That Was Easy! Expectancy Violations During Exposure and Response Prevention for Childhood Obsessive-Compulsive Disorder.

Violating expectancies during exposure therapy is proposed to promote inhibitory learning and improved treatment outcomes. Because people tend to overestimate how distressing emotionally challenging situations will be, violating expectations of distress may be an intuitive way to promote treatment outcome during exposure-based cognitive-behavioral therapy (CBT). This study evaluated overpredictions of distress during exposure tasks in 33 youth with obsessive-compulsive disorder (OCD; ages 8-17) participating in CBT. Youth with more variable prediction accuracy and a higher proportion of overpredictions experienced more rapid symptom reduction, b = -0.29, p = .002. Underpredictions were less common toward the end of therapy as youth experienced less severe OCD, b = 0.12, p= .001. Findings suggest that although youth often accurately predict the intensity of exposure, overpredictions are common as well. The frequency of these overpredictions promoted treatment outcome, supporting expectancy violations as one indicator of inhibitory learning during exposure therapy.

Changes in Dosing and Dose Timing of D-Cycloserine Explain Its Apparent Declining Efficacy for Augmenting Exposure Therapy for Anxiety-related Disorders: An Individual Participant-data Meta-analysis.

The apparent efficacy of d-cycloserine (DCS) for enhancing exposure treatment for anxiety disorders appears to have declined over the past 14 years. We examined whether variations in how DCS has been administered can account for this "declining effect". We also investigated the association between DCS administration characteristics and treatment outcome to find optimal dosing parameters. We conducted a secondary analysis of individual participant data obtained from 1047 participants in 21 studies testing the efficacy of DCS-augmented exposure treatments. Different outcome measures in different studies were harmonized to a 0-100 scale. Intent-to-treat analyses showed that, in participants randomized to DCS augmentation (n = 523), fewer DCS doses, later timing of DCS dose, and lower baseline severity appear to account for this decline effect. More DCS doses were related to better outcomes, but this advantage leveled-off at nine doses. Administering DCS more than 60 minutes before exposures was also related to better outcomes. These predictors were not significant in the placebo arm (n = 521). Results suggested that optimal DCS administration could increase pre-to-follow-up DCS effect size by 50%. In conclusion, the apparent declining effectiveness of DCS over time may be accounted for by how it has been administered. Optimal DCS administration may substantially improve outcomes. Registration: The analysis plan for this manuscript was registered on Open Science Framework (https://osf.io/c39p8/).

Parents' Perceptions of Internalizing and Externalizing Features in Childhood OCD.

Although obsessive-compulsive disorder (OCD) has often been characterized as an internalizing disorder, some children with OCD exhibit externalizing behaviors that are specific to their OCD. This study sought to demonstrate that parents perceive both internalizing and externalizing behaviors in childhood OCD by examining the factor structure of the Child Obsessive-Compulsive Externalizing/Internalizing Scale (COCEIS), a parent-report questionnaire intended to measure these constructs. This study also investigated clinical correlates of internalizing and externalizing factors in the COCEIS. A factor analysis of questionnaire responses from 122 parents of youth with OCD revealed both externalizing and internalizing factors in the COCEIS. Externalizing behaviors in childhood OCD were associated with other, co-occurring externalizing behavior problems, while both factors were positively correlated with OCD severity and co-occurring internalizing symptoms. They were positively associated with each other at a trend level, and neither showed a significant relationship with insight. Sixty-two percent of parents endorsed "often" or "always" to at least one externalizing item, though modal responses to items suggested that each individual feature captured by the COCEIS may be relatively uncommon. Mean responses were significantly greater for internalizing items. This study provides evidence for distinct but related externalizing and internalizing behaviors specific to childhood OCD. Treatment for children with OCD presenting with more externalizing behaviors may require a greater emphasis on behavioral parent training and motivational enhancement.

Exposure therapy for youth with anxiety: Utilization rates and predictors of implementation in a sample of practicing clinicians from across the United States.

Exposure therapy is a highly effective, evidence-based treatment technique for children and adolescents with anxiety disorders. Regardless, therapists in the community are reported to use exposure relatively rarely compared with other approaches. The goal of the present study was to identify how practicing clinicians treat youth with anxiety disorders across the United States and what factors contribute to their use of exposure therapy. Recruited from public directories, 257 private practice therapists who treat anxious youth were surveyed. Non-exposure cognitive-behavioral techniques like cognitive restructuring and relaxation techniques were used significantly more frequently than exposure. Providers with more training in exposure therapy and fewer negative beliefs about this approach reported using exposure significantly more in the treatment of youth with social anxiety, obsessive-compulsive, and panic disorders. Self-identification as an anxiety disorder specialist significantly predicted exposure use for youth with posttraumatic stress disorder. Most therapists in private practice have minimal training in exposure therapy, perceive a lack of training options, and believe there would be a benefit to acquiring more training. The implications of these findings are discussed, including how to optimally design training opportunities in exposure therapy.

The link between ADHD-like inattention and obsessions and compulsions during treatment of youth with OCD.

Attention-deficit/hyperactivity disorder (ADHD) has been found to be highly comorbid in children and adolescents with obsessive-compulsive disorder (OCD). Some have proposed, however, that obsessive anxiety may cause inattention and executive dysfunction, leading to inappropriate ADHD diagnoses in those with OCD. If this were the case, these symptoms would be expected to decrease following successful OCD treatment. The present study tested this hypothesis and evaluated whether ADHD symptoms at baseline predicted OCD treatment response. Obsessive-compulsive and ADHD symptoms were assessed in 50 youth enrolled in a randomized controlled trial investigating selective serotonin reuptake inhibitor and cognitive behavioral treatment. Repeated-measures analysis of variance (RMANOVA) revealed that ADHD symptoms at baseline do not significantly predict treatment outcome. A multivariate RMANOVA found that OCD treatment response moderated change in inattention; participants who showed greater reduction in OCD severity experienced greater reduction in ADHD-inattentive symptoms, while those with less substantial reduction in obsessions and compulsions showed less change. These findings suggest that children and adolescents with OCD and inattention may experience meaningful improvements in attention problems following OCD treatment. Thus, in many youth with OCD, inattention may be inherently tied to obsessions and compulsions. Clinicians may consider addressing OCD in treatment before targeting inattentive-type ADHD.

Common Barriers to the Dissemination of Exposure Therapy for Youth with Anxiety Disorders.

This study investigated the prevalence of common barriers to the use of exposure therapy (ET) in the treatment of youth with anxiety disorders, specifically examining both logistical limitations and negative beliefs about ET. Results from 230 practicing clinicians who treat youth with anxiety disorders found that the top three barriers were session length (56%), lack of training (48%), and concern about parent reaction (47%). Endorsement of barriers to ET was associated with less ET utilization and less optimal implementation of ET. Results suggest that several barriers, especially logistical limitations, must be addressed in order to improve the dissemination of ET.

D-Cycloserine Augmentation of Exposure-Based Cognitive Behavior Therapy for Anxiety, Obsessive-Compulsive, and Posttraumatic Stress Disorders: A Systematic Review and Meta-analysis of Individual Participant Data.

Importance: Whether and under which conditions D-cycloserine (DCS) augments the effects of exposure-based cognitive behavior therapy for anxiety, obsessive-compulsive, and posttraumatic stress disorders is unclear. Objective: To clarify whether DCS is superior to placebo in augmenting the effects of cognitive behavior therapy for anxiety, obsessive-compulsive, and posttraumatic stress disorders and to evaluate whether antidepressants interact with DCS and the effect of potential moderating variables. Data Sources: PubMed, EMBASE, and PsycINFO were searched from inception to February 10, 2016. Reference lists of previous reviews and meta-analyses and reports of randomized clinical trials were also checked. Study Selection: Studies were eligible for inclusion if they were (1) double-blind randomized clinical trials of DCS as an augmentation strategy for exposure-based cognitive behavior therapy and (2) conducted in humans diagnosed as having specific phobia, social anxiety disorder, panic disorder with or without agoraphobia, obsessive-compulsive disorder, or posttraumatic stress disorder. Data Extraction and Synthesis: Raw data were obtained from the authors and quality controlled. Data were ranked to ensure a consistent metric across studies (score range, 0-100). We used a 3-level multilevel model nesting repeated measures of outcomes within participants, who were nested within studies. Results: Individual participant data were obtained for 21 of 22 eligible trials, representing 1047 of 1073 eligible participants. When controlling for antidepressant use, participants receiving DCS showed greater improvement from pretreatment to posttreatment (mean difference, -3.62; 95% CI, -0.81 to -6.43; P = .01; d = -0.25) but not from pretreatment to midtreatment (mean difference, -1.66; 95% CI, -4.92 to 1.60; P = .32; d = -0.14) or from pretreatment to follow-up (mean difference, -2.98, 95% CI, -5.99 to 0.03; P = .05; d = -0.19). Additional analyses showed that participants assigned to DCS were associated with lower symptom severity than those assigned to placebo at posttreatment and at follow-up. Antidepressants did not moderate the effects of DCS. None of the prespecified patient-level or study-level moderators was associated with outcomes. Conclusions and Relevance: D-cycloserine is associated with a small augmentation effect on exposure-based therapy. This effect is not moderated by the concurrent use of antidepressants. Further research is needed to identify patient and/or therapy characteristics associated with DCS response.

Side-effects of SSRIs disrupt multimodal treatment for pediatric OCD in a randomized-controlled trial.

OBJECTIVE: Activation Syndrome (AS) is a side-effect of antidepressants consisting of irritability, mania, self-harm, akathisia, and disinhibition. The current study was conducted to analyze how AS may hinder treatment outcome for multimodal treatment for children and adolescents with Obsessive-Compulsive Disorder. METHODS: Fifty-six children or adolescents were recruited at two treatment sites in a double-blind randomized-controlled trial where participants received Cognitive-Behavioral Therapy and were randomized to slow titration of sertraline, regular titration of sertraline or placebo. RESULTS: Using a recently developed measure of AS, results suggested that higher average levels of irritability, akathisia, and disinhibition significantly interfered with treatment response and explained 18% of the variance in obsessive-compulsive symptoms during treatment. Interestingly, only session-to-session increases in irritability resulted in a session-to-session increase in obsessive-compulsive symptoms. The observed results were unchanged with the addition of SSRI dosage as a covariate. CONCLUSIONS: Results provide empirical support for the proposed hypothesis that AS may hinder multimodal treatment outcome for pediatric OCD. These findings suggest that dosage changes due to AS do not explain why those with higher AS had worse multimodal outcome. Other possible mechanisms explaining this observed disruption are proposed, including how AS may interfere with Cognitive-Behavioral Therapy.

Contemporary models of pediatric obsessive-compulsive disorder: An evaluation with a large clinical sample.

We evaluated the construct validity of the Child Yale-Brofwn Obsessive-Compulsive Scale (CYBOCS) in a large clinical sample (N=730) using confirmatory factor analysis. Results found inadequate fit for a priori models, though a model accounting for overlapping item content displayed good fit. Parallel obsessions/compulsions items may provide largely redundant information on the CYBOCS. Findings suggest modifying the CYBOCS to reduce burden on researchers, patients, and clinicians, and to more accurately measure pediatric obsessive-compulsive disorder (OCD).

Telehealth interventions to reduce management complications in type 1 diabetes: A review.

Type 1 diabetes is a chronic illness with a high burden of care. While effective interventions and recommendations for diabetes care exist, the intensive nature of diabetes management makes compliance difficult. This is especially true in children and adolescents as they have unique psychosocial and diabetes needs. Despite the development of effective in-person interventions targeting improving self-management and ameliorating psychosocial difficulties there are still a number of barriers to implementing these interventions, namely time, cost, and access. Telehealth interventions allow for the dissemination of these interventions to a broader audience. Self-management and psychosocial telehealth interventions are reviewed with a special emphasis on mobile phone and internet based technology use. While efficacy has been demonstrated in a number of telehealth interventions with improved cost effectiveness over in-person interventions, many challenges remain including high participant attrition and difficulties with receiving reimbursement for services rendered. These and other challenges are discussed with recommendations for researchers and telehealth providers provided.

Frequent nonprescription stimulant use and risky behaviors in college students: the role of effortful control.

OBJECTIVE: The goal of this study was to (a) investigate the association between nonprescription stimulant use (NPSU) and risky behaviors, including risky sex, driving, financial behaviors, and drug use and (b) collect preliminary evidence on mechanisms that may link NPSU to risky behaviors. PARTICIPANTS: A sample of 555 college students was collected between August 2010 and February 2012. METHODS: Students completed several self-report measures assessing their drug use history, attention-deficit and hyperactivity symptoms, temperament, and risky behaviors beyond drug use. RESULTS: Those who reported more frequent NPSU were more likely to engage in high-risk behavior across all 4 domains studied. Further, effortful control abilities partially mediated the link between NPSU and risky behaviors. CONCLUSIONS: These results highlight the associated risks of frequent NPSU for college students as well as provide future directions for examining effortful control as a potentially important mechanism linking NPSU to other risky behaviors.

Development of the pediatric accommodation scale: reliability and validity of clinician- and parent-report measures.

The present study developed parallel clinician- and parent-rated measures of family accommodation (Pediatric Accommodation Scale, PAS; Pediatric Accommodation Scale-Parent Report; PAS-PR) for youth with a primary anxiety disorder. Both measures assess frequency and impact of family accommodation on youth and families. Studying youth ages 5-17 (N=105 caregiver-youth dyads), results provide evidence for the psychometric properties of the PAS, including internal consistency, inter-rater reliability, and convergent and discriminant validity. The PAS-PR exhibited good internal consistency and convergent validity with the PAS. Nearly all parents (>95%) endorsed some accommodation and accommodation frequency was associated with parent-rated impairment (home and school), and with youth-rated impairment (school only). Greater impact of accommodation on parents was associated with parent self-reported depressive symptoms. Findings support the common occurrence of family accommodation in youth with anxiety disorders, as well as for the use of the PAS and PAS-PR to measure family accommodation in this population.

ADHD symptomatology and risky health, driving, and financial behaviors in college: the mediating role of sensation seeking and effortful control.

OBJECTIVE: To examine the extent to which effortful control (EC) and sensation seeking (SS) tendencies explain the association between the severity of ADHD symptoms and risky behaviors. METHOD: Participants included 555 college students (66% females) who completed self-report measures assessing their ADHD symptoms, EC abilities, SS tendencies, and risky health (e.g., substance use) and driving/financial behaviors (e.g., misuse of credit cards). RESULTS: Severity of college students' ADHD symptoms, EC abilities, and SS tendencies were related to all risky behaviors. Multiple mediational analyses further indicated that students' SS tendencies significantly mediated the association between ADHD symptoms and the risky health factor but not the risky driving/financial factor. EC, however, significantly mediated the association between ADHD symptoms and both the risky health and driving/financial factors. CONCLUSION: The current study provides initial data showing potentially different mechanisms that explain the link between college students' severity of ADHD symptoms and risky behaviors.

Predictors of treatment response to intensive cognitive-behavioral therapy for pediatric obsessive-compulsive disorder.

Intensive outpatient treatments for pediatric obsessive-compulsive disorder (OCD) have demonstrated efficacy for treating youth with OCD and may be especially useful for youth with severe symptomology and/or those who are partial- or non-responders to other forms of intervention. However, participation in these treatments can present challenges for youth and their families, and it is unclear if intensive treatments are more appropriate for certain individuals than others. Identification of potential predictors of treatment response and viability of intensive treatment at an individual level may aid families in their decision to participate in intensive cognitive-behavioral therapy (CBT). The present study aimed to examine the effects of three categories of predictors (demographics, OCD symptom characteristics, and comorbidity) on key target outcomes (post-treatment symptom severity, remission, and treatment response). Participants included 78 youth with a primary diagnosis of OCD who received 14 sessions of family based intensive CBT treatment over 3 weeks. Of the entire sample, 88.5% were classified as treatment responders, with 62.8% of the sample achieving clinical remission. Results identified three significant predictor variables (i.e., symptom severity, family accommodation, and gender) for post-treatment symptom severity and remission status within the context of the examined predictive models. No variables were identified as predictive of treatment response, and comorbidity was not identified as a predictor variable for any treatment outcome.

Defining clinical severity in pediatric obsessive-compulsive disorder.

Despite extensive use of the Children's Yale Brown Obsessive Compulsive Scale (CYBOCS; Scahill et al., 1997), the lack of normative data impedes interpretation of individual CYBOCS scores. Consequently, psychometrics on CYBOCS severity scores from 815 treatment-seeking youth with obsessive-compulsive disorder (OCD) are presented, across age and sex, so that normative comparisons of obsessive, compulsive, and combined obsessive-compulsive severity could be calculated. Our findings suggest no evidence for marked age or sex differences. Further, obsessive-compulsive symptom severity scores (measured via the CYBOCS) appear consistent with global OCD syndrome severity (measured via the Clinician Global Impression-Severity scale [CGI-S; Guy, 1976]; r = .58). This study contributes the 1st empirically based guidelines for interpreting obsessive-compulsive symptom severity scores. After a diagnosis of OCD is determined, the CYBOCS can be used to determine severity of illness (however, categories of severity proposed by this article should not be used in the screening of OCD symptoms). Findings can facilitate clinicians' and investigators' ability to draw comparisons across obsessive-compulsive severity scores.

Prospective relationship between obsessive-compulsive and depressive symptoms during multimodal treatment in pediatric obsessive-compulsive disorder.

The present study examined the prospective relationship between obsessive-compulsive and depressive symptoms during a multimodal treatment study involving youth with obsessive-compulsive disorder (OCD). Participants included fifty-six youth, aged 7-17 years (M = 12.16 years) who were enrolled in a two-site randomized controlled pharmacological and cognitive behavioral therapy treatment trial. Obsessive-compulsive severity was measured using the Children's Yale-Brown Obsessive-Compulsive Scale, and depressive symptoms were rated using the Children's Depression Rating Scale-Revised. Multi-level modeling analyses indicated that, on average over the course of treatment, variable and less severe obsessive-compulsive symptoms significantly predicted a decrease in depressive symptoms. Additionally, week-to-week fluctuations in OCD severity did not significantly predict weekly changes in depressive symptom severity. Level of baseline depressive symptom severity did not moderate these relationships. Findings suggest that when treating youth with OCD with co-occurring depression, therapists should begin by treating obsessive-compulsive symptoms, as when these are targeted effectively, depressive symptoms diminish as well.

The diabetes online community: the importance of forum use in parents of children with type 1 diabetes.

Online forums for chronic health conditions emerged as early as 30 yr ago and interest in their study has blossomed. Type 1 diabetes (T1D) forums have grown exponentially since 2005. Therefore, a comprehensive evaluation of these forums is needed. This study assesses the demographics and motivations of parents who use type 1 diabetes forums and the potential impact that forum membership (FM) has on parenting stress and hypoglycemic fear. One hundred and two parents were recruited through online T1D forums and asked to complete qualitative and quantitative measures of their experience with the T1D forums. Results of this study suggest that parents who use T1D forums mirror those who participate in clinic-based research protocols and are primarily motivated to participate in forums to increase their diabetes knowledge and gain social support. Indeed, parents who use T1D forums report high levels of trust, social support, and perceived knowledge gained. However, FM was positively related to increased self-reported parenting stress frequency and hypoglycemic fear behaviors. Taken together, the relationships formed within these communities may have a significant impact on the experience of these caregivers. The need for future research and potential implications for physicians, including parent debriefing, are discussed.

Randomized, placebo-controlled trial of cognitive-behavioral therapy alone or combined with sertraline in the treatment of pediatric obsessive-compulsive disorder.

BACKGROUND: To examine the efficacy of sequential sertraline and cognitive-behavioral therapy (CBT) treatment relative to CBT with pill placebo over 18 weeks in children and adolescents with obsessive-compulsive disorder (OCD). METHODS: Forty-seven children and adolescents with OCD (Range = 7-17 years) were randomized to 18-weeks of treatment in one of three arms: 1) sertraline at standard dosing + CBT (RegSert + CBT); 2) sertraline titrated slowly but achieving at least 8 weeks on the maximally tolerated daily dose + CBT (SloSert + CBT); or 3) pill placebo + CBT (PBO + CBT). Assessments were conducted at screening, baseline, weeks 1-9, 13, and 17, and post-treatment. Raters and clinicians were blinded to sertraline (but not CBT) randomization status. Primary outcomes included the Children's Yale-Brown Obsessive-Compulsive Scale, and response and remission status. Secondary outcomes included the Child Obsessive Compulsive Impact Scale-Parent/Child, Children's Depression Rating Scale-Revised, Multidimensional Anxiety Scale for Children, and Clinical-Global Impressions-Severity. RESULTS: All groups exhibited large within-group effects across outcomes. There was no group by time interaction across all outcomes suggesting that group changes over time were comparable. CONCLUSIONS: Among youth with OCD, there was no evidence that sequentially provided sertraline with CBT differed from those receiving placebo with CBT. CLINICALTRIALSGOV IDENTIFIER: NCT00382291.