Efficacy and acceptability of cognitive-behavioral therapy and serotonin reuptake inhibitors for pediatric obsessive-compulsive disorder: a network meta-analysis.

BACKGROUND: Cognitive-behavioral therapy (CBT) and serotonin reuptake inhibitors (SRIs) are recommended treatments for pediatric obsessive-compulsive disorder (OCD), but their relative efficacy and acceptability have not been comprehensively examined. Further, it remains unclear whether the efficacy of in-person CBT is conserved when delivered in other formats, such as over telephone/webcam or as Internet-delivered CBT (ICBT). METHODS: PubMed, PsycINFO, trial registries, and previous systematic reviews were searched for randomized controlled trials (RCTs) comparing CBT (in-person, webcam/telephone-delivered, or ICBT) or SRIs with control conditions or each other. Network meta-analyses were conducted to examine efficacy (post-treatment Children's Yale-Brown Obsessive Compulsive Scale) and acceptability (treatment discontinuation). Confidence in effect estimates was evaluated with CINeMA (Confidence in Network Meta-Analysis). RESULTS: Thirty eligible RCTs and 35 contrasts comprising 2,057 youth with OCD were identified. In-person CBT was significantly more efficacious than ICBT, waitlist, relaxation training, and pill placebo (MD range: 3.95-11.10; CINeMA estimate of confidence: moderate) but did not differ significantly from CBT delivered via webcam/telephone (MD: 0.85 [-2.51, 4.21]; moderate), SRIs (MD: 3.07 [-0.07, 6.20]; low), or the combination of in-person CBT and SRIs (MD: -1.20 [-5.29, 2.91]; low). SRIs were significantly more efficacious than pill placebo (MD: 4.59 [2.70, 6.48]; low) and waitlist (MD: 8.03 [4.24, 11.82]; moderate). No significant differences for acceptability emerged, but confidence in estimates was low. CONCLUSIONS: In-person CBT and SRIs produce clear benefits compared to waitlist and pill placebo and should be integral parts of the clinical management of pediatric OCD, with in-person CBT overall having a stronger evidence base. The combination of in-person CBT and SRIs may be most efficacious, but few studies hinder firm conclusions. The efficacy of CBT appears conserved when delivered via webcam/telephone, while more trials evaluating ICBT are needed.

In Search of Conceptual Clarity About the Structure of Psychopathic Traits in Children: A Network-Based Proposal.

Psychopathic traits in childhood have been revealed as potential identifiers of risk, being predictive of later forms of behavioral maladjustment. Yet, it is still under debate how psychopathic traits in children should be best conceptualized and which are the core dimensions for construct definition and prediction. The present study aims to examine the structure of psychopathic traits in childhood, and its predictive value, by using a combination of traditional factor analysis and more recent network-based methods. Data on psychopathic traits, as measured by the Child Problematic Traits Inventory (CPTI), were collected in a large sample of children (n = 2454; 48.2% girls), aged 3 to 6 at the onset of the study (Mage = 4.26; SD = 0.91), who were followed-up one and two years later using parent- and teacher-reports. Results showed that psychopathic traits measured via CPTI are best conceptualized as five latent factors encompassing grandiosity, deceitfulness, callousness, impulsivity and need of stimulation, a result that converged across informants and time. Callousness and grandiosity emerged as central traits using network analysis of parent-reports, while deceitfulness was most central using teacher-reports. Finally, callousness, impulsivity and deceitfulness emerged as the best predictors of concurrent, prospective and stable conduct problems. These results provide a refined structure of psychopathic traits in children that better accounts for the core elements of the construct. Additional theoretical and practical implications will be discussed in terms of assessment, diagnostic classification and tailored prevention/intervention.

Examining the validity of the Mini-Mental State Examination (MMSE) and its domains using network analysis.

BACKGROUND: The Mini-Mental State Examination (MMSE) is the most widely used standardised screener for impairments across a range of cognitive domains. However, the degree to which its domains (orientation, registration, attention, recall, language, and visuospatial) capture cognitive functioning measured using standardised neuropsychological tests is unclear. METHOD: A longitudinal research design with four biannual assessments over a 6-year period was used with an initial sample of 1037 older adults (aged above 70 years). Participants completed MMSE and neuropsychological tests at each assessment. Network analysis was utilised to investigate unique associations among the MMSE and its domains and neuropsychological test performance at each time point. RESULTS: The total MMSE and two of its domains, language and recall, were associated with neuropsychological memory performance. The MMSE orientation, registration and visuospatial domains did not have any unique associations with neuropsychological performance. No stable internal interconnections between MMSE domains were found over time. The association of total MMSE as well as its recall domain with neuropsychological memory performance remained very similar over the 6-year period. CONCLUSIONS: The present study adds evidence to the validity of the MMSE and supports the clinical usage of the MMSE, whereby the total score is used for screening patients with or without cognitive impairments, with repeated administration to monitor cognitive changes over time, to inform intervention. However, the tool is not able to diagnose the cases for changes in specific cognitive domains and as such, should not replace a complete neuropsychological assessment.

Using network analysis to validate domains of the modified telephone interview for cognitive status.

BACKGROUND: The modified Telephone Interview for Cognitive Status (TICS-M) is a widely used tool for assessing global cognitive functions and screening for cognitive impairments. The tool was conceptualised to capture various cognitive domains, but the validity of such domains has not been investigated against comprehensive neuropsychological assessments tools. Therefore, this study aimed to explore the associations between the TICS-M domains and neuropsychological domains to evaluate the validity of the TICS-M domains using network analysis. MATERIALS AND METHODS: A longitudinal research design was used with a large sample of older adults (aged above 70 years; n = 1037 at the baseline assessment) who completed the TICS-M and comprehensive neuropsychological assessments biennially. We applied network analysis to identify unique links between the TICS-M domains and neuropsychological test scores. RESULTS: At baseline, there were weak internal links between the TICS-M domains. The TICS-M memory and language domains were significantly related to their corresponding neuropsychological domains. The TICS-M attention domain had significant associations with executive function and visuospatial abilities. The TICS-M orientation domain was not significantly associated with any of the five neuropsychological domains. Despite an attrition of almost 50% at wave four, weak internal links between the TICS-M domains and most associations between TICS-M and neuropsychological domains that were found initially, remained stable at least over two waves within the 6-year period. CONCLUSIONS: This study supports the overall structural validity of the TICS-M screener in assessing enduring global cognitive function. However, separate TICS-M cognitive domains should not be considered equivalent to the analogous neuropsychological domains.

Everyday executive functioning in pediatric obsessive-compulsive disorder: diagnostic specificity, clinical correlations, and outcome.

BACKGROUND: Obsessive-compulsive disorder (OCD) typically onsets during childhood or adolescence and difficulties with executive functioning (EF) may be involved in its onset and maintenance. Yet, few studies have examined everyday EF difficulties in youth with OCD and no study has compared EF in youth with OCD to EF in youth with anxiety disorders, leaving the diagnostic specificity of EF unclear. METHODS: In this study, parents of treatment-seeking children and adolescents with OCD (n = 96, Mage = 13.3, SD = 2.7, 59% girls) or anxiety disorders (n = 67, Mage = 14.0, SD = 2.6, 78% girls) reported on their children's everyday EF using the Behavior Rating Inventory of Executive Function (BRIEF) measure. RESULTS: Compared to community youth, the two clinical groups showed moderately elevated EF deficits but did not differ significantly from each other. EF deficits were not associated with the major symptom dimensions of OCD, age of OCD symptom onset, duration of OCD symptoms, and OCD severity, and did not predict treatment outcome in OCD. CONCLUSIONS: Compared to peers, youth with OCD show moderate difficulties with EF, but very similar difficulties are seen in youth with anxiety disorders, and it is unclear whether these difficulties are of clinical relevance. Among youth with OCD, EF difficulties were not differentially associated with the major symptom dimensions of OCD, which is inconsistent with findings from adults. Difficulties with EF did not predict treatment outcome, indicating that integrating EF modules into OCD treatment may be of limited value, although EF may be important for treatment planning in individual cases.

Sensory Overresponsivity and Symptoms Across the Obsessive-Compulsive Spectrum: Web-Based Longitudinal Observational Study.

BACKGROUND: Sensory overresponsivity (SOR) has emerged as a potential endophenotype in obsessive-compulsive disorder (OCD), but few studies have examined SOR in relation to the major symptom dimensions of OCD and to symptoms across the full obsessive-compulsive (OC) symptom spectrum. OBJECTIVE: This study had 2 main objectives. First, we examined the psychometric properties of the SOR Scales in a community-based sample of Spanish adolescents and adults. Second, we identified how SOR difficulties are related to symptoms across the full OC spectrum (eg, OC, body dysmorphic, hoarding, skin-picking, and hair-pulling symptoms), including the heterogeneity of OC symptoms. METHODS: We translated the SOR Scales into Spanish-a measure that assesses SOR across the 5 sensory modalities-and created a web-based version of the measure. A sample of 1454 adolescents and adults (mean age 23.84, SD 8.46 years) participated in the study, and 388 (26.69%) participants completed the survey twice (approximately 8 months apart). The survey also contained a web-based measure that assesses symptoms across the full OC spectrum: harm and checking, taboo obsessions, contamination or cleaning, symmetry and ordering, body dysmorphic, hoarding, hair-pulling, and skin-picking symptoms. RESULTS: The psychometric properties of the SOR Scales were excellent, and the test-retest reliability was adequate. All types of SOR were related to all major symptom dimensions of OCD and to all OC spectrum symptoms. CONCLUSIONS: SOR across the sensory modalities can be validly assessed using a web-based measure. SOR emerged as a pure transdiagnostic phenomenon in relation to symptoms across the OC spectrum, with no specific sensory modality being more strongly related to OC symptoms. SOR can shed much needed light on basic mechanisms that are important for the onset and maintenance of OC spectrum symptoms, and this study shows that large-scale web-based studies can aid in this endeavor. Future studies should examine whether SOR precedes or emerges alongside OC symptoms.

Developmental signs of ADHD and autism: a prospective investigation in 3623 children.

Attention-deficit/hyperactivity disorder (ADHD) and autism spectrum disorder (ASD) are neurodevelopmental disorders with an early onset. Guidelines recommend a careful evaluation of developmental history when assessing the disorders, but it is unclear how children with ADHD and ASD differ from their peers growing up. In this study, physical, family, psychological, social, and educational information were examined in 3623 ethnically diverse children that were prospectively followed from birth to age 15 as part of the Fragile Families and Child Wellbeing Study. Fifteen-thousand variables were screened, and 506 variables included in the final analyses. Accuracy of the most indicative information to predict ADHD and ASD diagnoses in adolescence was evaluated. Adolescents with ADHD (n = 627) and ASD (n = 91) differed from their peers on a plethora of developmental signs, with signs closely related to the core symptoms of the disorders after age 5 being most indicative of the disorders. Predictive models correctly identified 66% of individuals with ADHD and 81% of those with ASD, but 62-88% of identified cases were false positives. The mean proportion of developmental deviations was 18.7% in the ADHD group, 20.0% in the ASD group, and 15.6% in peers; youth with both ADHD and ASD (n = 50) deviated on 21.8% of all developmental signs and had more pronounced deviations than those with ADHD or ASD alone. ADHD and ASD are characterized by broad and non-specific developmental deviations. Developmental information alone cannot be used to accurately predict diagnostic status in adolescence and false positives are likely if the diagnostic process relies heavily on such information. Developmental deviations are part of normal development and common in children without ADHD and ASD. Etiological heterogeneity and considerable temporal fluctuation in the core characteristics of ADHD and ASD may explain the lack of distinct developmental patterns.

Symptom Dimension Breakpoints for the Obsessive-Compulsive Inventory-Child Version (OCI-CV).

Pediatric obsessive-compulsive disorder (OCD) clusters around three major symptom dimensions: contamination/cleaning, symmetry/ordering, and disturbing thoughts/checking. The Obsessive-Compulsive Inventory-Child Version (OCI-CV) is a self-report questionnaire that provides scores along six theory-based OCD dimensions, but no study has evaluated how well OCI-CV identifies clinically significant symptoms within each of the three major symptom dimensions of OCD. We examined this question using data from 197 Swedish and Spanish youth with OCD. All youth completed the OCI-CV and clinically significant symptom severity within each major OCD dimension was established with a validated interview-based measure. Results showed that a score ≥ 3 on the OCI-CV washing scale excellently captured those with clinically significant contamination/cleaning symptoms (AUC = 0.85 [0.80-0.90], 79% accuracy). A score ≥ 4 on the obsessing scale adequately captured those with disturbing thoughts/checking symptoms (AUC = 0.71 [0.64-0.78], 67% accuracy) and a score ≥ 3 on the ordering scale adequately captured those with symmetry/ordering symptoms (AUC = 0.72 [0.65-0.79], 70% accuracy). Similar accuracy of the breakpoints was found in the Swedish and Spanish samples. OCI-CV works well to identify youth with pediatric OCD that have clinically significant contamination/cleaning symptoms. The measure can also with adequate precision identify those with clinically significant disturbing thoughts/checking and symmetry/ordering symptoms. The breakpoints provided in this study can be used to examine differences in clinical presentation and treatment outcome for youth with different types of OCD.

Establishing conversion of the 16-item Informant Questionnaire on Cognitive Decline in the Elderly scores into interval-level data across multiple samples using Rasch methodology.

BACKGROUND: The 16-item Informant Questionnaire on Cognitive Decline in the Elderly (IQCODE-16) is a well-validated and widely-used measure of cognitive changes (CCs) among older adults. This study aimed to use Rasch methodology to establish psychometric properties of the IQCODE-16 and validate the existing ordinal-to-interval transformation algorithms across multiple large samples. METHODS: A Partial Credit Rasch model was employed to examine psychometric properties of the IQCODE-16 using data (n = 918) from two longitudinal studies of participants aged 57-99 years: the Older Australian Twins Study (n = 450) and the Canberra Longitudinal Study (n = 468), and reusing the Sydney Memory and Ageing Study (MAS) sample (n = 400). RESULTS: Initial analyses indicated good reliability for the IQCODE-16 (Person Separation Index range: 0.82-0.90). However, local dependency was identified between items, with several items showing misfit to the model. Replicating the existing Rasch solution could not reproduce the best Rasch model fit for all samples. Combining locally dependent items into three testlets resolved all misfit and local dependency issues and resulted in the best Rasch model fit for all samples with evidence of unidimensionality, strong reliability, and invariance across person factors. Accordingly, new ordinal-to-interval transformation algorithms were produced to convert the IQCODE-16 ordinal scores into interval data to improve the accuracy of its scores. CONCLUSIONS: The findings of this study support the reliability and validity of the IQCODE-16 in measuring CCs among older adults. New ordinal-to-interval conversion tables generated using samples from multiple independent datasets are more generalizable and can be used to enhance the precision of the IQCODE-16 without changing its original format. An easy-to-use converter has been made available for clinical and research use.

Towards a definitive symptom structure of obsessive-compulsive disorder: a factor and network analysis of 87 distinct symptoms in 1366 individuals.

BACKGROUND: The symptoms of obsessive-compulsive disorder (OCD) are highly heterogeneous and it is unclear what is the optimal way to conceptualize this heterogeneity. This study aimed to establish a comprehensive symptom structure model of OCD across the lifespan using factor and network analytic techniques. METHODS: A large multinational cohort of well-characterized children, adolescents, and adults diagnosed with OCD (N = 1366) participated in the study. All completed the Dimensional Yale-Brown Obsessive-Compulsive Scale, which contains an expanded checklist of 87 distinct OCD symptoms. Exploratory and confirmatory factor analysis were used to outline empirically supported symptom dimensions, and interconnections among the resulting dimensions were established using network analysis. Associations between dimensions and sociodemographic and clinical variables were explored using structural equation modeling (SEM). RESULTS: Thirteen first-order symptom dimensions emerged that could be parsimoniously reduced to eight broad dimensions, which were valid across the lifespan: Disturbing Thoughts, Incompleteness, Contamination, Hoarding, Transformation, Body Focus, Superstition, and Loss/Separation. A general OCD factor could be included in the final factor model without a significant decline in model fit according to most fit indices. Network analysis showed that Incompleteness and Disturbing Thoughts were most central (i.e. had most unique interconnections with other dimensions). SEM showed that the eight broad dimensions were differentially related to sociodemographic and clinical variables. CONCLUSIONS: Future research will need to establish if this expanded hierarchical and multidimensional model can help improve our understanding of the etiology, neurobiology and treatment of OCD.

Technology-delivered cognitive-behavioral therapy for pediatric anxiety disorders: a meta-analysis of remission, posttreatment anxiety, and functioning.

BACKGROUND: The efficacy of technology-delivered cognitive-behavioral therapy (tCBT) for pediatric anxiety disorders (ADs) is uncertain as no meta-analysis has examined outcomes in trials that used structured diagnostic assessments at pre- and posttreatment. METHODS: We carried out a systematic review and meta-analysis of randomized controlled trials (RCTs) of tCBT for pediatric ADs that included participants <18 years of age with a confirmed primary AD according to a structured diagnostic interview. Nine studies with 711 participants were included. RESULTS: tCBT outperformed control conditions for remission for primary AD (37.9% vs. 10.2%; k = 9; OR = 4.73; p < .0001; I2 = 0%; moderate certainty), remission for all ADs (19.5% vs. 5.3%; k = 8; OR = 3.32; p < .0001; I2 = 0%; moderate certainty), clinician-rated functioning (k = 7; MD = -4.38; p < .001; I2 = 56.9%; low certainty), and caregiver-reported anxiety (k = 7; SMD = 0.27; p = .02; I2 = 41.4%; low certainty), but not for youth-reported anxiety (k = 9; SMD = 0.13; p = .12; I2 = 0%; low certainty). More severe pretreatment anxiety, a lower proportion of completed sessions, no face-to-face sessions, media recruitment, and a larger proportion of females were associated with lower remission rates for primary AD. CONCLUSIONS: tCBT has a moderate effect on remission for pediatric ADs and clinician-rated functioning, a small effect on caregiver-reported anxiety, and no statistically significant effect on youth-reported anxiety. The certainty of these estimates is low to moderate. Remission rates vary substantially across trials and several factors that may influence remission were identified. Future research should examine for whom tCBT is most appropriate and what care to offer the large proportion that does not remit. Future RCTs should consider contrasting tCBT with partial tCBT (e.g., including therapist-led exposure) and/or face-to-face CBT.

Operational Definitions of Treatment Response and Remission in Obsessive-Compulsive Disorder Capture Meaningful Improvements in Everyday Life.

INTRODUCTION: The operational definitions of treatment response, partial response, and remission in obsessive-compulsive disorder (OCD) are widely used in clinical trials and regular practice. However, the clinimetric sensitivity of these definitions, that is, whether they identify patients that experience meaningful changes in their everyday life, remains unexplored. OBJECTIVE: The objective was to examine the clinimetric sensitivity of the operational definitions of treatment response, partial response, and remission in children and adults with OCD. METHODS: Pre- and post-treatment data from five clinical trials and three cohort studies of children and adults with OCD (n = 1,528; 55.3% children, 61.1% female) were pooled. We compared (1) responders, partial responders, and non-responders and (2) remitters and non-remitters on self-reported OCD symptoms, clinician-rated general functioning, and self-reported quality of life. Remission was also evaluated against post-treatment diagnostic interviews. RESULTS: Responders and remitters experienced large improvements across validators. Responders had greater improvements than partial responders and non-responders on self-reported OCD symptoms (Cohen's d 0.65-1.13), clinician-rated functioning (Cohen's d 0.53-1.03), and self-reported quality of life (Cohen's d 0.63-0.73). Few meaningful differences emerged between partial responders and non-responders. Remitters had better outcomes across most validators than non-remitters. Remission criteria corresponded well with absence of post-treatment diagnosis (sensitivity/specificity: 93%/83%). Using both the Yale-Brown Obsessive-Compulsive Scale (Y-BOCS) and the Clinical Global Impression Scale yielded more conservative results and more robust changes across validators, compared to only using the Y-BOCS. CONCLUSIONS: The current definitions of treatment response and remission capture meaningful improvements in the everyday life of individuals with OCD, whereas the concept of partial response has dubious clinimetric sensitivity.

Networks of inflammation, depression, and cognition in aging males and females.

BACKGROUND: Prioritizing the maintenance of healthy cognitive aging and personalizing preventive interventions to enhance their effectiveness is crucial as the global population ages. Systemic inflammation and depression in older people have been associated with decreased levels of cognition but results have been inconsistent. AIMS: To explore the interactive network of inflammation, depression and cognition by sex in older people. METHODS: We used novel network analysis to explore the unique associations between inflammatory biomarkers, depression, cognition, and somatic, genetic, and lifestyle risk factors in an older (aged 70-90 years), non-demented, community-dwelling sample from the longitudinal Sydney Memory and Aging Study (N = 916) at baseline and at a two-year follow-up. RESULTS: The networks of biomarkers, depression, cognition, and relevant covariates were significantly different between males and females. A stable negative link between depression and cognition was found in females only; a stable positive association between biomarker interleukin-6 and depression was found in females only; and a stable positive association between biomarker interleukin-8 and alcohol was found in females only. For both males and females, a stable, positive relationship was found between the presence of APOE-ε4 gene and biomarker C-reactive protein; between education and cognition; and between biomarker interleukin-6 and all other biomarkers. CONCLUSIONS: These findings suggest different psychophysiological mechanisms underlie the interactive network of biomarkers, depression and cognition in males and females that should be considered when designing personalized preventive interventions to maintain cognitively healthy aging.

Perceived causal symptom network of adolescent mental health issues.

Adolescent mental health is difficult to capture in categories such as depression or specific anxiety disorders. An alternative is to approach psychiatric symptoms as causal networks, potentially revealing feedback loops that maintain a pathological state. One approach to creating such networks, implemented in the PECAN methodology, is to ask adolescents about their perceptions of the causes to their symptoms. For this purpose, a transdiagnostic item list was created, and adolescents who screened positive for depression (N = 55) completed twice in two weeks a survey quantifying perceptions of causality between their mental health problems. A network that was averaged across all participants was reliable and revealed three strong feedback loops: a first loop running through stress, insomnia, fatigue, procrastination, and back to stress; a second loop between stress and overthinking; and a third loop between stress and procrastination. Although all adolescents in the study screened positive for depression, symptoms of depression were not particularly central to the network. Instead, the most central symptoms were procrastination and overthinking. The average test-retest reliability for individual networks was low, limiting clinical application. In conclusion, PECAN was found to be reliable and useful when creating a group-level network of adolescent mental health problems. While informative at a group level, the method should be improved before it can be used to inform treatment at the individual level.

A Network Analysis of Clinical Variables in Chronic Pain: A Study from the Swedish Quality Registry for Pain Rehabilitation (SQRP).

BACKGROUND: Efforts to identify specific variables that impact most on outcomes from interdisciplinary pain rehabilitation are challenged by the complexity of chronic pain. Methods to manage this complexity are needed. The purpose of the study was to determine the network structure entailed in a set of self-reported variables, examine change, and look at potential predictors of outcome, from a network perspective. METHODS: In this study we apply network analysis to a large sample of people seeking interdisciplinary pain treatment (N = 2,241). Variables analyzed include pain intensity, pain interference, extent of pain, depression, anxiety, insomnia, and psychological variables from cognitive behavioral models of chronic pain. RESULTS: We found that Acceptance, Pain Interference, and Depression were key, "central," variables in the pretreatment network. Interestingly, there were few changes in the overall network configuration following treatment, specifically with respect to which variables appear most central relative to each other. On the other hand, Catastrophizing, Depression, Anxiety, and Pain Interference each became less central over time. Changes in Life Control, Acceptance, and Anxiety were most strongly related to changes in the remainder of the network as a whole. Finally, no network differences were found between treatment responders and non-responders. CONCLUSIONS: This study highlights potential future targets for pain treatment. Further application of a network approach to interdisciplinary pain rehabilitation data is recommended. Going forward, it may be better to next do this in a more comprehensive theoretically guided fashion, and ideographically, to detect unique individual differences in potential treatment processes.

Involvement of fear, incompleteness, and disgust during symptoms of pediatric obsessive-compulsive disorder.

Fear has been assigned a central role in models of obsessive-compulsive disorder (OCD), but empirical investigations into the emotions that underpin OCD symptoms are few, especially in pediatric samples. Using validated, clinician-led structured interviews, 124 youth with OCD reported on the presence and severity of symptoms across the main symptom dimensions of OCD (aggressive, symmetry, contamination) and the degree to which fear, incompleteness, and disgust accompanied these symptoms. For comparison purposes, the degree of fear, incompleteness, and disgust during symptoms was obtained also from youth with social anxiety disorder (SAD; n = 27) and generalized anxiety disorder (GAD; n = 28). Participants with OCD reported that all three emotions were involved in their symptoms; however, fear was most strongly linked to aggressive symptoms, incompleteness to symmetry symptoms, and disgust to contamination symptoms. Incompleteness differentiated youth with OCD from those with SAD and GAD. No differences for these emotions were found for youth with OCD with versus without the tic-disorder subtype or comorbid autism. A positive association between incompleteness and self-reported hoarding emerged among youth with OCD. Further studies of the emotional architecture of pediatric OCD, and its relationship to etiology and treatment, are warranted.

Posttraumatic Symptoms in 3-7 Year Old Trauma-Exposed Children: Links to Impairment, Other Mental Health Symptoms, Caregiver PTSD, and Caregiver Stress.

Few studies have examined how PTSD symptoms in young children are associated with other mental health symptoms and mood and functioning in caregivers. This is an important gap in the literature as such knowledge may be important for assessment and treatment. This study used network analysis to identify how the major symptom domains of PTSD in young trauma-exposed children were related to impairment, internalizing and externalizing symptoms, caregiver PTSD, and caregiver stress. Caregivers of 75 trauma-exposed 3-7 year old children reported on their child's symptoms and impairment and their own PTSD symptoms and caregiver stress. A strong association between the child PTSD domains of intrusions and avoidance emerged, which is in line with theoretical notions of how PTSD onsets and is maintained in adolescents and adults. Externalizing child symptoms were strongly linked to PTSD-related impairment and caregiver stress, highlighting the need to carefully assess and address such symptoms when working with young trauma-exposed children. Internalizing symptoms were uniquely associated with all three of the major childhood PTSD symptom domains with further implications for assessment and treatment.

A Network Analysis to Identify Associations between PTSD and Dissociation among Teenagers.

We conducted a network analysis of measures of dissociation and posttraumatic symptoms (PTS) with a varied sample of adolescents (N = 312), some of them previously exposed to war scenarios. The global measure of dissociation (A-DES) was uniquely linked to the arousal PTS symptom cluster (CRIES-13), in particular sleep problems, but not to the reexperiencing and avoidance clusters. Three of four (i.e., depersonalization/derealization, amnesia, mental partition/compartmentalization) dissociation clusters were uniquely linked to PTS severity, but not absorption. The results with the pooled groups were generally representative of both groups. The DP/DR relation to PTS was based on data from both samples, whereas the link between amnesia and partition/parts might have been driven by the normative group, although the refugee sample had significantly higher scores in those variables. The results replicate some previous findings with adult samples and suggest new paths for research and theory.

Outcomes of Interdisciplinary Pain Rehabilitation Across Subgroups of the Multidimensional Pain Inventory - A Study From the Swedish Quality Registry for Pain Rehabilitation.

INTRODUCTION: The Multidimensional Pain Inventory (MPI) is frequently used in the assessment of chronic pain. Three subgroups have been derived from MPI: adaptive coper (AC), dysfunctional (DYS), and interpersonally distressed (ID). The primary aim of this study was to examine whether outcome of Interdisciplinary Multimodal Pain Rehabilitation Programs (IMMRPs) differed across the MPI subgroups. METHODS: Patients with chronic pain (N = 34,513), included in the Swedish Quality Registry for Pain Rehabilitation, were classified into MPI subgroups and a subset that participated in IMMRPs (N = 13,419) was used to examine overall treatment outcomes using a previously established Multivariate Improvement Score (MIS) and 2 retrospective patient-evaluated benefits from treatment. RESULTS: The subgroups differed on sociodemographic characteristics, pain duration, and spatial spreading of pain. DYS and ID had the best overall outcomes to MIS. AC had the best outcomes according to the 2 retrospective items. Transition into other subgroups following IMMRP was common and most prominent in DYS and least prominent in AC. CONCLUSION: The validity of the MPI subgroups was partially confirmed. DYS and ID had the most severe clinical presentations at baseline and showed most improvement following IMMRP, but overall severity in DYS and ID at post-treatment was still higher than in the AC group. Future studies should examine how processes captured by MPI interact with neurobiological, medical, sociodemographic, and adaptation/coping factors and how these interactions impact severity of chronic pain and treatment outcome.

Symptom-specific effects of cognitive-behavioral therapy, sertraline, and their combination in a large randomized controlled trial of pediatric anxiety disorders.

BACKGROUND: Pediatric anxiety disorders are highly prevalent and associated with significant functional disabilities and lifelong morbidity. Cognitive-behavioral therapy (CBT), sertraline, and their combination are effective treatments, but little is known about how these treatments exert their effects. METHODS: Using network intervention analysis (NIA), we analyzed data from the largest randomized controlled treatment trial of pediatric anxiety disorders (Child/Adolescent Anxiety Multimodal Study, NCT00052078, clinicaltrials.gov/ct2/show/NCT00052078) and outlined the causal symptom domain-specific effects of CBT, sertraline, and their combination over the course of the 12-week treatment while taking into account both specificity and overlap between symptom domains. RESULTS: All active treatments produced positive effects with the most pronounced and consistent effects emerging in relation to psychological distress, family interference, and avoidance. Psychological distress was consistently the most and physical symptoms the least central symptom domain in the disorder network. CONCLUSIONS: All active treatments showed beneficial effects when compared to placebo, and NIA identified that these effects were exerted similarly across treatments and primarily through a reduction of psychological distress, family interference, and avoidance. CBT and sertraline may have differential mechanisms of action in relation to psychological distress. Given the lack of causal effects on interference outside family and physical symptoms, interventions tailored to target these domains may aid in the building of more effective treatments. Psychological distress and avoidance should remain key treatment focuses because of their central roles in the disorder network. The findings inform and promote developing more effective interventions.