Exploring latent clusters in pediatric OCD based on symptoms, severity, age, gender, and comorbidity.

Given diverse symptom expression and high rates of comorbid conditions, the present study explored underlying commonalities among OCD-affected children and adolescents to better conceptualize disorder presentation and associated features. Data from 830 OCD-affected participants presenting to OCD specialty centers was aggregated. Dependent mixture modeling was used to examine latent clusters based on their age- and gender adjusted symptom severity (as measured by the Children's Yale-Brown Obsessive-Compulsive Scale; CY-BOCS), symptom type (as measured by factor scores calculated from the CY-BOCS symptom checklist), and comorbid diagnoses (as assessed via diagnostic interviews). Fit statistics favored a four-cluster model with groups distinguished primarily by symptom expression and comorbidity type. Fit indices for 3-7 cluster models were only marginally different and characteristics of the clusters remained largely stable between solutions with small clusters of distinct presentations added in more complex models. Rather than identifying a single classification system, the findings support the utility of integrating dimensional, developmental, and transdiagnostic information in the conceptualization of OCD-affected children and adolescents. Identified clusters point to the centrality of contamination concerns to OCD, relationships between broader symptom expression and higher levels of comorbidity, and the potential for complex/neurodevelopmental presentations.

Daily use of digital technologies to feel better: Adolescents' digital emotion regulation, emotions, loneliness, and recovery, considering prior emotional problems.

INTRODUCTION: Adolescents report using digital technologies for emotion regulation (digital ER), with the aim of feeling better (i.e., improving emotions and reducing loneliness). In this 7-day diary study, we investigated associations of digital ER, emotions, and loneliness, and tested whether prior emotional problems moderated these associations. METHOD: Participants were 312 Australian adolescents (Mage = 13.91, SD = 1.52; 44% boys). Daily surveys measured digital ER; end-of-day happiness, sadness, worry, anger, and loneliness; and peak sadness, worry, and anger. End-of day emotions were subtracted from peak emotions to calculate emotion recovery for sadness, worry, and anger. Participants were randomly selected from two symptom strata (high/low) defined by depression and social anxiety measures collected before the diary. Data were analyzed using multilevel path modeling. Cross-level interactions tested whether symptom strata moderated associations. RESULTS: Digital ER was associated with more recovery from peak to end-of-day sadness and worry, but also with increased sadness, worry, anger, and loneliness by the next end-of-day. Higher end-of-day loneliness was associated with increased next-day digital ER. Prior emotional symptoms were not a significant moderator of daily digital ER and emotion associations. CONCLUSION: Adolescents who report more digital ER in a day show more recovery from the peak of negative emotion that day, but this recovery dissipates, with digital ER also associated with increased negative emotion and loneliness by the next day for all adolescents, regardless of prior symptom status. Lonelier adolescents use more digital ER by the next day, suggesting they need support to make social connections-online or offline.

Reaching Young People in Urban and Rural Communities with Mental Health and Wellbeing Support Within a Youth Sports Development Program: Integrating In-Person and Remote Modes of Service Delivery.

Embedding mental health and wellbeing programs within youth sports development programs can help provide more young people with mental health support. However, delivering such programs in multiple locations across metropolitan, regional, and rural areas requires novel solutions to overcome geographic and logistical barriers. We examined the delivery of an integrated system delivered within an Australian junior rugby league program. The program included online assessment and feedback about youth mental health, as well as connection with evidence-informed resources and referral sources via parent telephone and email support. There were four methods of delivering player workshops during training sessions: (a) In-person Delivery Only, (b) In-person + Remote Real-time (video-conferenced), (c) In-person + Remote Prerecorded (video-recorded), and (d) Remote Delivery Only (video-conferenced and/or video-recorded). In-person delivered player workshops were facilitated by local rugby league personnel. Remote delivered workshops were facilitated by psychologists from the mental health research team. Participants were 671 boys (12-15 years; M age = 13.35; SD = 0.35) in 21 metropolitan, regional and rural locations. Regardless of delivery condition, players with elevated anxiety, depression and behavioural problems reported significant declines in symptoms from pre- to post-program, and those within healthy ranges did not change from pre- to post-program. Player workshop enjoyment ratings were higher in the In-person + Remote Real-time condition and the Remote Delivery Only condition than the In-person Delivery Only condition. However, non-completion of the post-program assessment across all conditions was higher than in prior studies and a comparison group of players who did not complete the program was not included. Mental health benefits may be observed across in-person and remote modes of delivering mental health workshops within youth sports programs. However, the involvement of mental health personnel, whether in-person or remotely, and mixed delivery modes, may be important for young people's retention and satisfaction.

A pattern-centered analysis of adolescents' concerns and hopes about future crises: Differences in ways of coping and personal adjustment.

INTRODUCTION: Many adolescents are concerned about global and future crises, such as the health of the planet or terrorism/safety. Yet, adolescents can also express hope about the future. Thus, asking adolescents about their concern and hope could yield subgroups with different ways of coping and personal adjustment. METHOD: Australian adolescents (N = 863; age 10-16) completed surveys to report their concern (worry and anger) and hope about the planet, safety, jobs, income, housing, and technology, as well as their active and avoidant coping, depression, and life satisfaction. RESULTS: Four distinct subgroups were identified using cluster analysis: Hopeful (low on concern and high on hope across all issues, 32%), Uninvolved (low in concern and hope; 26%), Concerned about the Planet (CP, 27%), and Concerned about Future Life (CFL, 15%). When compared (adjusting for age, sex, and COVID timing), the CP subgroup was highest in active coping (e.g., taking action) but moderate in personal adjustment. Hopeful had the most positive adjustment, whereas CFL had the poorest adjustment. Uninvolved were lowest in coping but moderate in adjustment. CONCLUSIONS: Findings suggest ways of coping and adjustment may not always align, in that CP is connected with more active coping but also some cost to personal adjustment, whereas Hopeful is associated with optimal adjustment but perhaps at the cost of active coping. In addition, although CFL adolescents emerged as the at-risk group, the low levels of hope and coping in Uninvolved adolescents raise the possibility that they are at risk of future problems.

Adolescent Anxiety, Depression and Flourishing before and During COVID-19 and the Predictive Role of Baseline Psychological Capital (PsyCap) on Student Mental Health and Subjective Wellbeing During the Pandemic.

Studies indicate the COVID-19 pandemic has resulted in rises in adolescent mental health symptoms globally, although the impact of the pandemic on subjective wellbeing is under-researched in this population. Psychological capital (PsyCap), a cluster of four positive psychological constructs comprising hope, efficacy, resilience and optimism (HERO), has demonstrated preventative and promotive qualities on mental health symptoms and subjective wellbeing outcomes with adult populations (employees, university students). However, PsyCap's influence on these outcomes in young people is unclear. The present exploratory study investigated changes in self-reported anxiety and depressive symptoms (measured via the RCADS-SV) and subjective wellbeing (measured by the Flourishing Scale) from pre-pandemic levels to 3 months into the pandemic and explored gender differences at each time point in a sample of Australian Year 10 students (N = 56, Mage = 14.93 years, SD = 0.50, 51.8% male). The longitudinal predictive role of baseline PsyCap on follow-up assessments of anxiety symptoms, depressive symptoms and flourishing were also examined. There were no significant changes in levels of anxiety and depressive symptoms between the timepoints, but flourishing significantly declined from T1 to T2. Baseline PsyCap was not a significant predictor of T2 anxiety and depressive symptoms but was a significant predictor of T2 flourishing. Further, different baseline HERO constructs predicted T2 mental health symptoms and flourishing. Future larger studies building on the current preliminary findings investigating the roles of student PsyCap, mental health and subjective wellbeing are warranted to better understand these constructs in the COVID-19 era and beyond.

Paediatric Obsessive-Compulsive Disorder and Comorbid Body Dysmorphic Disorder: Clinical Expression and Treatment Response.

This study explored the expression, occurrence, and treatment outcomes of comorbid body dysmorphic disorder (BDD) in 107 youth (7-17 years) seeking treatment for primary obsessive-compulsive disorder (OCD). In the overall sample, appearance anxiety (AA) was positively associated with OCD-related impairment, severity, symptom frequency, comorbid symptoms, and maladaptive emotion regulation. Comorbid BDD occurred in 9.35% of youth, equally affected males and females, and was associated with older age. AA negligibly reduced following treatment. Compared to those without (a) comorbid BDD and (b) without any comorbidity, youth with comorbid BDD reported greater social impairment and reduced global functioning but did not differ on the occurrence of comorbid anxiety and mood disorders. OCD response or remission rates did not differ. In youth with comorbid BDD, AA did not significantly reduce following treatment. Results suggest a more severe expression accompanies comorbid BDD in youth with OCD, with BDD persisting following OCD treatment.

Preliminary Effectiveness of a Brief School-Based HERO Intervention: Improving the Wellbeing of Final Year Adolescent Female Students.

Young people face multiple challenges, including appearance dissatisfaction, academic stressors, anxiety and depression. These challenges may increase during the final year of high school and may have become further exacerbated by the COVID-19 pandemic. This study examines the preliminary effectiveness of a brief, uncontrolled school-based intervention aimed at enhancing Psychological Capital (PsyCap), consisting of positive resources of hope, self-efficacy, resilience and optimism (HERO), and reducing mental health symptoms among female year 12 students (n = 95, Mage = 16.78, SD = 0.45). Outcomes on measures of HERO and secondary outcomes of flourishing, appearance dissatisfaction, anxiety and depression were measured at pre and post-intervention. In the overall cohort, no significant changes were found on the HERO outcomes or flourishing post-intervention, while symptoms of depression, anxiety and appearance dissatisfaction decreased significantly. For students with higher baseline anxiety, optimism and anxiety symptoms improved significantly at post-intervention. However, students with lower baseline anxiety experienced significant decreases in self-efficacy and optimism, as well as a significant increase in anxiety symptoms post-intervention. Baseline depression levels did not impact intervention outcomes. The findings, although mixed and limited by the lack of control group, suggest that a brief intervention grounded in PsyCap theory may improve student wellbeing under challenging circumstances.

Mindful Parenting Group Intervention for Parents of Children with Anxiety Disorders.

Parenting behaviour and rearing style contribute to the intergenerational relationship between parental and child anxiety. Current psychological interventions for child anxiety typically do not adequately address parental mental health, parenting behaviours or the parent-child relationship. The current pilot study examines the effectiveness of a mindful parenting intervention (MPI) for parents of young children with clinical anxiety. It was hypothesised that the intervention would be associated with improvements in parental stress, mental health, and mindfulness, and a reduction in child clinical anxiety symptoms. Twenty-one parents of children aged 3-7 years diagnosed with anxiety disorders participated in an 8-week group MPI program that aimed to increase their intentional moment to moment awareness of the parent-child relationship. Parental (anxiety, depression, hostility, stress, burden, mindfulness, mindful parenting) and child (anxiety diagnoses, anxiety severity, comorbidities) outcomes were assessed at pre- and post-intervention, and at 3-month follow-up. Parents reported a significant increase in mindful parenting and a significant reduction in parent-child dysfunctional interaction, but no change in mental health symptoms. There was a significant reduction in parent-rated child anxiety symptoms, severity of child anxiety diagnosis and number of comorbid diagnoses at post and 3-month follow-up. Limitations include a lack of waitlist control, small sample size, and participants were largely mothers, from intact families and highly educated. There was attrition of 43% and outcomes were predominantly self-report. MPIs offer a novel and potentially effective method of increasing mindful parenting, decreasing dysfunctional parent-child interactions, reducing parenting stress and might also be an effective early intervention for indirectly decreasing young children's clinical anxiety symptoms. Larger-scale controlled trials of MPIs are needed.

Efficacy of D-cycloserine augmented brief intensive cognitive-behavioural therapy for paediatric obsessive-compulsive disorder: A randomised clinical trial.

OBJECTIVE: To examine the efficacy of weight-adjusted D-cycloserine (DCS) (35 or 70 mg) relative to placebo augmentation of intensive exposure therapy for youth with obsessive-compulsive disorder (OCD) in a double-blind, randomised controlled trial, and examine whether antidepressant medication or patient age moderated outcomes. METHODS: Youth (n = 100, 7-17 years) with OCD were randomised in a 1:1 ratio to either DCS + exposure (n = 49) or placebo + exposure (n = 51). Assessments occurred posttreatment, 1 month later, and at 3 and 6 months. Pills were ingested immediately before sessions. RESULTS: Significant improvements on all outcomes were observed at posttreatment, and to 6-month follow-up. Treatment arms did not differ across time, with no significant time-by-medication interactions on symptom severity (T1 to T2 estimate: 9.3, 95% confidence interval [CI]: -11.2 to -7.4, and estimate -10.7, 95% CI: -12.6 to -8.7), diagnostic severity (T1 to T2 estimate: -2.0, 95% CI: -2.4 to -1.5 and estimate -2.5, 95% CI: -3.0 to -2.0) or global functioning (T1 to T2 estimate: 13.8, 95% CI: 10.6 to 17.0, and estimate 16.6, 95% CI: 13.2 to 19.9). Neither antidepressants at baseline nor age moderated primary outcomes. There were significantly fewer responders/remitters at 1- and 6-month follow-up among youth in the DCS condition stabilised on SSRIs, relative to youth not taking SSRIs. CONCLUSIONS: DCS augmented intensive exposure therapy did not result in overall additional benefits relative to placebo. Intensive exposure proved effective in reducing symptoms for the overall sample.

Examining the Process of Implementing a Three-Step Mental Health and Wellbeing System of Care for Children and Adolescents Across Multiple Community Settings.

Mental health problems affect large numbers of young people. Integrated systems are required that can be applied in diverse settings to reach youth 'where they are'. We evaluated the process of implementing a three-step youth mental health and wellbeing system in diverse community settings according to three implementation outcomes: feasibility, penetration and acceptability. The study describes 49 applications of the 'Life-Fit-Learning system' designed to assess the mental health and wellbeing of youth (Assess step), provide feedback on assessment results (Reflect step), and connect them to resources and services proportionate to their needs (Connect step). Within a participatory research approach, 3798 administrations were conducted with youth between 9 and 18 years and 90 administrations were conducted with adults. Implementation was based on the four phases of the Quality Implementation Framework and was staged to integrate stakeholder and consumer feedback and experience gained from focus groups and two pilot phases before full implementation. Feasibility ratings of successful implementation ranged from 86.7 to 96.4% across applications and settings. High penetration rates were achieved. The Life-Fit-Learning system successfully reached 91.9% to 96% of youth with the Assess and Reflect steps and low intensity Connect step resources. Of those, 14.7% to 23% were identified at-risk for mental health problems and 93% to 97% of those at-risk youth additionally received Connect step co-delivered group-based programs (moderate intensity care) and/or individual treatment (high intensity care). Youth and parents reported high satisfaction across all steps and delivery modes. With strong collaboration, an integrated model of care can be delivered feasibly, effectively and satisfactorily to reach large numbers of young people across settings.

Risk factors and temporal patterns of disordered eating differ in adolescent boys and girls: Testing gender-specific appearance anxiety models.

Adolescent dieting and disordered eating (DE) are risks for clinical eating disorders. In this five-wave longitudinal study, we tested gender-specific models linking early risk factors to temporal patterns of DE, considering appearance anxiety as a mediator. Participants were 384 Australian students (age 10 to 13; 45% boys) who reported their purging and skipping meals, experience with appearance-related teasing, media pressure, and appearance anxiety. Parents reported pubertal maturation and height/weight was measured. Gender differences in temporal patterns of DE were found and predictive models were tested using latent-variable growth curve and path models. Boys' DE was generally stable over time; girls showed stability in purging but an average increase in skipping meals. Peer teasing, media pressure, and pubertal maturation were associated with more elevated initial DE in girls, and pubertal maturation was associated with a steeper increase in DE. For boys, body mass index had a direct positive association with DE. Appearance anxiety was associated with more DE, but there was only one significant indirect effect via anxiety, which was for boys' pubertal maturation. Findings support the dominant role of social interactions and messages, as well as pubertal maturation, for girls' DE and the prominence of physical risk factors for explaining boys' DE.

Tackling Mental Health in Youth Sporting Programs: A Pilot Study of a Holistic Program.

Linking mental health services to organised sport offers an avenue to identify and improve mental health among adolescents. In this study, we investigated the efficacy, acceptability and feasibility of an integrated mental health system embedded within a junior sports development program. A three-step integrated mental health program for 12- to 15-year-old rugby league players (N = 74) was delivered in urban (n = 44) and rural (n = 33) areas. Specifically, this system (a) assessed participant mental health on primary outcome measures of anxiety, depression, and anger/conduct problems (and secondary outcome measures of personal attributes and relationships), (b) provided feedback to participants, parents and program coordinators, and (c) connected participants and parents to a multi-component intervention including online resources, a group-based workshop program (4 × 30-min sessions), and tailored individual-level follow-up and referral to further care for participants at high risk of mental health problems. From pre- to post-program, boys' anxiety symptoms declined significantly (with only a trend-level reduction in depression), and there were significant improvements in grit (for urban boys only), efficacy to manage negative emotions, and prosocial behaviour. In addition, when boys reported symptoms associated with high risk for mental health problems, providing parents with feedback enhanced boys' access to care and was associated with significant declines in anxiety symptoms. The program was generally acceptable and feasible, with very high retention in the youth sports development program. Overall, early findings support further deployment and evaluation of integrated mental health systems embedded within sporting contexts to address mental health problems among adolescent boys.

Searching for the HERO in Youth: Does Psychological Capital (PsyCap) Predict Mental Health Symptoms and Subjective Wellbeing in Australian School-Aged Children and Adolescents?

Psychological capital (PsyCap) comprising the positive psychological resources of hope, efficacy, resilience, and optimism (HERO) has strong empirical associations with increased wellbeing and reduced mental health symptoms in adult samples. Emerging studies of PsyCap among school-age students have also shown preliminary, positive associations between PsyCap and student wellbeing. The present study is the first to examine PsyCap-HERO constructs and associations with both mental health symptoms and subjective wellbeing in school-aged children and adolescents (aged 9-14 years). A convenience sample of Australian school students (N = 456, Mage = 11.54, SD = 1.20, 47% female) completed an online survey during class time. Measures of hope, efficacy, resilience, optimism, flourishing, anxiety, and depression previously well-validated in school samples were used. Significant associations between each HERO construct and flourishing, anxiety and depression symptoms in the expected direction were found, and importantly, the combination of HERO constructs was shown to be a stronger predictor of increased levels of student flourishing, and decreased levels of anxiety and depression symptoms, than individual HERO constructs. Findings indicate that student PsyCap may be a promising area of further investigation for schools, policymakers, clinicians and researchers looking to identify positive psychological resources in youth that may buffer poor mental health and promote wellbeing.

Perceived Parental Rearing in Paediatric Obsessive-Compulsive Disorder: Examining the Factor Structure of the EMBU Child and Parent Versions and Associations with OCD Symptoms.

Parental rearing behaviours characterised by high levels of rejection and overprotection have been implicated in the development and maintenance of child psychopathology, including paediatric obsessive-compulsive disorder (OCD). The Egna Minnen Beträffande Uppfostran (EMBU) is a commonly used measure of perceived parental rearing. Using confirmatory factor analysis, the factor structure of the EMBU child and parent versions were examined in a sample of children and youth with OCD (n = 176), and their mothers (n = 162). Associations between rearing and clinical correlates of OCD were explored. For parents, a 4-factor model provided the best fit. For children, a higher order model was the best fit. Greater parent and child perceived negative rearing behaviours and lower perceived positive behaviours were associated with greater OCD severity, comorbid symptoms and impairment. The EMBU has a conceptually meaningful factor structure and provides a useful measure for assessing perceived rearing behaviours within paediatric OCD.

Inflated Responsibility Beliefs in Paediatric OCD: Exploring the Role of Parental Rearing and Child Age.

Cognitive-behavioural models of obsessive-compulsive disorder (OCD) propose that inflated responsibility beliefs are central to the maintenance of the disorder and are proposed to originate during early childhood via experiences of harsh and/or controlling parenting. The current study aimed to examine the associations between perceived parental rearing behaviours, inflated responsibility/threat beliefs, and OCD severity and impairment in children (aged 7-12 years) and adolescents (aged 13-17 years) with OCD (n = 136). Results indicated that for younger children, greater child perceptions of overprotection and anxious rearing were each associated with increased inflated responsibility beliefs. For older children, these positive associations remained, and furthermore, inflated responsibility beliefs mediated the association between perceived maternal anxious rearing and OCD impairment. Results highlight the role of the family in the development of inflated responsibility bias and OCD-related impairment.

The Multidimensional Youth Body Dysmorphic Inventory: Development and Preliminary Validation.

A new measure specifically designed for adolescents to assess body dysmorphic disorder (BDD) symptoms is needed to identify youth who could benefit from intervention to reduce their BDD-related symptomology. To address this gap, the Multidimensional Youth Body Dysmorphic Inventory (MY BODI) was developed and the psychometric properties were evaluated. Following development and expert assessment, Australian secondary school students (N = 582; 55% female; Mage = 13.62, SD = 1.59, aged 11 to 18 years, grades 7 to 12) completed a survey with the new items and validation measures. Results from the factor analysis supported a 3-factor, 21-items measure, which aligned with the DSM-5 diagnostic criteria of Impairment/avoidance, Preoccupation/repetitive behaviours, and Insight/distress. Supporting the convergent validity of the measure, the MY BODI total score and sub-scale scores correlated with measures of BDD symptoms, including the Appearance Anxiety Inventory (AAI) and Body Dysmorphic Disorder Questionnaire-Adolescent Version (BDDQ-A). This study provides preliminary validation of the MY BODI, a self-report measure of BDD symptoms and symptom severity, using a response set aimed to facilitate more reliable reporting, which may identify risk for BDD, and symptoms of BDD.

Behavioral Sleep-Related Problems in Clinically Anxious Children: A Parent-Report Diary Study.

Anxiety disorders and behavioral sleep-related problems (SRPs) frequently co-occur during childhood. However, few studies have used the recommended method of a sleep-diary. The present study examined parental perceptions of behavioral SRPs in anxious compared to non-anxious children using a sleep-diary. Parents of 22 clinically anxious children and 29 healthy controls (aged 6-13 years) completed a 7-day sleep-diary of their child's behavioral SRPs. Compared to non-anxious peers, anxious children were rated by parents as more often (a) having a negative mood before bed, (b) delaying bed, (c) requiring parental assistance during the night, especially on weeknights, (d) having difficulty waking on their own the next morning, (e) falling back to sleep after morning waking, and (f) waking in a negative mood. There were no significant group differences in sleep onset latency or sleep duration, and behavioral SRPs of anxious children did not negatively affect their functioning or that of their parents the next day based on parent report. Parents of anxious children are more likely to perceive their children as engaging in behavioral SRPs compared to parents of non-anxious children.

Girls' and boys' trajectories of appearance anxiety from age 10 to 15 years are associated with earlier maturation and appearance-related teasing.

Adolescents' appearance-related concerns can provoke increasing emotional, social, and eating-related problems. The aims of this five-wave (2.5-year), multiple-informant longitudinal study were to (a) examine growth trajectories of appearance anxiety symptoms and appearance esteem, (b) identify whether trajectories differed by gender, and (c) examine several launching factors including parent-reported physical maturation, peer-rated physical appearance, body mass index, and appearance teasing by parents and peers. Participants were 387 adolescents (44% boys) aged 10 to 13 years at the first assessment. Steep growth in appearance anxiety symptoms was found for both girls and boys, but there was no average change in appearance esteem. Girls had more elevated appearance anxiety symptoms and lower appearance esteem than boys, girls' body mass index was associated with symptoms, and earlier physical maturation and teasing about appearance, alone and in combination, were associated with growth in appearance anxiety symptoms for girls and boys. Earlier maturing boys who were highly teased by parents, but even more so when teased by peers, were at utmost risk for elevated appearance anxiety symptoms and increasing symptoms over time. In contrast, all girls exhibited elevated or increasing appearance anxiety symptoms across time, with the exception of girls with the latest maturation who also reported little teasing about their appearance.

Play-Modified One-Session Treatment for Young Children with a Specific Phobia of Dogs: A Multiple Baseline Case Series.

The one-session treatment (OST) approach for SPs is deemed well-established, and has been found to be highly effective for older children and adults; however, has not yet been trialled with very young children. The present study examines the preliminary effectiveness of play-modified OST for young children with a SP of dogs, using a multiple baseline controlled case series design. Treatment involved play modified one-session of intensive cognitive-behavioural therapy (OST plus Play) which was followed by brief telephone delivered maintenance calls over the 3 weeks immediately following treatment. Four young children (4 years of age) participated and symptoms were assessed at pre-treatment, across a 1-3 week baseline phase, immediately following the OST plus Play, and at 1 and 3 months follow-up. Visual inspection provided evidence for stability of symptoms across the baseline phase, followed by reductions in symptoms over the course of treatment and follow-up. Non-parametric analyses offered further support, with significant improvements in following the intensive OST plus Play intervention.