A Low-Intensity Transcranial Focused Ultrasound Parameter Exploration Study of the Ventral Capsule/Ventral Striatum.

OBJECTIVES: Deep brain stimulation (DBS) of the ventral capsule/ventral striatum (VC/VS) is effective for treatment-resistant obsessive-compulsive disorder (OCD); however, DBS is associated with neurosurgical risks. Transcranial focused ultrasound (tFUS) is a newer form of noninvasive (ie, nonsurgical) stimulation that can modulate deeper regions, such as the VC/VS. tFUS parameters have just begun to be studied and have often not been compared in the same participants. We explored the effects of three VC/VS tFUS protocols and an entorhinal cortex (ErC) tFUS session on the VC/VS and cortico-striato-thalamo-cortical circuit (CSTC) in healthy individuals for later application to patients with OCD. MATERIALS AND METHODS: Twelve individuals participated in a total of 48 sessions of tFUS in this exploratory multisite, within-subject parameter study. We collected resting-state, reward task, and arterial spin-labeled (ASL) magnetic resonance imaging scans before and after ErC tFUS and three VC/VS tFUS sessions with different pulse repetition frequencies (PRFs), pulse widths (PWs), and duty cycles (DCs). RESULTS: VC/VS protocol A (PRF = 10 Hz, PW = 5 ms, 5% DC) was associated with increased putamen activation during a reward task (p = 0.003), and increased VC/VS resting-state functional connectivity (rsFC) with the anterior cingulate cortex (p = 0.022) and orbitofrontal cortex (p = 0.004). VC/VS protocol C (PRF = 125 Hz, PW = 4 ms, 50% DC) was associated with decreased VC/VS rsFC with the putamen (p = 0.017), and increased VC/VS rsFC with the globus pallidus (p = 0.008). VC/VS protocol B (PRF = 125 Hz, PW = 0.4 ms, 5% DC) was not associated with changes in task-related CSTC activation or rsFC. None of the protocols affected CSTC ASL perfusion. CONCLUSIONS: This study began to explore the multidimensional parameter space of an emerging form of noninvasive brain stimulation, tFUS. Our preliminary findings in a small sample suggest that VC/VS tFUS should continue to be investigated for future noninvasive treatment of OCD.

Parent-Led Cognitive Behavioral Teletherapy for Anxiety in Autistic Youth: A Randomized Trial Comparing Two Levels of Therapist Support.

Parent-led cognitive behavioral therapy (CBT) is an efficient, promising form of therapy that may be well suited for autistic youth with anxiety disorders, though to date it has been minimally tested. In this study, 87 autistic youth (7 to 13 years old) with anxiety disorders and their parents were randomized to two forms of parent-led CBT in which parents led their child through a guided CBT workbook across 12 weeks: one with low therapist contact (four 30-minute telehealth calls), and one with standard therapist contact (ten 60-minute telehealth calls). Anxiety, functional impairment, and autism features significantly declined across therapy, without differences between groups. High satisfaction was reported in both groups, though significantly higher satisfaction ratings were reported in standard-contact CBT. Responder rates were 69% of completers at posttreatment (70% in standard contact, 68% in low contact) and 86% at 3-month follow-up (86% in standard contact, 87% in low contact). Low-contact CBT was estimated to incur an average cost of $755.70 per family compared with $1,978.34 in standard-contact CBT. Parent-led CBT with minimal or standard therapist contact both appear to be effective CBT delivery formats for autistic youth with anxiety disorders, with significant cost savings for low-contact CBT.

Family Accommodation in Children and Adolescents With Misophonia.

Family accommodation (e.g., reassurance, modifying routines, assisting avoidance) has not been explored among youth with misophonia but may have important clinical and intervention implications. We examined family accommodation in 102 children and adolescents with interview-confirmed misophonia and compared its frequency and content to family accommodation in 95 children and adolescents with anxiety disorders. Findings showed that family accommodation was ubiquitous in pediatric misophonia and may be even more frequent than in youth with anxiety disorders. Assisting the child, participating in misophonia-related behaviors, and modifying family routines were endorsed by more than 70% of parents of children with misophonia. Further, compared to parents of children with anxiety disorders, parents of children with misophonia more frequently reported child distress and anger when they did not accommodate. Family accommodation was moderately to strongly associated with misophonia severity even when accounting for co-occurring internalizing and externalizing symptoms and sociodemographic factors. This first study of family accommodation in pediatric misophonia suggests accommodation may be an important clinical feature. A notable study limitation is that the measure of misophonia did not delineate between adaptive versus maladaptive accommodations. Excessive and maladaptive accommodation may be one potential candidate to target in interventions when considered within a broader treatment plan. Importantly, adaptive accommodations should also be considered in day-to-day management if they improve functioning and quality of life.

Co-occurring PTSD in intensive OCD treatment: Impact on treatment trajectory vs. response.

BACKGROUND: Obsessive-compulsive disorder (OCD) and co-occurring posttraumatic stress disorder (PTSD) is associated with more severe and chronic OCD. However, findings regarding treatment effectiveness of cognitive behavioral treatment (CBT) with exposure and response prevention (ERP) with this comorbidity are mixed. Research aimed at understanding the precise barriers to OCD treatment effectiveness for individuals with co-occurring PTSD may help elucidate unique treatment needs. METHODS: The current study used linear regression and latent growth curve analysis comparing treatment response and trajectory from patients with OCD (n = 3083, 94.2 %) and OCD + PTSD (n = 191, 5.2 %) who received CBT with ERP in two major intensive OCD treatment programs. RESULTS: Although patients with OCD + PTSD evidenced similar trajectories of overall severity change, patients at one site required nearly 11 additional treatment days to achieve comparable reduction in OCD severity. Further, at the dimensional level, those with OCD + PTSD had poorer treatment response for unacceptable thoughts and symmetry symptoms. The moderate effect for unacceptable thoughts, indicating the widest gap in treatment response, suggests these symptoms may be particularly relevant to PTSD. LIMITATIONS: Findings are limited by a naturalistic treatment sample with variation in treatment provision. CONCLUSIONS: Findings emphasize caution in using a one-size-fits-all approach for patients with co-occurring OCD + PTSD within intensive OCD treatment programs, as broadly defined outcomes (e.g., reduction in overall severity) may not translate to reduction in the nuanced symptom dimensions likely to intersect with trauma. Unacceptable thoughts and symmetry symptoms, when co-occurring with PTSD, may require a trauma-focused treatment approach within intensive OCD treatment.

Perceived worsening of obsessive-compulsive disorder symptoms after childbirth in women and men: An understudied phenomenon.

The aim of this study was to examine worsening of OCD symptoms after childbirth in individuals seeking assessment or treatment of OCD. The postpartum period may make parents biologically and psychologically vulnerable to OCD symptoms. Participants included 222 parents with OCD who completed surveys through a self-help website. Most women and almost half of men with self-reported OCD reported an increase in OCD symptoms following childbirth. Retrospective report of perceived worsening of OCD symptoms after childbirth was associated with more aggressive obsessions for both men and women, in comparison to individuals whose OCD symptoms did not worsen around childbirth. Women whose OCD symptoms worsened after childbirth reported more impairment in social functioning than individuals whose symptoms did not worsen. These results highlight the need to develop a better understanding of aggressive obsessions in parents, and improve education about prevalence, content, assessment, and intervention for aggression-focused intrusive thoughts.

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.

The clinical presentation of major depressive disorder in youth with co-occurring obsessive-compulsive disorder.

BACKGROUND: Major depressive disorder (MDD) is common in youth and among the most frequent comorbid disorders in pediatric obsessive-compulsive disorder (OCD), but it is unclear whether the presence of OCD affects the symptom presentation of MDD in youth. METHODS: A sample of youth with OCD and MDD (n = 124) and a sample of youth with MDD but no OCD (n = 673) completed the Patient Health Questionnaire for Adolescents (PHQ-A). The overall and symptom-level presentation of MDD were examined using group comparisons and network analysis. RESULTS: Youth with MDD and OCD, compared to those with MDD and no OCD, had more severe MDD (Cohen's d = 0.39) and more reported moderate to severe depression (75 % vs 61 %). When accounting for demographic variables and the overall severity of MDD, those with comorbid OCD reported lower levels of anhedonia and more severe difficulties with psychomotor retardation/agitation. No significant differences in the interconnections among symptoms emerged. LIMITATIONS: Data were cross-sectional and self-reported, gold standard diagnostic tools were not used to assess OCD, and the sample size for the group with MDD and OCD was relatively small yielding low statistical power for network analysis. CONCLUSIONS: Youth with MDD and OCD have more severe MDD than those with MDD and no OCD and they experience more psychomotor issues and less anhedonia, which may relate to the behavioral activation characteristic of OCD.

Alterations in attentional processing in youth with misophonia: A phenotypical cross-comparison with anxiety patients.

BACKGROUND: Misophonia is a complex condition characterized by extreme emotional distress in response to specific sounds or specific visual stimuli. Despite a growing body of clinical and neuroscientific literature, the etiology of this condition remains unclear. Hyperarousal, that is, a state of heightened alertness and disinhibition, as a core feature of misophonia is supported by behavioral and neuroimaging literature and might represent a viable clinical target for the development of both behavioral and pharmacological interventions. The aim of this study was to investigate how hyperarousal might be linked to neurocognitive processes associated with vigilance and stimulus discrimination in youth with misophonia. METHODS: We compared 72 children and adolescents with misophonia (13.74 ± 2.44 years) (64 % female) and 89 children and adolescents with anxiety (12.35 ± 2.57 years) (58.4 % female) on behavioral and signal detection performance of the immediate memory task (IMT). Anxiety patients were used as a clinical control group to distinguish attentional processes specific for misophonia. RESULTS: Both groups demonstrated similar behavioral performance, including response rate and reaction time. However, misophonia was associated with elevated stimulus discrimination (d prime), which in turn was positively correlated with the severity of misophonia trigger reports. CONCLUSIONS: Our findings are in line with previous cognitive and neuroimaging studies, and support an arousal-based model of misophonia, where individuals with misophonia experience a state of heightened vigilance, being more aware of stimuli in the environment. Our findings provide a neurocognitive basis for future study of neurochemical imaging that might further progress towards clinical targets.

Randomized trial comparing standard versus light intensity parent training for anxious youth.

OBJECTIVE: To examine the efficacy of the parent-led intervention Supportive Parenting for Anxious Childhood Emotions (SPACE) relative to a low-dose version of the protocol among children and adolescents with clinically significant anxiety and/or obsessive-compulsive disorder (OCD). METHOD: 68 youth (7-17) with anxiety/OCD and their parents were randomized to receive 12 weekly telehealth SPACE sessions (SPACE-Standard) or bibliotherapy plus 4 telehealth sessions over 12 weeks (SPACE-light). After screening, assessments were conducted via videoconferencing at baseline, post-treatment, and one-month follow-up. Independent evaluators were blind to treatment condition. RESULTS: Treatment condition did not predict whether a participant responded to the intervention (SPACE-Standard = 70%; SPACE-Light = 68%), nor was treatment condition a predictor of anxiety severity, parent-reported anxiety, or parent-/child-reported functional impairment at post-treatment or one-month follow-up. Youth in SPACE-Light self-reported higher post-treatment anxiety than youth in SPACE-standard, though this was no longer significant at one-month follow-up. Parent-reported family accommodation total change scores were associated with anxiety severity at post-treatment across both arms. CONCLUSION: This is the second randomized controlled trial (RCT) evaluating SPACE and provides further support for the efficacy of this intervention both in standard and low-dose formats. This study provides support for parent-led anxiety treatment targeting family accommodation as a primary mechanism of change and extends evidence of efficacy to a more clinically diverse sample. TRIAL REGISTRATION: ClinicalTrials.gov Registry: NCT04922502.https://classic. CLINICALTRIALS: gov/ct2/show/NCT04922502.

Pulsation artifact removal from intra-operatively recorded local field potentials using sparse signal processing and data-specific dictionary.

Neural recordings frequently get contaminated by ECG or pulsation artifacts. These large amplitude components can mask the neural patterns of interest and make the visual inspection process difficult. The current study describes a sparse signal representation strategy that targets to denoise pulsation artifacts in local field potentials (LFPs) recorded intraoperatively. To estimate the morphology of the artifact, we first detect the QRS-peaks from the simultaneously recorded ECG trace as an anchor point. After the LFP data has been epoched with respect to each beat, a pool of raw data segments of a specific length is generated. Using the K-singular value decomposition (K-SVD) algorithm, we constructed a data-specific dictionary to represent each contaminated LFP epoch in a sparse fashion. Since LFP is aligned to each QRS complex and the background neural activity is uncorrelated to the anchor points, we assumed that constructed dictionary will be formed to mainly represent the pulsation artifact. In this scheme, we performed an orthogonal matching pursuit to represent each LFP epoch as a linear combination of the dictionary atoms. The denoised LFP data is thus obtained by calculating the residual between the raw LFP and its approximation. We discuss and demonstrate the improvements in denoised data and compare the results with respect to principal component analysis (PCA). We noted that there is a comparable change in the signal for visual inspection to observe various oscillating patterns in the alpha and beta bands. We also see a noticeable compression of signal strength in the lower frequency band (<13 Hz), which was masked by the pulsation artifact, and a strong increase in the signal-to-noise ratio (SNR) in the denoised data.Clinical Relevance- Pulsation artifact can mask relevant neural activity patterns and make their visual inspection difficult. Using sparse signal representation, we established a new approach to reconstruct the quasiperiodic pulsation template and computed the residue signal to achieve noise-free neural activity.

Obsessive-Compulsive Disorder in Children and Adolescents.

Obsessive-compulsive disorder (OCD) in children and adolescents is a neurobehavioral condition that can lead to functional impairment in multiple domains and decreased quality of life. We review the clinical presentation, diagnostic considerations, and common comorbidities of pediatric OCD. An overview of the biological and psychological models of OCD is provided along with a discussion of developmental considerations in youth. We also describe evidence-based treatments for OCD in childhood and adolescence, including cognitive behavioral therapy (CBT) with exposure and response prevention (ERP) and pharmacotherapy. Finally, research evaluating the delivery of CBT in different formats and modalities is discussed, and we conclude with suggestions for future research directions. Expected final online publication date for the Annual Review of Clinical Psychology, Volume 20 is May 2024. Please see http://www.annualreviews.org/page/journal/pubdates for revised estimates.

Predictors and Moderators of Treatment Outcomes for Anxious Children Randomized to Computer-Assisted Cognitive Behavioral Therapy or Standard Community Care.

Introduction: Computer-assisted cognitive behavioral therapy (CCBT) for childhood anxiety disorders may aid the dissemination of CBT, while maintaining treatment fidelity. Although CCBT is an effective intervention, not everyone benefits equally from treatment. Identifying patient characteristics that predict who will benefit from treatment and to what extent can help with matching patients to suitable interventions, and allow researchers and clinicians to modify, and individualize, their treatment formats more effectively. Such predictors and moderators have not yet been examined for CCBT outcomes in anxious children and studies of more traditional treatment formats have yielded inconsistent results. Methods: Using data from a randomized clinical trial evaluating CCBT for children with anxiety disorders, this study examined predictors and moderators of treatment outcomes in a sample of 100 children (age: mean [M] = 9.82, standard deviation [SD] = 1.82), randomized to either CCBT (n = 49) or standard community care (n = 51). Potential predictors and moderators were identified from the literature and examined in stepwise multiple linear regression models, using posttreatment anxiety severity and global impairment as outcomes. Results: Parent-rated internalizing symptoms predicted posttreatment anxiety severity for both treatment groups. High pretreatment levels of anxiety severity predicted higher global impairment at posttreatment for the group receiving community care, but not for the CCBT group. Conclusion: Further research is needed to clarify which patient characteristics are associated with CCBT outcomes in a consistent way. ClinicalTrials.gov identifier: NCT01416805.

Psychometric properties of the revised children's anxiety and depression scale (RCADS) for autistic youth without co-occurring intellectual disability.

Autistic youth often present with comorbid anxiety and depression yet there is a dearth of validated assessment tools. The Revised Children's Anxiety and Depression Scale (RCADS) assesses internalizing symptoms but there is little psychometric data in autistic youth. Treatment-seeking autistic youth with anxiety or obsessive-compulsive symptoms (N = 74; age 6-14 years), and caregivers, were administered the RCADS-Parent, RCADS-Child, and assessments of internalizing, externalizing symptoms and social impairment indicative of autism. RCADS-Parent and RCADS-Child total anxiety scores demonstrated excellent internal consistency, and the six subscales demonstrated acceptable-to-good internal consistency. The RCADS-Child and Parent total anxiety scores were weakly correlated, and neither child age nor gender altered the strength of this association. Convergent validity was supported by moderate-to-strong correlations with clinician and parent-reported anxiety symptoms. Support for divergent validity was mixed. Results provide support for the RCADS-Parent and RCADS-Child as reliable, valid measures of internalizing symptoms in autistic youth.

COVID-19-related intrusive thoughts and associated ritualistic behaviors.

This study evaluated COVID-19-related intrusive thoughts and associated ritualistic behaviors (CITRB). From March to May 2020, 1,118 Chinese high school students, college students, psychiatric outpatients, and community members completed a survey assessing CITRB, generalized anxiety, depression, somatization, obsessive-compulsive symptoms, and pandemic-related disruptions. Overall, participants reported mild to moderate CITRB, although certain thoughts/behaviors were more frequently endorsed, such as repeatedly telling others to take precautions against COVID-19 and checking COVID-19-related news. Being male, younger, a health-care worker, or in isolation/quarantine was associated with CITRB severity in community members. Obsessive-compulsive symptom severity, depression, somatic symptoms, and anxiety were associated with CITRB severity, although only obsessive-compulsive symptoms were uniquely associated with CITRB. This study provided evidence for the construct of CITRB, which may help mental health providers identify the nature and sources of COVID-19-related distress for some individuals as well as serve as a framework for evaluating obsessive-compulsive symptoms specific to large-scale crises.

Geospatial Distribution of Obsessive-Compulsive Disorder Specialists: Understanding Access as a Function of Distance, Insurance Status, and Neighborhood Socioeconomic Status.

Obsessive-compulsive disorder is an impairing psychiatric condition affecting 1-2% of adults and youth. Cognitive-behavioral therapy with exposure and response prevention (CBT) is an efficacious intervention but requires specialty training and access is often limited. While certain factors are associated with treatment access, one key barrier that has not been explored is the geographic availability of OCD treatment providers. Using integrated geographically-referenced data, we examined the geographic distribution of OCD CBT specialty providers across the state of Texas, with particular attention to the relationship to neighborhood socioeconomic disadvantage, insurance status, and rural versus urban status. We found that specialist providers are almost exclusively located inside the highly urbanized parts of the state, primarily in more affluent areas, and often only accept self-pay. The characteristics of the areas located the furthest away from specialty OCD care include a high proportion of persons identifying as Hispanic; a high proportion of non-English speakers, households with income below poverty; households with no vehicles; and persons with no health insurance. Average household income decreased as distances from specialist providers increased. Broadly, findings confirm that OCD CBT specialty providers are clustered in large socially advantaged areas and that economic disadvantage remains a significant barrier to care. As inadequate or inappropriate treatment of OCD is likely to result in sustained and impairing symptoms, this is of great concern.

Obsessive-compulsive disorder in youth and young adults with depression: Clinical characteristics of comorbid presentations.

Obsessive-compulsive disorder (OCD), anxiety disorders, and depressive disorders are highly comorbid, and each contribute to significant functional impairment for affected youth. Comorbid anxiety disorders in depressed youth have been associated with greater depressive symptom severity and impairment, but the impact of comorbid OCD in this population remains unclear. Accordingly, the present study examined the differential clinical characteristics of youth with depression and comorbid OCD relative to age/gender matched depressed youth with no such comorbidity and to those with depression and a comorbid (non-OCD) anxiety disorder. A sample of 797 youth and young adults ages 8-20 years who met diagnostic criteria for depression alone, depression with co-occurring OCD or any anxiety disorder were included in the present study. Rates of comorbid anxiety and OCD were very high (60.5% and 15.5%, respectively). Relative to youth with only depression, depressed youth with comorbid OCD or anxiety had greater severity of depression, suicidality, and overall impairment in social, physical, and emotional functioning. These results highlight the contribution of OCD or anxiety comorbidity in more complex clinical presentations for depressed youth.

Measuring misophonia in youth: A psychometric evaluation of child and parent measures.

BACKGROUND: Misophonia is characterized by intense emotional reactions to specific sounds or visual stimuli and typically onsets during childhood. An obstacle for research and clinical practice is that no comprehensively evaluated measures for pediatric misophonia exist. METHODS: In a sample of 102 youth meeting the proposed diagnostic criteria of misophonia, we evaluated the child and parent-proxy versions of the self-reported Misophonia Assessment Questionnaire (MAQ; assessing broad aspects of misophonia) and the child version of the Amsterdam Misophonia Scale (A-MISO-S; assessing misophonia severity). Confirmatory and exploratory factor analysis were used to examine factor structures of the measures. Further, child-parent agreement on the MAQ and associations between both measures and misophonia-related impairment, quality of life, and misophonia-related school interference were examined to evaluate aspects of convergent validity. RESULTS: For both youth- and parent-ratings, four MAQ factors emerged: pessimism, distress, interference, and non-recognition. A-MISO-S showed a unidimensional structure, but the item 'effort to resist' did not load significantly onto the unidimensional factor. Good child-parent agreement on the MAQ scales were found and both MAQ and A-MISO-S were moderately to strongly associated with misophonia-related impairment, quality of life (inverse association), and misophonia-related school interference. LIMITATIONS: MAQ and A-MISO-S assess sensitivity to auditory but not visual stimuli, the sample size was modest, and repeated assessments were not conducted. CONCLUSIONS: The combination of MAQ and A-MISO-S shows promise as a multidimensional assessment approach for pediatric misophonia. Future evaluations should include known-groups validity, screening performance, and sensitivity to change in symptom severity.

A systematic review of treatments for misophonia.

Research into misophonia treatments has been limited and it is unclear what treatment approaches may be effective. This systematic review extracted and synthesized relevant treatment research on misophonia to examine the efficacy of various intervention modalities and identify current trends in order to guide future treatment research. PubMed, PsycINFO, Google Scholar, and Cochrane Central were searched 4using the keywords "misophonia," "decreased sound tolerance," "selective sound sensitivity," or "decreased sound sensitivity." Of the 169 records available for initial screening, 33 studied misophonia treatment specifically. Data were available for one randomized controlled trial, one open label trial, and 31 case studies. Treatments included various forms of psychotherapy, medication, and combinations of the two. Cognitive-behavioral therapy (CBT) incorporating various components has been the most often utilized and effective treatment for reduction of misophonia symptoms in one randomized trial and several case studies/series. Beyond CBT, various case studies suggested possible benefit from other treatment approaches depending on the patient's symptom profile, although methodological rigor was limited. Given the limitations in the literature to date, including overall lack of rigor, lack of comparative studies, limited replication, and small sample size, the field would benefit from the development of mechanism-informed treatments, rigorous randomized trials, and treatment development with an eye towards dissemination and implementation.

Promoting OCD WEllness and resilience (POWER) study: Rationale, design, and methods.

Obsessive-compulsive disorder (OCD) affects 1-2% of children and is associated with functional impairment and diminished quality of life. Several treatments are efficacious: cognitive behavioral therapy (CBT) with exposure and response prevention, serotonin reuptake inhibitor (SRI) monotherapy, and combined treatment (SRI + CBT). Expert clinician-informed practice parameters suggest that youth with mild to moderate OCD should be treated initially with CBT yet SRIs are frequently employed as the first-line intervention or in combination with psychotherapy in applied practice. Empirical data to guide SRI discontinuation in pediatric OCD are very limited. This study, Promoting OCD Wellness and Resiliency (POWER), aims to address this gap through a two phase, double-blinded, placebo-controlled, randomized controlled non-inferiority trial with the purpose of evaluating whether youth with OCD on an SRI can discontinue their medication after successful CBT augmentation and maintain wellness for a period of 24 weeks during which they receive maintenance CBT that models standard-of-care. In this paper we describe the rationale and methodological design of the POWER study.