Internet-based cognitive behavioral therapy in children and adolescents with obsessive compulsive disorder: a feasibility study.

Cognitive behavioral therapy (CBT) is the first choice of treatment of obsessive-compulsive disorder (OCD) in children and adolescents. However, there is often a lack of access to appropriate treatment close to the home of the patients. An internet-based CBT via videoconferencing could facilitate access to state-of-the-art treatment even in remote areas. The aim of this study was to investigate feasibility and acceptability of this telemedical approach. A total of nine children received 14 sessions of CBT. The first session took place face-to-face, the remaining 13 sessions via videoconference. OCD symptoms were recorded with a smartphone app and therapy materials were made accessible in a data cloud. We assessed diagnostic data before and after treatment and obtained measures to feasibility, treatment satisfaction and acceptability. Outcomes showed high acceptance and satisfaction on the part of patients with online treatment (89%) and that face-to-face therapy was not preferred over an internet-based approach (67%). The majority of patients and their parents classified the quality of treatment as high. They emphasized the usefulness of exposures with response prevention (E/RP) in triggering situations at home. The app itself was rated as easy to operate and useful. In addition to feasibility, a significant decrease in obsessive-compulsive symptoms was also achieved. Internet-based CBT for pediatric OCD is feasible and well received by the patients and their parents. Furthermore, obsessive-compulsive symptomatology decreased in all patients. The results of this study are encouraging and suggest the significance of further research regarding this technology-supported approach, with a specific focus on efficacy.Trial registration number: Clinical trials AZ53-5400.1-004/44.

Testing Mediators of Youth Intervention Outcomes Using Single-Case Experimental Designs.

The major aim of this manuscript is to bring together two important topics that have recently received much attention in child and adolescent research, albeit separately from each other: single-case experimental designs and statistical mediation analysis. Single-case experimental designs (SCEDs) are increasingly recognized as a valuable alternative for Randomized Controlled Trials (RCTs) to test intervention effects in youth populations. Statistical mediation analysis helps provide understanding about the most potent mechanisms of change underlying youth intervention outcomes. In this manuscript we: (i) describe the conceptual framework and outline desiderata for methods for mediation analysis in SCEDs; (ii) describe the main aspects of several data-analytic techniques potentially useful to test mediation in SCEDs; (iii) apply these methods to a single-case treatment data set from one clinically anxious client; and (iv) discuss pros and cons of these methods for testing mediation in SCEDs, and provide future directions.

Professional identity in clinician-scientists: brokers between care and science.

CONTEXT: Despite increasing numbers of publications, science often fails to significantly improve patient care. Clinician-scientists, professionals who combine care and research activities, play an important role in helping to solve this problem. However, despite the ascribed advantages of connecting scientific knowledge and inquiry with health care, clinician-scientists are scarce, especially amongst non-physicians. The education of clinician-scientists can be complex because they must form professional identities at the intersection of care and research. The successful education of clinician-scientists requires insight into how these professionals view their professional identity and how they combine distinct practices. OBJECTIVES: This study sought to investigate how recently trained nurse- and physiotherapist-scientists perceive their professional identities and experience the crossing of boundaries between care and research. METHODS: Semi-structured interviews were conducted with 14 nurse- and physiotherapist-scientists at 1 year after they had completed MSc research training. Interviews were thematically analysed using insights from the theoretical frameworks of dialogical self theory and boundary crossing. RESULTS: After research training, the initial professional identity, of clinician, remained important for novice clinician-scientists, whereas the scientist identity was experienced as additional and complementary. A meta-identity as broker, referred to as a 'bridge builder', seemed to mediate competing demands or tensions between the two positions. Obtaining and maintaining a dual work position were experienced as logistically demanding; nevertheless, it was considered beneficial for crossing the boundaries between care and research because it led to reflection on the health profession, knowledge integration, inquiry and innovation in care, improved data collection, and research with a focus on clinical applicability. CONCLUSIONS: Novice clinician-scientists experience dual professional identities as care providers and scientists. The meta-position of being a broker who connects care and research is seen as core to the unique clinician-scientist identity. To develop this role, identity formation and boundary-crossing competencies merit explicit attention within clinician-scientist programmes.

Attentional bias to activity of different parts of the body in children with functional abdominal pain: an experimental study.

OBJECTIVES: To investigate whether children with functional abdominal pain (FAP) show an attentional bias for their bodily activity, and whether receiving information about bodily activity influenced perception of bodily sensations. METHODS: A total of 30 children with FAP and 30 healthy children performed a dot-probe task, in which they were shown sham pictures about their bodily activity. RESULTS: Contrary to our hypotheses, no attentional bias for gut activity was found in either group. However, children with FAP were slower than healthy children on all supraliminal gut-activity trials, suggesting that pictures of gut activity distracted children with FAP from the task they were performing. Both groups showed an attention bias away from supraliminal pictures about heart activity. As hypothesized, more children with FAP than healthy children reported increases in pain after the experiment. CONCLUSIONS: Children with FAP seemed more strongly influenced by information about gut activity than healthy children. The present study should be replicated for intervention purposes.

Mediators of cognitive behavioral therapy for anxiety-disordered children and adolescents: cognition, perceived control, and coping.

The purpose is to investigate whether a change in putative mediators (negative and positive thoughts, coping strategies, and perceived control over anxious situations) precedes a change in anxiety symptoms in anxiety-disordered children and adolescents receiving cognitive behavioral therapy (CBT). Participants were 145 Dutch children (8-18 years old, M = 12.5 years, 57% girls) with a primary anxiety disorder. Assessments were completed pretreatment, in-treatment, posttreatment, and at 3-month follow-up. Sequential temporal dependencies between putative mediators and parent- and child-reported anxiety symptoms were investigated in AMOS using longitudinal Latent Difference Score Modeling. During treatment an increase of positive thoughts preceded a decrease in child-reported anxiety symptoms. An increase in three coping strategies (direct problem solving, positive cognitive restructuring, and seeking distraction) preceded a decrease in parent-reported anxiety symptoms. A reciprocal effect was found for perceived control: A decrease in parent-reported anxiety symptoms both preceded and followed an increase in perceived control. Using a longitudinal design, a temporal relationship between several putative mediators and CBT-outcome for anxious children was explored. The results suggest that a change in positive thoughts, but not negative thoughts, and several coping strategies precedes a change in symptom reduction and, therefore, at least partly support theoretical models of anxiety upon which the anxiety intervention is based.

The anxiety severity interview for children and adolescents: an individualized repeated measure of anxiety severity.

The Anxiety Severity Interview for Children and Adolescents (ASICA) was developed for the repeated assessment of the impact of anxiety and control over anxiety symptoms. The ASICA incorporates three main components of anxiety: physical response, avoidant behaviour and anxious thoughts. The objective of this study was to evaluate the psychometric properties of the ASICA in children with anxiety disorder (n = 139, age 8-18 years) and a non-anxious control group (n = 40, age 8-18 years). A confirmatory factor analysis confirmed the intended factor structure. Internal reliability was moderate to good; inter-rater reliability was excellent. Four-week test-retest reliability was good. The ASICA discriminated between anxious and non-anxious children and appeared sensitive to treatment change. A cut-off score of 13 was determined. Convergent validity with anxiety symptoms was moderate; discriminant validity with depressive symptoms was less strong. The results suggest that the ASICA is a reliable instrument that could be used in clinical practice to repeatedly monitor anxiety severity.

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.

Developmental aspects of error and high-conflict-related brain activity in pediatric obsessive-compulsive disorder: a fMRI study with a Flanker task before and after CBT.

BACKGROUND: Heightened error and conflict monitoring are considered central mechanisms in obsessive-compulsive disorder (OCD) and are associated with anterior cingulate cortex (ACC) function. Pediatric obsessive-compulsive patients provide an opportunity to investigate the development of this area and its associations with psychopathology. METHODS: Repeated measures were carried out using functional magnetic resonance imaging (fMRI) during the performance of an interference task, the arrow version of the Flanker paradigm, before and after cognitive-behavioral treatment of 25 medication-free pediatric obsessive-compulsive patients compared with age- and gender-matched healthy controls. RESULTS: During error trials compared to correct trials, pediatric OCD patients and controls showed an interaction effect of Group × Time × Age in the ACC and insula. This effect was mainly driven by an increased activation in older OCD subjects, which was also present after treatment. During high-conflict trials compared with low-conflict trials, a Group × Time × Age interaction effect was found in bilateral insula. This effect was driven by an increase of BOLD (blood oxygen level dependent) signal in older OCD patients before but not after treatment. In addition, a Group × Time interaction effect in dorsomedial prefrontal cortex, premotor region and ACC was found. This effect was driven by an increase of BOLD signal in OCD subjects relative to controls over time. CONCLUSIONS: Compared to healthy controls, children and adolescents with OCD show increased activation of the ACC during error responses and in bilateral insular cortex during high-conflict tasks, which is age dependent and which is only partially affected by cognitive-behavioral therapy (CBT). Therefore, we suggest that ACC functioning is a vulnerability marker in pediatric OCD, whereas insular dysfunction may be state dependent.

Temperament, attentional processes, and anxiety: diverging links between adolescents with and without anxiety disorders?

The present study first examined the links between reactive temperament (negative affectivity), regulative temperament (effortful control [EC]) and internalizing problems in adolescents (12-18 years) with anxiety disorders (ANX; N = 39) and without anxiety disorders (nANX; N = 35). Links differed between ANX and nANX participants. Negative affectivity predicted internalizing problems, with almost no role of EC in nANX, but a protective role of EC was found in ANX youth. Second, we investigated the role of attentional bias as a mediator between temperament and internalizing problems. Strategic threat-related bias was predicted by initial attention and EC, but these relations differed in both groups. In nANX participants, higher initial bias scores were predictive for lower strategic bias scores and higher levels of EC were associated with higher bias scores. In ANX participants, there was almost no effect of initial bias or EC on strategic attention. Internalizing problems were predicted by strategic attention, but again differently in ANX and nANX participants. High strategic bias scores were associated with an increase in anxiety in ANX and a decrease in anxiety in nANX participants.

Development and initial validation of the obsessive belief questionnaire-child version (OBQ-CV).

BACKGROUND: Cognitive models of obsessive-compulsive disorder (OCD) propose that beliefs are important in the etiology and maintenance of OCD and that these beliefs develop during childhood [Neal et al., 1991: Psychol Bull 109:400-410; Rachman, 1997: Behav Res Ther 35:793-802; Cronbach, 1951: Psychometrika 16:297-334]. However, the ability to test these predictions has been hampered by the lack of a standardized measure of OCD-related beliefs for youth. Therefore, this article presents initial data on a youth version of the widely used Obsessive Belief Questionnaire (OBQ) [Bonett, 2002: J Educ Behav Stat 27:335-340]. METHODS: Data examining the psychometric properties of the Obsessive Belief Questionnaire-Child Version (OBQ-CV) are presented from two pediatric OCD samples: a North American (n=29, aged 9-17 years) and a Dutch sample (n=48, aged 8-18 years). RESULTS: Preliminary findings from both samples support the internal consistency, retest reliability, and convergent validity of the OBQ-CV. CONCLUSIONS: Results of this study suggest that the OBQ-CV is a promising tool for examining the role of cognitions in pediatric OCD. Development of the OBQ-CV to augment the existing adult version of the scale creates unique opportunities for investigating the role of cognitions in OCD across the lifespan.

Abdominal pain in Dutch schoolchildren: relations with physical and psychological comorbid complaints in children and their parents.

OBJECTIVES: Children with functional abdominal pain (FAP) frequently report comorbid complaints such as anxiety and activity limitations. Their parents often experience heightened levels of anxiety, depression, and somatization. The aim of the present study was to investigate whether these comorbid complaints in children and their parents are specific for FAP or can also be found in a community sample. PATIENTS AND METHODS: Six hundred sixty-five schoolchildren (ages 7-18 years) filled out questionnaires concerning AP, activity limitations, somatic complaints, quality of life, and symptoms of anxiety and depression. A total of 391 of their parents filled out questionnaires concerning parental anxiety, depression, and somatization. Pearson correlations and multiple regression analyses were performed. RESULTS: A total of 56.5% of the children reported AP at least once in a 2-week period. Univariate relations with AP were found for activity limitations (r = 0.392), somatic complaints (r = 0.408), 3 of 5 domains of quality of life (r ranging from -0.120 to -0.209), and symptoms of anxiety and depression (r, respectively, 0.329 and 0.361). Multivariate analyses showed only significant relations for female sex (ß = 0.230), younger age (ß = -0.077), activity limitations (ß = 0.247), somatic complaints (ß = 0.170), and depressive symptoms (ß = 0.093). CONCLUSIONS: Activity limitations, somatic complaints, and depressive symptoms are related to AP in the general population, whereas a reduced quality of life, anxiety, and parental internalizing problems seem specific comorbid complaints for FAP. Future research on parental internalizing problems, quality of life, and anxiety as risk factors for FAP is warranted.

Automatic evaluations in clinically anxious and nonanxious children and adolescents.

Automatic evaluations of clinically anxious and nonanxious children (n = 40, aged 8-16, 18 girls) were compared using a pictorial performance-based measure of automatic affective associations. Results showed a threat-related evaluation bias in clinically anxious but not in nonanxious children. In anxious participants, automatic evaluations of anxiety-relevant stimuli were more negative than those of negative stimuli. In nonanxious participants, evaluations of negative and anxiety-relevant stimuli did not differ. Furthermore, anxious youth had stronger negative evaluations of anxiety-relevant stimuli than nonanxious children. Automatic evaluations of positive, neutral, and negative stimuli did not differ between groups. Threat-related evaluations were predictive of parent-reported, but not child-reported, anxiety.

Psychological factors addressed in cognitive behaviour therapy for paediatric functional abdominal pain: Which are most important to target?

The effectiveness of cognitive behaviour therapy for paediatric functional abdominal pain leaves room for improvement. We studied which factors addressed in cognitive behaviour therapy relate most strongly to the physical and psychological functioning of children with functional abdominal pain and are thus most important to target. Questionnaires were filled out by 117 children with functional abdominal pain and their parents. Multiple regression analyses showed that children's passive coping and parental and children's positive cognitions relate to child functioning. Negative cognitions and parental solicitous behaviour were unrelated to child functioning. Cognitive behaviour therapy for functional abdominal pain may benefit most from changing children's passive coping and promoting positive cognitions.

Cognitive versus behavior therapy: processes of change in the treatment of obsessive-compulsive disorder.

BACKGROUND: Behavior therapy [exposure and response prevention (ERP)] and cognitive therapy (CT) have proven effective in the treatment of obsessive-compulsive disorder. Direct comparisons between these treatment modalities have exposed no differences in efficacy. However, very little research has been conducted into the differences between the change processes in ERP and CT. This investigation is a first attempt to study change by measuring scores on a weekly basis rather than at specific stages in the treatment and follow-up. METHODS: We used the Yale-Brown Obsessive-Compulsive Scale (Y-BOCS) at weekly intervals to rate and compare the severity of the obsessions and compulsions of 61 completers of either CT or ERP. The aim was to ascertain whether the process of change in CT is different from the process of change in ERP. We expected that ERP would primarily affect behavior, thus reducing compulsions first, while CT would primarily affect thought, thus reducing obsessions first. RESULTS: Firstly, no differences were found between ERP and CT with respect to the change process for obsessions and compulsions. Secondly, it emerged that changes in compulsions predicted all treatment effects better than changes in obsessions. CONCLUSIONS: These results suggest that reduction of compulsions is the process through which both ERP and CT affect change.

An indirect and direct measure of anxiety-related perceived control in children: the Implicit Association Procedure (IAP) and Anxiety Control Questionnaire for Children (ACQ-C).

A perceived lack of control over negative events is assumed central to the development of anxiety disorders. So far, only questionnaires were used to test this theory, but they have several disadvantages. In this study, the Implicit Association Procedure (IAP) was adapted to measure anxiety-related perceived control in an indirect way. IAP data of 33 non-selected children were compared to a direct measure of perceived control, the Anxiety Control Questionnaire for Children (ACQ-C). Results showed that higher anxious children had lower perceived control over anxiety-related events than lower anxious children, on both the indirect and the direct measure.

Costs and cost-effectiveness of family CBT versus individual CBT in clinically anxious children.

The objective of this study was to investigate the cost-effectiveness of family cognitive-behavioral therapy (CBT) compared with individual CBT in children with anxiety disorders. Clinically anxious children (aged 8-18 years) referred for treatment were randomly assigned to family or individual CBT and were assessed pre-treatment, post treatment, and at 3 months and 1 year after treatment. Cost-effectiveness ratios were calculated expressing the incremental costs per anxiety-free child and the incremental costs per Quality Adjusted Life Year (QALY) for the referred child. Neither societal costs nor effectiveness were significantly different between individual and family CBT. However, the point estimates of the cost-effectiveness ratios resulted in dominance for individual CBT, indicating that individual CBT is more effective and less costly than family CBT. These results were confirmed by bootstrap analyses and cost-effectiveness acceptability curves. Several secondary and sensitivity analyses showed that the results were robust. It can be concluded that family CBT is not a cost-effective treatment for clinically anxious children, compared with individual CBT.

Cognitive therapy and exposure in vivo alone and in combination with fluvoxamine in obsessive-compulsive disorder: a 5-year follow-up.

BACKGROUND: Information regarding the long-term effectiveness of the combination of pharmacotherapy and cognitive-behavioral therapy (CBT) in the treatment of obsessive-compulsive disorder (OCD) is limited. Our study is the first to examine the long-term effectiveness of cognitive therapy (CT) and to compare long-term effectiveness of CT alone, exposure in vivo with response prevention (ERP) alone, and CBT (either CT or ERP) in combination with fluvoxamine in the treatment of OCD. METHOD: Of 122 outpatients with primary DSM-III-R-defined OCD originally enrolled in 2 randomized controlled trials, 102 patients (45 male/57 female; mean +/- SD age = 36.2 +/- 10.7 years; range, 19-64 years) were available to be assessed for the presence and severity of OCD and comorbid psychopathology at follow-up. Follow-up data were collected from November 1996 to June 1999. RESULTS: After 5 years, 54% of the participants no longer met the DSM-III-R criteria for OCD. Long-term outcome did not differ between the 3 treatment groups. At follow-up, treatment dropouts appeared to have more severe OCD complaints compared with treatment completers. Compared with patients receiving CT alone, significantly (p < .005) more patients receiving CBT with fluvoxamine used antidepressants 5 years later. CONCLUSIONS: This study demonstrates that at 5-year follow-up (1) prevalence of OCD had declined in all 3 treatment conditions, (2) the clinical benefits of all 3 treatment conditions were maintained, (3) OCD complaints were more severe for treatment dropouts than for treatment completers, and (4) about half of the patients initially treated with fluvoxamine continued antidepressant use.

Augmentation of Treatment As Usual with online Cognitive Bias Modification of Interpretation training in adolescents with Obsessive Compulsive Disorder: A pilot study.

BACKGROUND AND OBJECTIVES: Cognitive Behavioral Therapy for children and adolescents with Obsessive Compulsive Disorder (OCD) is effective. However, since almost half of patients remain symptomatic after treatment, there remains room for improvement. Cognitive Bias Modification training of Interpretations (CBM-I) is a promising new intervention, as it targets misinterpretation of intrusions, which is seen as an important characteristic in OCD. To date, there have been no published studies of CBM-I in adolescents with OCD. The aim of the current pilot study was to examine the added value of online CBM-I training as an adjunctive treatment to the Treatment As Usual (TAU; that included CBT and pharmacotherapy) in adolescents with OCD. METHODS: Patients receiving TAU were randomly assigned to either an additional CBM-I training (n = 9), or to an additional placebo variant of this procedure (n = 7). RESULTS: Immediate, on-line interpretations changed in response to the CBM-I training, while no such effects were observed on slower retrospective off-line interpretations. Patients in the CBM-I training condition reported fewer obsessive compulsive symptoms after training, and clinicians rated them as having fewer obsessive symptoms (corresponding to medium-large effect sizes). No such changes were observed in the placebo group. LIMITATIONS: The small sample size precludes strong conclusions and replication is necessary to test the robustness of the findings. CONCLUSIONS: This small randomized controlled trial is suggestive, although not conclusive, regarding the promising additive value of OC-related CBM-I training as an adjunctive intervention to TAU in an adolescent clinical population.

Evaluating statistical and clinical significance of intervention effects in single-case experimental designs: an SPSS method to analyze univariate data.

Single-case experimental designs are useful methods in clinical research practice to investigate individual client progress. Their proliferation might have been hampered by methodological challenges such as the difficulty applying existing statistical procedures. In this article, we describe a data-analytic method to analyze univariate (i.e., one symptom) single-case data using the common package SPSS. This method can help the clinical researcher to investigate whether an intervention works as compared with a baseline period or another intervention type, and to determine whether symptom improvement is clinically significant. First, we describe the statistical method in a conceptual way and show how it can be implemented in SPSS. Simulation studies were performed to determine the number of observation points required per intervention phase. Second, to illustrate this method and its implications, we present a case study of an adolescent with anxiety disorders treated with cognitive-behavioral therapy techniques in an outpatient psychotherapy clinic, whose symptoms were regularly assessed before each session. We provide a description of the data analyses and results of this case study. Finally, we discuss the advantages and shortcomings of the proposed method.

A longitudinal VBM study in paediatric obsessive-compulsive disorder at 2-year follow-up after cognitive behavioural therapy.

OBJECTIVES: To identify neurodevelopmental differences in regional brain volume between medication-free paediatric obsessive-compulsive disorder (OCD) patients and controls at 2-year follow-up after cognitive behavioural therapy. METHODS: We assessed 17 medication-free paediatric OCD patients (mean age 13.8 years; SD = 2.8; range 8.2-19.0) and 20 controls, matched on age and gender, with T1-weighted MR scans in a repeated measures design at three time points with intervals of 6 months and 2 years. Voxel based morphometry (VBM) was used to test whole brain voxel-wise for the effects of diagnosis and time on regional grey matter (GM) and white matter volumes. RESULTS: GM volume of the orbitofrontal cortex showed a group × time interaction effect, driven by an increase of GM volume over the whole time period in OCD patients and a decrease in controls. When splitting the groups in two age groups (8-12 and 13-19 years) this interaction effect was only seen in the youngest age group. CONCLUSIONS: Neuroimaging findings in paediatric OCD after 6 months of CBT in the GM volume of the orbital frontal cortex are still present at 2-year follow-up.