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.

Remission and Relapse Across Three Years in Pediatric Obsessive-Compulsive Disorder Following Evidence-Based Treatments.

OBJECTIVE: To examine relapse rates following remission in a 3-year follow-up study in pediatric patients with obsessive-compulsive disorder (OCD) treated with cognitive-behavioral therapy (CBT) in a first step, and either continued CBT or sertraline (randomized selection) in a second step. METHOD: Participants (N = 269) fulfilled DSM-IV OCD criteria with a mean severity on the Children's Yale-Brown Obsessive Compulsive Scale (CY-BOCS) of 24.6 (SD = 5.1) and were included in analyses according to intent-to-treat principles. CBT used manualized exposure and response prevention (ERP) during both steps 1 and 2, and step 2 sertraline medication used flexible dosing. The follow-up schedules were timed to 6, 12, 24, and 36 months following step 1 CBT. Remission was defined as a CY-BOCS score ≤10 and relapse as an elevated CY-BOCS score ≥16 in those who had remitted. RESULTS: A good third of our patients were in stable and full remission at all examinations (n = 98, 36.4%). Further, some in remission following treatment (n = 36, 13.4%) had mild OCD at some examinations. Relapses during follow-up were not uncommon (n = 28, 10.4%), but in many patients these improved again (n = 10, 3.7%) and were in remission at the final 3-year follow-up. Furthermore, a considerable proportion (n = 50, 18.6%) of the patients were initial non-remitters to the treatment but achieved remission at some point during the follow-up. In addition, 11.5% (n = 31) had persistent OCD but reached remission by the last follow-up. Finally, a smaller segment of our sample (9.7%, n = 26), did not attain remission at any point during the study. CONCLUSION: Our outcome paints a more promising picture of pediatric OCD long-term outcome than previous studies have done. However, both relapse rates and the presence of initial non-remitters and persistent OCD show that treatments need improvement, particularly for those who respond slowly, partially, or not at all. The lack of a general psychiatric interview at follow-up is a marked limitation. CLINICAL TRIAL REGISTRATION INFORMATION: Nordic Long-term Obsessive compulsive disorder (OCD) Treatment Study; https://www.isrctn.com; ISRCTN66385119.

Family Accommodation in Pediatric Obsessive-Compulsive Disorder: Investigating Prevalence and Clinical Correlates in the NordLOTS Study.

Family accommodation (FA) involves the actions taken by family members, particularly parents, to accommodate a child´s obsessive-compulsive disorder (OCD) symptoms, reducing distress or impairment. This behavior may maintain compulsive and avoidant behavior, preventing corrective learning or habituation. This study aims to investigate the prevalence and factors influencing FA in a large Scandinavian sample of children with OCD. We assessed 238 children using standardized diagnostic interviews, OCD symptom severity assessments and questionnaires evaluating functional impairment and internalizing and externalizing symptoms. FA was measured using the Family Accommodation Scale, a 12-item clinician-rated interview. Our results confirmed a high frequency of accommodation, with approximately 70% of primary caregivers reporting some accommodation daily and 98% at least once per week. FA was associated with increased OCD symptom severity, contamination/cleaning symptoms, internalizing and externalizing behavior, and functional impairment. Linear regression analysis showed that high levels of FA are specifically associated with lower age, higher OCD symptom severity, parent-reported impairment, internalizing, and externalizing symptoms. A path analysis revealed that FA partially mediated the relationship between OCD severity, externalizing symptoms, and child's age, highlighting the role of FA in the progression of OCD and related symptoms. The findings emphasize the importance of evaluating FA before initiating treatment and specifically addressing it during the therapeutic process.

Do Autistic Traits Predict Outcome of Cognitive Behavioral Therapy in Pediatric Obsessive-Compulsive Disorder?

The first aim of this study was to explore whether children with obsessive compulsive disorder (OCD) and subclinical autistic traits can be differentiated from children with OCD without these traits based on clinical OCD-related characteristics, distinct OCD symptom patterns, and type of comorbidity. The second aim was to investigate whether autistic traits predict immediate and long-term outcome of exposure-based cognitive behavioral therapy (CBT) in pediatric OCD.The participants in this study were a total of 257 children and adolescents aged 7-17 years, recruited from Denmark, Norway, and Sweden as a part of the Nordic long-term OCD treatment study (NordLOTS). Inclusion criteria were an OCD diagnosis based on DSM-IV criteria and a Children's Yale-Brown Obsessive-Compulsive Scale (CY-BOCS) total severity score of 16 or higher. No children with a diagnosis on the autism spectrum were included. An Autism Spectrum Screening Questionnaire (ASSQ) cut-off score of ≥ 17 was used to define the group of OCD patients with autistic traits and all participants were treated with 14 weekly sessions of manualized CBT.Comorbid attention-deficit/hyperactivity disorder and tic disorders, subclinical internalizing and externalizing symptoms, lower insight into OCD symptoms, more indecisiveness and pervasive slowness, and ordering/arranging OCD symptoms were found to be significantly associated with having OCD with autistic traits. No difference was found between the groups on treatment outcomes.Results suggest that children and adolescents with OCD and autistic traits portray a different clinical profile than those without these traits, but that CBT is equally effective for those with and without autistic traits.

Long-term functional impairment in pediatric OCD after and during treatment: An analysis of distinct trajectories.

The present study aimed to: (a) identify latent class trajectories of OCD-related functional impairment, before, during and over three years after stepped-care treatment in children and adolescents with OCD; (b) describe these classes according to pretreatment characteristics; (c) identify predictors of trajectory class membership and (d) examine the relationship of functional impairment trajectory classes with OCD symptom severity trajectory classes. The sample consisted of 266 children and adolescents (aged 7-17 years) with OCD, participating in the Nordic long-term OCD treatment study. Latent class growth analysis was conducted using Child Obsessive-Compulsive Impact Scale-Revised (COIS-R) data from children and parents on seven assessment points over a three-year period. A 3-class solution was identified. The largest class (70.7%) initiated treatment with lower functional impairment and obtained moderate reduction which was maintained over time. The second class (24.4%) initiated with higher functional impairment which rapidly diminished over time. The third and smallest class (4.9%), initiated with moderate functional impairment which remained stable over time. The classes differed on measures of OCD severity and comorbid symptoms. Most participants improved with treatment and maintained low levels of impairment. However, a subgroup distinguished by higher levels of ADHD symptoms, remained at pretreatment levels of impairment throughout.

Body Dysmorphic Symptoms in Youth with Obsessive-compulsive Disorder: Prevalence, Clinical Correlates, and Cognitive Behavioral Therapy Outcome.

The aims of the study were to estimate the prevalence of body dysmorphic symptoms in a sample of children and adolescents with obsessive-compulsive disorder, possible clinical correlates and whether BDD symptoms predict poorer treatment outcomes after cognitive behavioral therapy. The study included 269 children and adolescents with OCD, aged 7-17 years, from Denmark, Sweden, and Norway, who were treated with 14 weekly sessions of manualized, exposure-based CBT. Twenty-one patients (7.8%) had BDD symptoms. BDD symptoms were associated with older age (p = 0.003) and a higher prevalence of comorbid anxiety disorders (p = 0.025). In addition, patients with BDD symptoms endorsed a greater number of OCD symptoms than did those without BDD symptoms. Having symptoms of BDD did not affect the CBT outcome on OCD. The results of the study suggest that CBT for OCD is equally effective for those with and without comorbid BDD symptoms.

Efficacy and safety of serotonin reuptake inhibitors (SSRI) and serotonin noradrenaline reuptake inhibitors (SNRI) for children and adolescents with anxiety disorders: a systematic review and meta-analysis.

PURPOSE: To assess the efficacy and safety of selective serotonin reuptake inhibitors (SSRIs) and selective noradrenaline reuptake inhibitors (SNRIs) in comparison with various control contingencies (e.g. pill placebo and cognitive behavioral treatment) for pediatric anxiety disorders. Additionally, we wanted to investigate whether serious adverse events or adverse events are more common with medication treatment compared with pill placebo. MATERIALS AND METHODS: Studies were selected if they were randomized controlled trials evaluating SSRIs or SNRIs. Eligible studies included participants aged 17 years or younger. Eleven studies were included, with 2122 participants. Primary outcomes were (1) remission, (2) a continuous scale such as the Social Phobia and Anxiety Inventory for Children and (3) serious adverse events. We also calculated number needed to treat and number needed to harm. RESULTS: SSRIs and SNRIs are an effective treatment of childhood anxiety disorders and are superior to pill placebo. While the risk of serious adverse events was low with SSRI/SNRI treatment, there was an increased risk of experiencing behavioral activation with SSRI/SNRI treatment. CONCLUSION: SSRI and SNRI treatment is effective for childhood anxiety disorders, with positive effect of treatment outweighing the negative effects.

eCBT Versus Standard Individual CBT for Paediatric Obsessive-Compulsive Disorder.

Obsessive-compulsive disorder (OCD) is characterized by recurring obsessions and compulsions often with severe impairment affecting 1-3% of children and adolescents. Cognitive behavioural therapy (CBT) is the therapeutic golden standard for paediatric OCD. However, face-to-face CBT is limited by accessibility, availability, and quality of delivery. Enhanced CBT (eCBT) a combination of face-to-face sessions at the clinic and treatment at home via webcam and a supportive app system aims to address some of these barriers. In this pilot study, we compared eCBT outcomes of 25 paediatric patients with OCD benchmarked against traditional face-to-face CBT (n = 269) from the Nordic Long-term OCD Treatment Study, the largest paediatric OCD CBT study to date. Pairwise comparisons showed no difference between eCBT and NordLOTS treatment outcomes. Mean estimate difference was 2.5 in favour of eCBT (95% CI - 0.3 to 5.3). eCBT compared to NordLOTS showed no significant differences between response and remission rates, suggesting similar effectiveness.

Specific Contamination Symptoms are Associated with Experiencing a Limited Response of Cognitive-Behavioral Therapy in Pediatric Patients with OCD.

A recent study identified three distinct treatment-response trajectories in pediatric OCD where higher levels of contamination symptoms predicted a limited response to cognitive-behavioral therapy (CBT). This study extends these findings by examining which specific symptoms characterize limited CBT response from baseline to 3-year follow-up, with an emphasis on contamination symptoms. The study sample comprised 269 pediatric patients with OCD, all receiving stepped-care treatment with manualized CBT. Differences in single item-reporting between the three trajectory groups were examined using linear mixed-effect modeling. Limited responders displayed a higher symptom load across all OCD symptom categories at 3-year follow-up, dominated by contamination symptoms. Five of these (obsessions about dirt and germs, about bodily fluids, about the feeling of contamination and compulsions regarding handwashing and showering) showed persistence from baseline to 3-year follow-up. The results indicate that presence of specific contamination symptoms may influence long-term symptom severity trajectories in young patients with OCD.

Age differences in children with obsessive-compulsive disorder: symptoms, comorbidity, severity and impairment.

BACKGROUND: Studies on child and adolescent obsessive-compulsive disorder (OCD) indicate that symptom severity is similar across age, but significant age differences of symptom profile and comorbid disorders have been observed. These earlier studies have yielded mixed results, are methodologically heterogenous and tend to have fairly small sample sizes. The current study examines these differences in one of the largest samples to date and the first sample outside of an English-speaking cultural context. METHODS: We compared children aged 11 years and younger to adolescents aged 12 years and older from the Nordic Long-Term Obsessive-Compulsive Disorder Treatment Study that included 269 children and adolescents with a primary diagnosis of OCD. The two groups were compared on measures of OCD severity, symptom profile, comorbid symptoms, and functional impairment. RESULTS: Results showed that the younger group had a poorer level of insight, higher rates of ADHD, and disruptive disorders. The older group had higher levels of mental compulsions, miscellaneous obsessions and compulsions, and self-rated functional impairment. No differences were found on the prevalence of anxiety, tic or depressive disorders between the age groups, nor on overall OCD severity. CONCLUSION: Overall, differences between the age groups were found to be less than in previous research. Defining groups by age of onset and duration of illness rather than age at evaluation did not change results. Mental health services in Scandinavia are free of cost, making early intervention more accessible, which may reduce subsequent secondary problems and explain these findings.

Internet-based psychotherapy in children with obsessive-compulsive disorder (OCD): protocol of a randomized controlled trial.

BACKGROUND: Obsessive-compulsive disorder (OCD) in children can lead to a huge burden on the concerned patients and their family members. While successful state-of-the art cognitive behavioral interventions exist, there is still a lack of available experts for treatment at home, where most symptoms manifest. Internet-based cognitive behavioral therapy (iCBT) could overcome these restrictions; however, studies about iCBT in children with OCD are rare and mostly target computerized self-help resources and only email contact with the therapist. Therefore, we intended to build up and to evaluate an iCBT approach for children with OCD, replacing successful elements of traditional in-office face-to-face CBT, with face-to-face teleconferences, online materials, and apps. METHODS: With the help of a pilot feasibility study, we developed the iCBT consisting of 14 teleconference sessions with the child and parents. The sessions are supported by an app assessing daily and weekly symptoms and treatment course completed by children and parents. Additionally, we obtain heart rate and activity scores from the child via wristbands during several days and exposure sessions. Using a waiting list randomized control trial design, we aim to treat and analyze 20 children with OCD immediately after a diagnostic session whereas the control group of another set of 20 OCD patients will be treated after waiting period of 16 weeks. We will recruit 30 patients in each group to take account for potential dropouts. Outcomes for the treatment group are evaluated before randomization (baseline, t0), 16 weeks (end of treatment, t1), 32 weeks (follow-up 1, t2), and 48 weeks after randomization (follow-up 2, t3). For the waiting list group, outcomes are measured before the first randomization (baseline), at 16 weeks (waiting list period), 32 weeks (end of treatment), 48 weeks after the first randomization (follow-up I), and 64 weeks after the first randomization (follow-up II). DISCUSSION: Based on our experience of feasibility during the pilot study, we were able to develop the iCBT approach and the current study will investigate treatment effectiveness. Building up an iCBT approach, resembling traditional in-office face-to-face therapy, may ensure the achievement of well-known therapy effect factors, the acceptance in both patients and clinicians, and the wide distribution within the health system. TRIAL REGISTRATION: ClinicalTrials.gov NCT05037344 . Registered May 2019, last release August 13th, 2021.

Systematic Review and Meta-analysis: An Empirical Approach to Defining Treatment Response and Remission in Pediatric Obsessive-Compulsive Disorder.

OBJECTIVE: A lack of universal definitions for response and remission in pediatric obsessive-compulsive disorder (OCD) has hampered the comparability of results across trials. To address this problem, we conducted an individual participant data diagnostic test accuracy meta-analysis to evaluate the discriminative ability of the Children's Yale-Brown Obsessive-Compulsive Scale (CY-BOCS) in determining response and remission. We also aimed to generate empirically derived cutoffs on the CY-BOCS for these outcomes. METHOD: A systematic review of PubMed, PsycINFO, Embase and CENTRAL identified 5,401 references; 42 randomized controlled clinical trials were considered eligible, and 21 provided data for inclusion (N = 1,234). Scores of ≤2 in the Clinical Global Impressions Improvement and Severity scales were chosen to define response and remission, respectively. A 2-stage, random-effects meta-analysis model was established. The area under the curve (AUC) and the Youden Index were computed to indicate the discriminative ability of the CY-BOCS and to guide for the optimal cutoff, respectively. RESULTS: The CY-BOCS had sufficient discriminative ability to determine response (AUC = 0.89) and remission (AUC = 0.92). The optimal cutoff for response was a ≥35% reduction from baseline to posttreatment (sensitivity = 83.9, 95% CI = 83.7-84.1; specificity = 81.7, 95% CI = 81.5-81.9). The optimal cutoff for remission was a posttreatment raw score of ≤12 (sensitivity = 82.0, 95% CI = 81.8-82.2; specificity = 84.6, 95% CI = 84.4-84.8). CONCLUSION: Meta-analysis identified empirically optimal cutoffs on the CY-BOCS to determine response and remission in pediatric OCD randomized controlled clinical trials. Systematic adoption of standardized operational definitions for response and remission will improve comparability across trials for pediatric OCD.

Quality of life in pediatric patients with obsessive-compulsive disorder during and 3 years after stepped-care treatment.

The present study aimed to investigate the long-term quality of life (QoL) in a large sample of pediatric obsessive-compulsive disorder (OCD) patients. The study included 220 pediatric OCD patients from the Nordic Long-term OCD Treatment Study (NordLOTS) who were evaluated at seven time points before, during, and after stepped-care treatment over a 3-year follow-up period. Data from three symptom severity trajectory classes formed the basis of the QoL evaluation: acute (n = 127, N = 147), slow (n = 46, N = 63), and limited responders (n = 47, N = 59). Patients' QoL was assessed using parent and child ratings of the revised Questionnaire for Measuring Health-related Quality of Life in Children and Adolescents (KINDL-R). QoL was analyzed by trajectory class using a random mixed effects model. The association between pre-treatment factors and long-term QoL was investigated across classes in a multivariate model. Three years after treatment, the acute responder class had reached QoL levels from a general population, whereas the limited responder class had not. The slow responder class reached norm levels for the child-rated QoL only. Higher levels of co-occurring externalizing symptoms before treatment were associated with lower parent-rated QoL during follow-up, while adolescence and higher levels of co-occurring internalizing symptoms were associated with lower child-rated QoL during follow-up. For some patients, residual OCD symptoms in the years after treatment, even at levels below assumed clinical significance, are associated with compromised QoL. Co-occurring symptoms could be part of the explanation. Assessing QoL after OCD treatment, beyond the clinician-rated symptom severity, could detect patients in need of further treatment and/or assessment. Trial registry: Nordic Long-term Obsessive-Compulsive Disorder (OCD) Treatment Study; www.controlled-trials.com ; ISRCTN66385119.

Neurochemical properties measured by 1H magnetic resonance spectroscopy may predict cognitive behaviour therapy outcome in paediatric OCD: a pilot study.

To identify neurochemical factors measured pre-treatment that may predict cognitive behavioural treatment (CBT) outcome, aiming at understanding possible causes of poor CBT response. 1H magnetic resonance spectroscopy was used before treatment with CBT in treatment naïve 11-18 year-old patients with moderate-severe OCD. Diagnoses and assessment of OCD severity were based on semi-structured interviews. Linear mixed effects models were used to analyse the association between metabolite level and treatment outcome. Worse CBT outcome was associated with higher concentration of glutamine and glutamate combined (Glx) in middle cingulate cortex (MCC) (F = + 3.35, p = 0.004) and of N-acetylaspartate and N-acetylaspartylglutamate combined (tNAA) (F = + 2.59, p = 0.019). Also, we noted a tendency towards higher thalamic Glx concentration (F = + 1.91, p = 0.077) to be associated with worse CBT outcome. In general, the findings of the current pilot study are compatible with the hypothesis of an overweight of excitatory to inhibitory factors in brain circuits driving goal-directed behaviours (GDB). Higher MCC Glx and tNAA may be involved in the selection of GDB. A more detailed understanding of how these brain areas function in health and illness is needed.

Internet-based cognitive behavioral therapy in children and adolescents with obsessive compulsive disorder: a feasibility study.

Cognitive behavioral therapy (CBT) is the first choice of treatment of obsessive-compulsive disorder (OCD) in children and adolescents. However, there is often a lack of access to appropriate treatment close to the home of the patients. An internet-based CBT via videoconferencing could facilitate access to state-of-the-art treatment even in remote areas. The aim of this study was to investigate feasibility and acceptability of this telemedical approach. A total of nine children received 14 sessions of CBT. The first session took place face-to-face, the remaining 13 sessions via videoconference. OCD symptoms were recorded with a smartphone app and therapy materials were made accessible in a data cloud. We assessed diagnostic data before and after treatment and obtained measures to feasibility, treatment satisfaction and acceptability. Outcomes showed high acceptance and satisfaction on the part of patients with online treatment (89%) and that face-to-face therapy was not preferred over an internet-based approach (67%). The majority of patients and their parents classified the quality of treatment as high. They emphasized the usefulness of exposures with response prevention (E/RP) in triggering situations at home. The app itself was rated as easy to operate and useful. In addition to feasibility, a significant decrease in obsessive-compulsive symptoms was also achieved. Internet-based CBT for pediatric OCD is feasible and well received by the patients and their parents. Furthermore, obsessive-compulsive symptomatology decreased in all patients. The results of this study are encouraging and suggest the significance of further research regarding this technology-supported approach, with a specific focus on efficacy.Trial registration number: Clinical trials AZ53-5400.1-004/44.

Diagnostic efficiency and validity of the DSM-oriented Child Behavior Checklist and Youth Self-Report scales in a clinical sample of Swedish youth.

The Child Behavior Checklist (CBCL) and Youth Self-Report (YSR) are widely used measures of psychiatric symptoms and lately also adapted to the DSM. The incremental validity of adding the scales to each other has not been studied. We validated the DSM subscales for affective, anxiety, attention deficit/hyperactivity (ADHD), oppositional defiant (ODD), conduct problems (CD), and obsessive-compulsive disorder (OCD) in consecutively referred child and adolescent psychiatric outpatients (n = 267) against LEAD DSM-IV diagnoses based on the K-SADS-PL and subsequent clinical work-up. Receiver operating characteristic analyses showed that the diagnostic efficiency for most scales were moderate with an area under the curve (AUC) between 0.70 and 0.90 except for CBCL CD, which had high accuracy (AUC>0.90) in line with previous studies showing the acceptable utility of the CBCL DSM scales and the YSR affective, anxiety, and CD scales, while YSR ODD and OCD had low accuracy (AUC<0.70). The findings mostly reveal incremental validity (using logistic regression analyses) for adding the adolescent to the parent version (or vice versa). Youth and parent ratings contributed equally to predict depression and anxiety disorders, while parent ratings were a stronger predictor for ADHD. However, the youth ADHD rating also contributed. Adding young people as informants for ODD and OCD or adding the parent for CD did not improve accuracy. The findings for depression, anxiety disorders, and ADHD support using more than one informant when conducting screening in a clinical context.

Specialty knowledge and competency standards for pharmacotherapy for pediatric obsessive-compulsive disorder.

Evidence based treatments for pediatric Obsessive-Compulsive Disorder (OCD) are delivered with varying levels of expertise. This paper is part of the phase two series by the International OCD Accreditation Task Force (ATF) to advance a standardized high level of care globally. This paper presents specific knowledge and competencies recommended for specialized practice for pediatric psychopharmacologists working with OCD, developed by an international group of clinicians with extensive expertise in assessment and treatment of OCD. Tabulated knowledge and competency standards are operationalized as clinician abilities with specification of evidence for each standard. The distinction between current practice guidelines and ATF standards is discussed. Drug treatment has a solid evidence base. However, it should not be applied isolated, but informed by broad competence in general child and adolescent psychiatry and pediatrics. Other treatment relevant areas such as specialty CBT, family functioning, developmental issues, and neurobiology require consideration. Drug treatment includes several phases with varying degrees of evidence: Starting up medication, titration to maximum tolerated dose, maintenance, termination, and relapse prevention. In complex cases, pharmacotherapy with weak evidence may be needed to target symptoms and/or co-morbidity. The ATF knowledge and competency standards presented will be reviewed and updated commensurate with research.

Screening efficiency of the Mood and Feelings Questionnaire (MFQ) and Short Mood and Feelings Questionnaire (SMFQ) in Swedish help seeking outpatients.

BACKGROUND: To evaluate screening efficiency and suggest cut-offs for parent and child Mood and Feelings Questionnaire (MFQ) and the short version (SMFQ) in unselected help seeking child- and adolescent psychiatric outpatients for subgroups of 6-12 versus 13-17 year olds and boys versus girls. METHOD: Eligible for inclusion were newly admitted outpatients age 6-17 years (n = 5908) in four Swedish child- and adolescent psychiatry clinics. They were prompted consecutively and n = 307 accepted a specific day for assessment until time slots randomly were filled. We prospectively validated the MFQ (33 items) and SMFQ (13 items) in patients (n = 186) using receiver operating characteristics against a reference test of Longitudinal Expert All Data DSM-IV depression based on a Kiddie-Schedule for Affective Disorders and Schizophrenia and 1.2 (sd .6) years of follow-up. RESULTS: A depressive disorder was confirmed in 59 (31.7%) patients ranging from 14.0% for girls 6-12 years to 53.3% for girls 13-17 years. SMFQ performed roughly equivalent to MFQ. Adolescent score on SMFQ discriminated fairly for boys with Area Under Curve .77 (95% confidence interval .59-.81) and good (.82, .69-.91) for girls and parent ratings for adolescent girls (.85, .73-.93), but not for boys. Depression in children below age 13 could not be discriminated by MFQ or SMFQ whether filled in by child and mostly also when filled in by parent. Favouring maximum kappa value, the optimal cut-off was for MFQ self-report girls ≥32 versus boys ≥11 and for SMFQ self-report girls ≥17 versus boys ≥ 6. Suggested clinical SMFQ cut-offs for girls were ≥12 and for boys ≥ 6. CONCLUSIONS: MFQ and SMFQ can, with gender-based cut-offs, be used for screening in clinical populations of adolescents but not in children. Parent MFQ and SMFQ can be used for adolescent girls but not boys. SMFQ is sufficient for screening.

Treatment Gains Are Sustainable in Pediatric Obsessive-Compulsive Disorder: Three-Year Follow-Up From the NordLOTS.

OBJECTIVE: This study evaluated the long-term outcomes of a stepped care treatment for pediatric obsessive-compulsive disorder (OCD) and investigated whether response to first-step cognitive-behavioral therapy (CBT) is an important indicator of 3-year outcomes. METHOD: This study is a part of the Nordic Long-term OCD Treatment Study (NordLOTS), in which 269 children and adolescents were treated with CBT. Nonresponders to CBT were randomized to extended treatment with continued CBT or pharmacotherapy with sertraline. Children's Yale-Brown Obsessive-Compulsive Scale (CY-BOCS) scores no higher than 15 and no higher than 10 were defined as treatment response and remission, respectively. Participants were assessed 2 and 3 years after first-step CBT. Linear mixed-effects models were used to analyze the outcomes. RESULTS: Intent-to-treat analyses showed a significant decrease in CY-BOCS total score from baseline (24.6) to 3-year follow-up (5.0; p = .001), with a mean decrease of 5.9 from after treatment to 3-year follow-up. Three years after treatment, 90% (n = 242) of participants were rated as responders and 73% were in clinical remission. The duration of treatment did not influence the symptom level at 3-year follow-up (p = .998) and no significant difference was found (p = .169) between the extended treatment conditions. CONCLUSION: The results suggest that evidence-based treatment for pediatric OCD has long-term positive effects, whether a first step of manual-based CBT or extended treatment with CBT or sertraline. The improvements were maintained, and the symptoms decreased further during follow-up and were, after 3 years, similarly independent of treatment duration and form of extended treatment. CLINICAL TRIAL REGISTRATION INFORMATION: Nordic Long-term Obsessive-Compulsive Disorder (OCD) Treatment Study; www.controlled-trials.com; ISRCTN66385119.