Improving Delivery Behaviors During Exposure for Pediatric OCD: A Multiple Baseline Training Trial With Community Therapists.

This study tested whether a new training tool, the Exposure Guide (EG), improved in-session therapist behaviors (i.e., indicators of quality) that have been associated with youth outcomes in prior clinical trials of exposure therapy. Six therapists at a community mental health agency (CMHA) provided exposure therapy for 8 youth with obsessive-compulsive disorder (OCD). Using a nonconcurrent multiple baseline design with random assignment to baseline lengths of 6 to 16 weeks, therapists received gold-standard exposure therapy training with weekly consultation (baseline phase) followed by addition of EG training and feedback (intervention phase). The primary outcome was therapist behavior during in-session exposures, observed weekly using a validated coding system. Therapist behavior was evaluated in relation to a priori benchmarks derived from clinical trials. Additional outcomes included training feasibility/acceptability, therapist response to case vignettes and beliefs about exposure, and independent evaluator-rated clinical outcomes. Three therapists reached behavior benchmarks only during the EG (intervention) phase. Two therapists met benchmarks during the baseline phase; one of these subsequently moved away from benchmarks but met them again after starting the EG phase. Across all therapists, the percentage of weeks meeting benchmarks was significantly higher during the EG phase (86.4%) vs. the baseline phase (53.2%). Youth participants experienced significant improvement in OCD symptoms and global illness severity from pre- to posttreatment. Results provide initial evidence that adding the EG to gold-standard training can change in-session therapist behaviors in a CMHA setting.

Therapist Behavior During Exposure Tasks Predicts Habituation and Clinical Outcome in Three Randomized Controlled Trials for Pediatric OCD.

This study measured therapist behaviors in relation to subsequent habituation within exposure tasks, and also tested their direct and indirect relationships (via habituation) with clinical outcomes of exposure therapy. We observed 459 videotaped exposure tasks with 111 participants in three clinical trials for pediatric obsessive-compulsive disorder (POTS trials). Within exposure tasks, therapist behaviors and patient fear were coded continuously. Outcomes were habituation and posttreatment change in symptom severity, global improvement, and treatment response. More therapist behaviors that encourage approach-and less use of accommodation, unrelated talk, and externalizing language-predicted greater subsequent habituation during individual exposure tasks (exposure-level), and also predicted improved patient clinical outcomes via higher "total dose" of habituation across treatment (patient-level indirect effect). For six of seven therapist behaviors analyzed, the relationship with subsequent habituation within exposure differed by patient fear (low, moderate, or high) at the time the behavior was used. Two therapist behaviors had direct effects in the opposite direction expected; more unrelated talk and less intensifying were associated with greater patient symptom reduction. Results shed light on the "black box" of in-session exposure activities and point to specific therapist behaviors that may be important for clinical outcomes. These behaviors might be best understood in the context of changing patient fear during exposure tasks. Future studies should test whether therapist behaviors can be experimentally manipulated to produce improvement in clinical outcomes.

A Neurocognitive Comparison of Pediatric Obsessive-Compulsive Disorder and Trichotillomania (Hair Pulling Disorder).

Obsessive-compulsive disorder (OCD) and trichotillomania (hair pulling disorder, HPD) are both considered obsessive-compulsive and related disorders due to some indications of shared etiological and phenomenological characteristics. However, a lack of direct comparisons between these disorders, especially in pediatric samples, limits our understanding of divergent versus convergent characteristics. This study compared neurocognitive functioning between children diagnosed with OCD and HPD. In total, 21 children diagnosed with HPD, 40 diagnosed with OCD, and 29 healthy controls (HCs), along with their parents, completed self-/parent-report measures and a neurocognitive assessment battery, which included tasks of inhibitory control, sustained attention, planning, working memory, visual memory, and cognitive flexibility. A series of analyses of variance (or covariance) indicated significant differences between groups on tasks examining planning and sustained attention. Specifically, children in both the OCD and HPD groups outperformed HCs on a task of planning. Further, children with OCD underperformed as compared to both the HPD and HC groups on a task of sustained attention. No between group differences were found with respect to tasks of reversal learning, working memory, spatial working memory, visual memory, or inhibitory control. The implications these findings may have for future, transdiagnostic work, as well as limitations and future directions are discussed.

Disruptions in the Amount and Timing of Sleep and Repetitive Negative Thinking in Adolescents.

Objective/Background: Numerous psychiatric conditions characterized by repetitive negative thinking (RNT) are also frequently associated with disruptions in the duration and timing of sleep. The emerging literature supports that these types of sleep disruptions may be associated with negative psychological consequences such as depressed mood, anxiety, and poor emotion regulation, all of which have features of RNT. There is a paucity of research on the association between RNT and disruptions in sleep duration and timing in adolescents. The aim of the current study was to examine if sleep duration and timing in an adolescent sample would be predictive of RNT. Participants: Participants included 1,021 adolescents (ages 11 to 17) from a public school district in upstate New York. Methods: Participants completed a survey about their sleep practices, symptoms of psychopathology, and RNT. Results: Results indicated that sleep timing was predictive of RNT, but sleep duration was not. This result remained even after controlling for symptoms of psychopathology. Further, sleep onset latency was also predictive of RNT. Conclusions: These results indicate that it may be important to make the distinction between sleep duration and sleep timing. Sleep timing may uniquely impact RNT in adolescents.

Later Bedtimes Predict Prospective Increases in Symptom Severity in Individuals with Obsessive Compulsive Disorder (OCD): An Initial Study.

Prior studies of sleep in individuals with OCD have often focused on sleep duration. Several studies have found that individuals with OCD sleep less than healthy controls while others have failed to find significant group differences. Addressing sleep timing has been much more rare, but have consistently shown that many individuals with severe OCD in inpatient facilities had markedly elevated rates of disruptions in sleep timing. We extend prior work by testing prospective relations between sleep and OC symptoms in individuals representing a range of OC symptom severity. Twenty-six individuals diagnosed with OCD, 18 healthy controls, and 10 with subthreshold OC symptoms, completed seven days of sleep diaries and OCD symptom ratings. Results showed that sleep timing (later bedtimes) predicted prospective increases in both obsessions and compulsions in individuals with OCD but not the other two groups. In contrast, there were no significant effects of sleep duration. The significant effects of sleep timing in the OCD group were maintained controlling for depressive symptoms and OCD symptoms did not predict prospective changes in sleep timing. In conclusion, there is increasing evidence that sleep timing may play an important role in OCD and additional work in this area is encouraged.

Circadian zeitgebers and treatment outcome in inpatient programs for obsessive compulsive disorder (OCD): a pilot study.

High rates of delayed sleep phase disorder have been observed in inpatients with obsessive compulsive disorder (OCD). Up to one-third of patients with OCD do not respond to treatment; therefore, new interventions or methods of enhancing current interventions are imperative. The theory of inpatient circadian care (TICC) posits that enhancing inpatient settings through environmental changes, such as, a set lights out time and consistent scheduling may facilitate symptom improvements in both medical and psychiatric illnesses. Symptom improvements related to these environmental changes have yet to be explored in inpatient and residential OCD treatment program outcomes. Therefore, data on OCD inpatient and residential programs were collected through a meta-analysis conducted by Veale and colleagues (2016). The programs listed in this meta-analysis were contacted to ask follow-up questions regarding their program's scheduling and lights out times. Programs who reported increased consistency in their patients' schedules were significantly more likely to be coded as obtaining treatment response (a post-treatment mean Y-BOCS score <16; X2 = 3.60, p = .05). Further, a Fisher's exact test indicated significant differences, in that 78% of programs with a set lights out time obtained treatment response compared to 0% of programs without a set lights out time. Programs who facilitate set lights out times and consistent schedules may improve treatment response for their patients with OCD, especially for the most severe cases.

Public Recognition and Perceptions of Obsessive Compulsive Disorder.

Previous research has indicated that the public's knowledge on obsessive compulsive disorder (OCD) is poor. Public understanding and perception of OCD may be one contributor to this issue. Given that mental health literacy is an important first step for those to receive the appropriate care, we sought to understand more about the public's awareness and perceptions of OCD. Data regarding knowledge of OCD were collected through a New York statewide telephone survey (N = 806). Results indicated that those who had never heard of OCD were more likely to be ethnic minorities, have a lower income, and less education. Most participants described OCD either in terms of compulsions or in terms of perfectionism. Almost half (46.5%) of participants did not think there is a difference between someone with OCD and someone who is obsessive-compulsive. These findings are consistent with previous literature regarding race and treatment seeking behaviors.

Cognitive performance of youth with primary generalized anxiety disorder versus primary obsessive-compulsive disorder.

BACKGROUND: Despite gains made in the study of childhood anxiety, differential diagnosis remains challenging because of indistinct boundaries between disorders and high comorbidity. This is certainly true for generalized anxiety disorder (GAD) and obsessive-compulsive disorder (OCD) as they share multiple cognitive processes (e.g., rumination, intolerance of uncertainty, and increased attention to threat). Disentangling such cognitive characteristics and, subsequently, underlying mechanisms could serve to inform assessment and treatment practices, and improve prognoses. METHODS: The current study sought to compare the cognitive performance (working memory, visuospatial memory, planning ability/efficiency, and cognitive flexibility), indexed by the Cambridge Neuropsychological Automated Battery (CANTAB) among three nonoverlapping groups of youth: (1) those diagnosed with OCD (n = 28), (2) those diagnosed with GAD, not OCD (n = 34), and (3) typically-developing controls (TDC) (n = 65). RESULTS: Results showed that OCD and GAD youth demonstrated neurocognitive deficits in planning ability/efficiency, cognitive flexibility, and visual processing when compared to TDC, with potential diagnostic specificity such that youth with GAD or OCD had unique deficits compared to TDC and to one another. Specifically, youth with OCD demonstrated significantly impaired planning ability compared to youth in the GAD and TDS groups, whereas youth with GAD demonstrated greater cognitive inflexibility and delayed visual processing compared to youth in the OCD and TDC groups. CONCLUSIONS: Future studies should expand upon these findings with more comprehensive assessment of cognitive functioning by including self- and parent-report forms, and neuroimaging to link behavioral findings with subjective ratings and neurocircuitry. Altogether, data can then inform future assessment and treatment targets.

Measuring fear change within exposures: Functionally-defined habituation predicts outcome in three randomized controlled trials for pediatric OCD.

OBJECTIVE: This study measured a variety of within-exposure fear changes and tested the relationship of each with treatment outcomes in exposure therapy. METHOD: We coded 459 videotaped exposure tasks from 111 participants in 3 clinical trials for pediatric obsessive-compulsive disorder (OCD; POTS trials). Within exposures, fear level was observed continuously and alongside exposure process. Fear change metrics of interest were selected for relevance to mechanistic theory. Fear decreases were classified by function; nonhabituation decreases were associated with observed nonlearning processes (e.g., avoidance), whereas habituation decreases appeared to result from an internal and indirect process. Outcomes were posttreatment change in symptom severity, global improvement, and treatment response. RESULTS: Greater cumulative habituation across treatment was associated with larger reductions in symptom severity, greater global improvement, and increased odds of treatment response. Fear activation, fear variability, and nonhabituation fear decreases did not predict any outcomes. Exploratory analyses examined fear changes during habituation and nonhabituation exposures; higher peak fear during nonhabituation exposures was associated with attenuated global improvement. CONCLUSIONS: Habituation is conceptually consistent with multiple mechanistic theories and should continue to be investigated as a practical marker of initial extinction learning and possible moderator of the relationship between fear activation and outcome. Results support the importance of functional and frequent fear measurement during exposures, and discussion considers implications of these findings for future studies aiming to understand learning during exposure and improve exposure delivery. (PsycINFO Database Record

Factors associated with practitioners' use of exposure therapy for childhood anxiety disorders.

The current study examines factors related to use of exposure therapy by clinicians who treat children with anxiety disorders. A sample of 331 therapists from a variety of backgrounds (i.e., social workers, doctoral psychologists, masters level counselors, and marriage and family therapists) completed a survey regarding use of exposure and other treatment techniques for childhood anxiety disorders, as well as beliefs about exposure and child resiliency. Although the majority of therapists endorsed a CBT orientation (81%) and use of CBT techniques, exposure therapy was rarely endorsed. Holding a PhD in psychology as well as more positive beliefs about exposure and child resiliency were associated with greater use of exposure. The results suggest that exposure-based therapy is rarely offered in community settings and that dissemination should focus on individual evidence-based principles and correcting therapist misconceptions.

Elevated Autism Spectrum Disorder Traits in Young Children with OCD.

Studies have shown a high prevalence of autistic spectrum traits in both children and adults with psychiatric disorders; however the prevalence rate has not yet been investigated in young children with OCD. The aim of the current study was to (1) determine whether ASD traits indicated by the Social Communication Questionnaire (SCQ) and the Social Responsiveness Scale (SRS) were elevated in young children with OCD who do not have a specific ASD diagnosis and (2) determine if ASD traits were associated with OCD severity. Participants (N = 127) were children ages 5-8 years enrolled in the pediatric obsessive-compulsive disorder treatment study for young children (POTS Jr.). Results indicated that the SRS showed elevated autistic traits in the sample and was associated with OCD severity whereas the SCQ did not indicate heightened ASD symptoms. Implications of these results are discussed.

Hoarding behavior among young children with obsessive-compulsive disorder.

Previous research has shown that among the various subtypes of obsessive-compulsive disorder (OCD), adults (e.g. Frost, Krause & Steketee, 1996) and older children and adolescents (Bloch et al., 2009; Storch et al., 2007) with problematic hoarding have distinct features and a poor treatment prognosis. However, there is limited information on the phenomenology and prevalence of hoarding behaviors in young children. The present study characterizes children ages 10 and under who present with OCD and hoarding behaviors. Sixty-eight children received a structured interview-determined diagnosis of OCD. Clinician administered, parent-report, and child-report measures on demographic, symptomatic, and diagnostic variables were completed. Clinician ratings of hoarding symptoms and parent and child endorsement of the hoarding item on the CY-BOCS checklist (Scahill, Riddle, McSwiggin-Hardin, & Ort, 1997) determined inclusion in the hoarding group (n=33). Compared to children without hoarding symptoms (n=35), the presence of hoarding symptoms was associated with an earlier age of primary diagnosis onset and a higher proportion of ADHD and provisional anxiety diagnoses. These results are partially consistent with the adult literature and with findings in older children (Storch et al., 2007). Additional data on clinical presentation and phenomenology of hoarding are needed to form a developmentally appropriate definition of the behavior.