An fMRI study of cognitive planning before and after symptom provocation in pediatric obsessive-compulsive disorder.

BACKGROUND: Pediatric obsessive-compulsive disorder (OCD) has been associated with poorer planning in laboratory, school and home settings. It is unclear whether this impairment is a standalone cognitive issue or the result of OCD symptoms. No study has examined the influence of provoked distress on planning performance and neural correlates in pediatric OCD. METHODS: Before and after a symptom provocation task, youth with OCD (n = 23; 9 boys; mean age ± standard deviation 15.1 ± 2.6 years) and matched healthy controls (n = 23) completed the Tower of London task during functional MRI scanning. RESULTS: During planning, participants with OCD recruited the left superior frontal gyrus to a greater extent than healthy controls after symptom provocation (group × time point interaction; t 44 = 5.22, p < 0.001). In a seeded, region of interest-constrained, functional connectivity analysis, we identified greater connectivity between the left superior frontal gyrus and the right middle frontal gyrus, left precuneus and left inferior parietal lobule in participants with OCD than healthy controls. We also identified greater connectivity between the right amygdala and right medial frontal gyrus in patients with OCD than healthy controls, but only before symptom provocation. LIMITATIONS: The fixed-order design of the study and the number of participants taking medication (n = 20) should be noted. CONCLUSION: Participants with OCD demonstrated greater amygdalar-cortical connectivity before symptom provocation, while sustaining greater recruitment and connectivity of task-related planning areas throughout the task. These results suggest that brain activity and connectivity is altered after symptom provocation, in the absence of impaired planning performance.

Effects of Treatment Setting on Outcomes of Flexibly-Dosed Intensive Cognitive Behavioral Therapy for Pediatric OCD: A Randomized Controlled Pilot Trial.

Introduction: Optimizing individual outcomes of cognitive-behavioral therapy (CBT) remains a priority. Methods: Youth were randomized to receive intensive CBT at a hospital clinic (n = 14) or within their home (n = 12). Youth completed 3 × 3 h sessions (Phase I) and up to four additional 3-h sessions as desired/needed (Phase II). An independent evaluator assessed youth after Phase I, Phase II (when applicable), and at 1- and 6-months post-treatment. A range of OCD-related (e.g., severity, impairment) and secondary (e.g., quality of life, comorbid symptoms) outcomes were assessed. Results: Families' satisfaction with the treatment program was high. Of study completers (n = 22), five youth (23%) utilized no Phase II sessions and 9 (41%) utilized all four (Median Phase II sessions: 2.5). Large improvements in OCD-related outcomes and small-to-moderate benefits across secondary domains were observed. Statistically-significant differences in primary outcomes were not observed between settings; however, minor benefits for home-based treatment were observed (e.g., maintenance of gains, youth comfort with treatment). Discussion: Intensive CBT is an efficacious treatment for pediatric OCD. Families opted for differing doses based on their needs. Home-based treatment, while not substantially superior to hospital care, may offer some value, particularly when desired/relevant. Clinical Trial Registration: www.ClinicalTrials.gov; https://clinicaltrials.gov/ct2/show/NCT03672565, identifier: NCT03672565.

Neurocognitive risk markers in pediatric obsessive-compulsive disorder.

BACKGROUND: Obsessive-compulsive disorder (OCD) has complex genetic underpinnings, particularly in its early-onset form, which places siblings at a 10-fold increased risk of developing the disorder. Examination for neurocognitive markers preceding pediatric OCD onset has not been conducted, although markers have been identified in adult OCD. This study compared neurocognition across groups of OCD-affected youth (n = 87), unaffected siblings of those with early-onset OCD (n = 67), and healthy controls (HC; n = 79). METHODS: A total of 233 participants aged 6-18 years old completed standardized neurocognitive tests of cognitive flexibility, decision making, planning, response inhibition, spatial working memory, attention, recognition nonverbal memory, and intelligence. They were administered the Anxiety Disorders Interview Schedule-Parent version (ADIS-P) and completed self-report anxiety and OCD questionnaires. Linear mixed-effects models tested for differences between groups, adjusting for age, gender, IQ, state anxiety, and ethnicity, and accounting for random effects of family membership. RESULTS: OCD-affected youth and unaffected siblings performed significantly worse on planning in comparison to HCs (Cohen's d = 0.74; 95% CI = [0.11, 1.36]; Cohen's d = 0.75; 95% CI = [0.12, 1.38], respectively; omnibus group effect p = .007). No other significant between-group differences were identified. CONCLUSIONS: Neurocognitive performance differences between groups identified planning as a preexisting trait marker of pediatric OCD, while no other domain presented as a marker of pediatric OCD. This differs from adult OCD, which is associated with broader cognitive impairments. Investigating longitudinal trajectories and predictive significance of neurocognition in those affected by, and at risk for, early-onset OCD is warranted. Ideally, this will enhance individualized risk stratification and inform future prevention and early intervention strategies.

Cognitive-behavioral therapy booster treatment in pediatric obsessive-compulsive disorder: A utilization assessment pilot study.

BACKGROUND: Cognitive-behavioral therapy (CBT) for pediatric obsessivecompulsive disorder (OCD) is effective, although many individuals report they need continued support after completing treatment. METHODS: Six monthly drop-in booster sessions were offered to 94 youth with OCD and their parents who previously had completed a 12-week group family-based CBT program (GF-CBT). This report describes program utilization rates and participant satisfaction levels. RESULTS: Twenty-three percent (n = 22) of invited youths with OCD attended ≥1 booster session; 63% of attendees participated in >1 session. The mean number of attended sessions was 2.84 (standard deviation = 1.74). No significant group differences between booster attendees and non-attendees were found in terms of age, sex, ethnicity, parental education, or symptom severity at baseline or end of GF-CBT. Booster session attendees were more likely to have comorbidities than non-attendees (82% vs 58%; P = .045). Most participants were recent treatment completers (59%). Based on participant feedback, booster sessions were valuable, with perceived benefits related to peer interaction and support, skills review, and homework development. CONCLUSIONS: Cognitive-behavioral therapy booster sessions for pediatric OCD seem to be an acceptable approach that a significant percentage of recent treatment completers would utilize. Further research is needed to examine program efficacy and to draw conclusions about key program features.

Academic skills in pediatric obsessive-compulsive disorder: A preliminary study.

BACKGROUND: Obsessive-compulsive disorder (OCD) is a prevalent and debilitating illness that often begins in childhood and has a significant impact on the functioning of youth and their families. Given that schooling represents a considerable portion of youth's lives and is a key contributor to their development, identifying impacts of OCD on school performance is important. METHODS: The present study evaluated academic skill differences in OCD-affected youth age 7 to 18 (n = 25) compared with matched healthy controls (HCs; n = 25), as captured via standardized testing. Analysis of variance was used to examine group effects on the outcome variables. RESULTS: In comparison with HCs, OCD-affected youth presented with significantly poorer performance in math calculation (P = .029), although mean scores fell in the normative range. Thirty-six percent of the OCD group were in the Below Average range, compared with 12% of the HCs (P = .047). There were no significant between-group differences in word reading or spelling. Academic skills were not associated with symptom severity. CONCLUSIONS: Findings suggest that underperformance in math may be present in a higher-than-expected proportion of OCD-affected youth. Further studies of academic skills are warranted to replicate the current findings and to examine roles of academic enhancers in this vulnerable population.

Group family-based cognitive behavioral therapy for pediatric obsessive compulsive disorder: Global outcomes and predictors of improvement.

This open, uncontrolled study examined the efficacy of a group family-based cognitive behavioral therapy (GF-CBT) protocol in treating pediatric obsessive-compulsive disorder (OCD) and explored predictors of symptom improvement. Eighty-five OCD-affected youth aged 8-18 years (M = 13.9 years, SD = 2.49; 46% male) and their parent(s) participated in a weekly, 12-session GF-CBT program. Data from multiple perspectives were gathered at the beginning and end of treatment, as well as at one-month follow-up. A broad range of assessment measures were utilized to capture clinically-relevant domains and a number of potential predictor variables were explored. Paired t-tests indicated that treatment was associated with significant reductions in clinician- and parent-rated OCD severity (d = 1.47, 1.32), youth and parent-rated functional impairment (d = 0.87, 0.67), coercive/disruptive behaviors (d = 0.75), and family accommodation (d = 1.02), as well as improvements in youth-, mother-, and father-rated family functioning (d = 1.05, 0.50, 0.88). Paired t-tests also indicated that youth remained improved at one-month follow-up. Step-wise regression identified greater homework success as a significant predictor of symptom improvement. This study provides evidence that GF-CBT significantly improves a wide range of domains for youth/families that extends beyond OCD symptom severity and supports homework as a core treatment component.