors of specific types of family needs varied according to category of need. CONCLUSIONS: Innovative psychosocial intervention programs are needed in primary care settings to reduce family needs and promote child health. More intensive family supports may be indicated for those with minority-group or low socioeconomic status, limited social support, or high perceived burden.