Immersive Virtual Reality Exposures for the Treatment of Childhood Anxiety.

Exposure-based cognitive behavior therapy (CBT) has demonstrated efficacy and is recommended as a front-line treatment for childhood anxiety. Unfortunately, challenges exist that impact the effective implementation of exposure-based CBT in clinical practice. One of the primary challenges is the accessibility and availability of exposure stimuli (e.g., spiders, storms, heights) in CBT sessions. Immersive virtual reality (VR) has shown promise as a scalable and sustainable solution to address this clinical need, but remains largely untested in youth with anxiety disorders. Here, we examine the use of VR exposures in the treatment of youth with an anxiety disorder (i.e., specific phobias). We aimed to investigate: (1) the feasibility and clinical benefit of VR exposures; (2) whether VR exposures elicit changes in physiological arousal and/or subjective distress; and (3) whether habituation serves as a mechanism across physiological and subjective outcomes for VR exposures. Three youth and their parents completed a clinical evaluation, which was followed by a one session treatment (OST) with VR exposures. Afterward, youth and parents completed clinical assessments one-week and 1-month after treatment. Immersive VR exposures were found to be feasible and demonstrated clinical benefit for reducing anxiety severity. Additionally, VR exposures elicited changes in both physiological and subjective outcomes. Finally, physiological habituation to VR exposures was observed among participants who exhibited treatment response at follow-up. Collectively, these findings demonstrate preliminary evidence that VR exposures are feasible, tolerable, and show some therapeutic benefit for treating youth with anxiety.

Impact of Self-Efficacy and Affective Functioning on Pediatric Concussion Symptom Severity.

OBJECTIVE: The purpose of this study was to examine whether self-efficacy predicted pediatric concussion symptom severity and explore whether affective mood states (e.g., depression) influenced this relationship. METHOD: Children (8-17 years) who were diagnosed with a concussion within 30 days of injury participated in the study (n = 105). Following a clinical assessment, participants and caregivers completed questionnaires that assessed overall concussion symptom severity and current depression symptoms. Participants also completed ratings capturing self-efficacy for managing concussion recovery. RESULTS: Linear regression models revealed that greater levels of self-efficacy predicted lower parent- (R2 = 0.10, p = .001) and youth-rated (R2 = 0.23, p < .001) concussion symptom severity. Interestingly, depression symptoms moderated the relationship between self-efficacy and concussion symptom severity. CONCLUSIONS: Findings provide initial support for a relationship between self-efficacy and concussion outcomes and highlight the influence of depressive symptoms. Interventions that optimize youth's self-efficacy have the potential to increase treatment adherence, reduce concussion symptom severity, and improve recovery prognosis.

Urge Intolerance and Impairment Among Youth with Tourette's and Chronic Tic Disorders.

Individuals with Tourette's Disorder and Persistent Tic Disorders (TD) often experience premonitory urges-aversive sensations that precede tics and are relieved by tic expression. Given its role in the neurobehavioral model of TD, understanding factors that influence premonitory urges and associated relief can advance understanding of urge phenomenology and optimize treatments for individuals with TD. This study examined whether the novel construct of urge intolerance-difficulty tolerating premonitory urges-predicted tic severity and tic-related disability. Participants included 75 youth with TD and their caregivers. Assessments characterized tic severity, premonitory urge, distress tolerance, internalizing symptoms, and tic-related disability. Structural equation modeling revealed that higher levels of urge intolerance predicted greater levels of tic-related disability. Furthermore, the relationship between urge intolerance and tic-related disability was more robust for youth with clinically-elevated levels of internalizing symptoms. While further investigation is needed, urge intolerance represents a promising treatment target to improve tic-related disability in youth with TD.

Research Review: Neuropsychological test performance in pediatric obsessive-compulsive disorder--a meta-analysis.

BACKGROUND: Research into the neuropsychology of pediatric obsessive-compulsive disorder (OCD) reveals inconsistent results, limiting the ability to draw conclusions about possible neurocognitive deficits in youth with OCD. The aim of this study was to conduct a meta-analysis of the available literature. METHODS: We identified 36 studies, of which 11 studies met inclusion criteria. Results were categorized into nine functional subdomains: planning, response inhibition/interference control, set shifting/cognitive flexibility, verbal memory, nonverbal memory, processing speed, working memory, visuospatial functions, and attention. For each domain, weighted pooled Hedges' g effect size was calculated using random model analyses. RESULTS: Small effect sizes were found across all subdomains, none of which were found to be statistically significant. DISCUSSION: Results indicate that youth with OCD do not exhibit noteworthy neuropsychological deficits. This is in line with recent suggestions that OCD may not be characterized by clinically meaningful neuropsychological impairments. However, the small number of available controlled studies highlights the urgent need for more neuropsychological research in this population, as well as for further exploration of the neurodevelopmental hypothesis in pediatric OCD. Finally, the relatively low persistence rates of OCD into adulthood should be taken under consideration, especially in the context of the putative neuropsychological performance differences between adult and pediatric OCD populations.

Advancements in the phenomenology, assessment, and treatment of Tourette syndrome.

PURPOSE OF REVIEW: Tourette syndrome (TS) and chronic tic disorders, collectively referred to as TS, are relatively common childhood onset neuropsychiatric conditions associated with functional impairment and distress. Over the past several years, clinical research has contributed to the advancement of the field's understanding of mechanisms and clinical correlates of TS. This progress has led to the development of key assessment tools and the implementation of novel interventions for individuals with TS. RECENT FINDINGS: This article provides a review of innovative TS research focusing on four key themes: investigation of clinical phenomenology of TS; validation of assessment tools for TS; dissemination of current evidence-based treatments for TS; and exploration of new intervention programs. SUMMARY: Cumulatively, this growing body of work presents considerable progress and provides a path forward to improve the assessment and treatment of TS.

Clinical Considerations for an Evidence-Based Assessment for Obsessive-Compulsive Disorder.

Obsessive-compulsive disorder (OCD) is an impairing mental health disease, generally beginning in childhood, affecting up to ∼3% of the population. Using evidence-based assessments (EBAs) is the starting point for the accurate diagnosis and treatment of OCD. EBAs consist of structured and semistructured clinician-administered interviews, parent-report and child-report, and self-report for adults. This article details the practical application, psychometric properties, and limitations of available assessments to determine the presence of OCD and evaluate OCD symptom severity. The following reviews measurement of constructs relevant to OCD (ie, insight, family accommodation, impairment) and details considerations for best clinical interview practices.

Urge intolerance predicts tic severity and impairment among adults with Tourette syndrome and chronic tic disorders.

Background: Individuals with Tourette Syndrome and Persistent Tic Disorders (collectively TS) often experience premonitory urges-aversive physical sensations that precede tics and are temporarily relieved by tic expression. The relationship between tics and premonitory urges plays a key role in the neurobehavioral treatment model of TS, which underlies first-line treatments such as the Comprehensive Behavioral Intervention for Tics (CBIT). Despite the efficacy of CBIT and related behavioral therapies, less than 40% of adults with TS respond to these treatments. Further examination of the relationship between premonitory urges, tic severity, and tic impairment can provide new insights into therapeutic targets to optimize behavioral treatment outcomes. This study examined whether urge intolerance-difficulty tolerating premonitory urges-predicted tic severity and tic-related impairment among adults with TS. Methods: Participants were 80 adults with TS. Assessments characterized premonitory urge, distress tolerance, tic severity, and tic impairment. We used structural equation modeling (SEM) to examine the construct of urge intolerance-comprised of premonitory urge ratings and distress tolerance ratings. We first evaluated a measurement model of urge intolerance through bifactor modeling, including tests of the incremental value of subfactors that reflect premonitory urge severity and distress tolerance within the model. We then evaluated a structural model where we predicted clinician-rated tic severity and tic impairment by the latent variable of urge intolerance established in our measurement model. Results: Analyses supported a bifactor measurement model of urge intolerance among adults with TS. Consistent with theoretical models, higher levels of urge intolerance predicted greater levels of clinician-rated tic severity and tic impairment. Conclusion: This investigation supports the construct of urge intolerance among adults with TS and distinguishes it from subcomponents of urge severity and distress tolerance. Given its predictive relationship with tic severity and tic impairment, urge intolerance represents a promising treatment target to improve therapeutic outcomes in adults with TS.

Homework adherence predicts therapeutic improvement from behavior therapy in Tourette's disorder.

Behavior therapy is a first-line intervention for Tourette's Disorder (TD), and a key component is the practice of therapeutic skills between treatment visits (i.e., homework). This study examined the relationship between homework adherence during behavior therapy for TD and therapeutic outcomes, and explored baseline predictors of homework adherence during treatment. Participants included 119 individuals with TD (70 youth, 49 adults) who received behavior therapy in a clinical trial. After a baseline assessment of tic severity and clinical characteristics, participants received 8 sessions of behavior therapy. Therapists recorded homework adherence at each therapy session. After treatment, tic severity was re-assessed by independent evaluators masked to treatment condition. Greater overall homework adherence predicted tic severity reductions and treatment response across participants. Early homework adherence predicted therapeutic improvement in youth, whereas late adherence predicted improvement in adults. Baseline predictors of greater homework adherence in youth included lower hyperactivity/impulsivity and caregiver strain. Meanwhile in adults, baseline predictors of increased homework adherence included younger age, lower hyperactivity/impulsivity, obsessive-compulsive severity, anger, and greater work-related disability. Homework adherence is an integral component of behavior therapy and linked to therapeutic improvement. Strategies that improve homework adherence may optimize the efficacy of behavioral treatments and improve treatment outcomes.

Defining tic severity and tic impairment in Tourette Disorder.

OBJECTIVE: Treatment guidelines for Tourette's Disorder (TD) are based on patients' degree of tic severity and impairment. However, clear benchmarks for determining tic severity and impairment have not been established. This study examined benchmarks of tic severity and tic impairment using the Yale Global Tic Severity Scale (YGTSS) and the Clinical Global Impression of Severity (CGI-S). METHOD: Individuals with TD or another Tic Disorder (N = 519) recruited across nine sites were administered a diagnostic interview, the YGTSS, and the CGI-S. Correlations and trend analyses contrasted YGTSS scores across CGI-S ratings. A logistic regression model examined predictive benchmarks for tic severity, tic impairment, and global severity. Model classifications were compared against CGI-S ratings, and agreement was examined using kappa. RESULTS: Spearman correlations between the CGI-S and YGTSS scores ranged from 0.54 to 0.63 (p < 0.001). Greater CGI-S ratings were associated with a linear stepwise increase in YGTSS Total Tic scores, Impairment scores, and Global Severity scores. Despite moderate-to-strong associations (ρ = 0.45-0.56, p < 0.001) between the CGI-S and predictive logistical regression models, only fair agreement was achieved when applying classification benchmarks (κ = 0.21-0.32, p < 0.001). CONCLUSIONS: CGI-S ratings are useful to characterize benchmarks for tic severity, tic impairment, and global severity on the YGTSS. Logistic regression model benchmarks had only fair agreement with the CGI-S and underscore the heterogeneity of TD symptoms. Collectively, findings offer guidance on the delineation of tic severity categorizations to apply evidence-based treatment recommendations.

Optimizing behavior therapy for youth with Tourette's disorder.

Tourette's Disorder (TD) is characterized by tics that cause distress and impairment. While treatment guidelines recommend behavior therapy as a first-line intervention, patients with TD may exhibit limited therapeutic response. Given the need to improve treatment outcomes, this study examined the efficacy of augmenting behavior therapy with D-cycloserine (DCS) to reduce tic severity in a placebo-controlled quick-win/fast-fail trial. Twenty youth with TD completed a baseline assessment to characterize tic severity, premonitory urges, medical history, and psychiatric comorbidity. Youth were randomly assigned to receive a single session of habit reversal training (HRT) augmented by either 50 mg of DCS or placebo. Two bothersome tics on the Hopkins Motor/Vocal Tic Scale (HM/VTS) were targeted for treatment during HRT. One week after the HRT session, youth completed a posttreatment assessment to evaluate change in the severity of bothersome tics. All assessments were completed by independent evaluators masked to treatment group. There was a Treatment Group by Time Interaction in favor of DCS-augmented HRT (p < 0.01), controlling for baseline tic severity, tic medication, and attention deficit hyperactivity disorder. Follow-up comparisons revealed small group differences at the treatment visit (d = 0.27), with the DCS group exhibiting slightly greater severity for targeted tics. There was a large group difference at posttreatment, in which the DCS group exhibited lower severity for targeted tics (d = 1.30, p < 0.001) relative to the placebo group. Findings demonstrate the preliminary enhancement of tic severity reductions by augmenting HRT with DCS compared with placebo augmentation.

Neurocognitive function in paediatric obsessive-compulsive disorder.

OBJECTIVES: The small body of neuropsychological research in paediatric obsessive-compulsive disorder (OCD) yields inconsistent results. A recent meta-analysis found small effect sizes, concluding that paediatric OCD may not be associated with cognitive impairments, stressing the need for more research. We investigated neuropsychological performance in a large sample of youths with OCD, while assessing potential moderators. METHODS: Participants with OCD (n = 102) and matched controls (n = 161) were thoroughly screened and blindly evaluated for comorbidities, and completed a neuropsychological battery assessing processing speed, visuospatial abilities (VSA), working memory (WM), non-verbal memory (NVM), and executive functions (EF). RESULTS: Compared to controls, youths with OCD exhibited underperformance on tasks assessing processing speed. On tests of VSA and WM, underperformance was found only on timed tasks. There were no differences on NVM and EF tasks. Notably, the OCD group's standardised scores were in the normative range. Test performance was not associated with demographic or clinical variables. CONCLUSIONS: Youths with OCD exhibited intact performance on memory and EF tests, but slower processing speed, and underperformance only on timed VSA and WM tasks. While the OCD group performed in the normative range, these findings reveal relative weaknesses that may be overlooked. Such an oversight may be of particular importance in clinical and school settings.

Prayer in Response to Negative Intrusive Thoughts: Closer Examination of a Religious Neutralizing Strategy.

Few studies have systematically examined the covert neutralizing strategies that serve to maintain and exacerbate the frequency and distress related to intrusive thoughts. Given the lack of research in this area, this study aimed to highlight development and maintenance factors for one such strategy, compensatory prayer, to inform assessment and treatment of related obsessional phenomena. We used a multimethod approach to examine the predictors and function of prayer when it is used in response to negative intrusive thoughts. Participants were 85 undergraduate students (ages 18-55 years) who self-identified with a branch of Christianity. In addition to self-report measures, participants were administered an in vivo negative thought induction and were subsequently asked about their use of compensatory prayer behaviors. Results indicated that religiosity, intrinsic religious motivation, and moral thought-action fusion (TAF) positively predicted the use of prayer, with moral TAF emerging as a unique predictor and a complete mediator between religiosity and the use of prayer. Regarding the function of prayer, results indicated that when prayer is used maladaptively (i.e., negative coping style), it is associated with higher scores on religious measures and moral TAF, as well as more frequent engagement in prayer, and a greater reduction in anxiety postprayer. Surprisingly, likelihood TAF was not found to be related to the use or function of prayer. Results are discussed in terms of certain religious teachings and TAF-related beliefs, neurobiological explanations for our pattern of findings, and clinical implications for religious-related intrusive thoughts. Future directions and limitations are also discussed.

Advances in the treatment of pediatric obsessive-compulsive d-cycloserine with exposure and response prevention.

Exposure-based cognitive-behavioral therapy and serotonin reuptake inhibitor medications are efficacious treatment options for the management of pediatric obsessive-compulsive disorder. Despite established efficacy, many youths receiving either therapy remain symptomatic after acute treatment. Regardless of the rationale for persistent symptoms, a clear need emerges for treatment options that restore functioning efficiently to symptomatic youths. One innovative approach builds upon the identified role of NMDA receptors in the fear extinction process. Instead of breaking existing connections during fear extinction, new associations develop that eventually predominate over prior associations. Recent investigations have explored augmenting exposure-based cognitive-behavioral therapy with the NMDA partial agonist d-cycloserine, with preliminary results demonstrating expedited treatment gains and moderately larger effects above exposure and response prevention therapy alone. A large randomized clinical trial is underway to evaluate the efficacy and efficiency of this therapeutic combination in pediatric obsessive-compulsive disorder. Results from this trial may translate into improved management practices.