Indication and therapy of obsessive-compulsive disorder in children and adolescents

Based on normal developmental phenomena we describe characteristics of obsessive-compulsive disorder in childhood. The functionalities of OCD symptoms are crucial for the treatment planning. According to the functions of symptoms a treatment of OCD symptoms or a treatment of their underlying problems or even a treatment with the family members of the child with OCD is indicated. Finally the peculiarities of OCD treatment with children and adolescents are described.     

Cognitive-behavioral treatment for posttraumatic stress disorder in children and adolescents

Several cognitive-behavioral therapy (CBT) approaches are available for treating child and adolescent posttraumatic stress disorder (PTSD). These treatments include common elements (eg, psychoeducation, gradual exposure, relaxation). This review (1) delineates common elements in CBT approaches for treating child and adolescent PTSD; (2) provides a detailed review of three CBT approaches with substantial evidence of effectiveness; and (3) describes promising practices in the area of CBT approaches to treating child and adolescent PTSD. Cultural and implementation considerations are also included.     

Cognitive-behavioral group therapy for obsessive-compulsive disorder: a 1-year follow-up

OBJECTIVE: The aim of this study was to evaluate the results of cognitive-behavioral group therapy (CBGT) for obsessive-compulsive disorder (OCD) over a 1-year follow-up period. METHOD: Forty-two OCD patients, who completed 12 sessions of CBGT, were followed for 1 year. Measures of the severity of symptoms were obtained at the end of the acute treatment and at 3, 6, and 12 months post-treatment using the Yale-Brown obsessive-compulsive scale (Y-BOCS) and the clinical global impression (CGI). RESULTS: The reduction in the severity of symptoms observed at the end of the treatment was maintained during 1 year (F2,41=1.1; P=0.342). Eleven patients (35.5%) relapsed in the follow-up period. The intensity of improvement (log rank=12.97, GL=1, P=0.0003) and full remission (log rank=6.17; GL=1; P=0.001) were strong predictors for non-relapsing. CONCLUSION: The CBGT is an effective treatment for OCD and its results are maintained for 1 year. However, further long-term randomized controlled trials are needed in order to confirm this finding.     

Treatment of obsessive-compulsive disorder in children and adolescents

The literature on treatment of childhood and adolescent obsessive-compulsive disorder is reviewed. Most studies concerning treatment of obsessive-compulsive disorder has been based on experience from adult patients. Only a few controlled trials using medication with obsessive-compulsive children have been produced. No controlled study has as yet documented the effect of behavioural therapy alone. The most effective treatment seems to be a combination of behavioural therapy and medication with a serotonin reuptake inhibitor. In the treatment of children with OCD, it is important to consider the child's personality and comorbid disorders.     

Cognitive-behavioral therapy for medication nonresponders with obsessive-compulsive disorder: a wait-list-controlled open trial

BACKGROUND: Cognitive-behavioral therapy (CBT) is generally recommended for obsessive-compulsive disorder (OCD) patients who have failed to respond to approved medications. However, few studies of the efficacy of CBT have selected patients who did not respond to medications. METHOD: We selected 20 adult OCD (DSM-IV criteria) patients with a history of inadequate response to adequate doses of multiple medications, as well as a high rate of comorbid disorders. After a 1-month wait-list period, patients received 15 sessions of outpatient CBT incorporating exposure and ritual prevention. RESULTS: OCD severity (as measured with the Yale-Brown Obsessive Compulsive Scale) decreased significantly (p <.05) after treatment, and gains appeared to have been maintained over a 6-month follow-up period. Analysis of clinical significance indicated that 53% (8/15) of treatment completers met this criterion at posttreatment and 40% (6/15) met the criterion at 6-month follow-up. The sample was characterized as having generally poor insight and putting low effort into CBT; these factors significantly (p <.05) predicted degree of improvement. CONCLUSION: CBT is a useful treatment for OCD patients who have failed to respond adequately to multiple serotonin reuptake inhibitor medications. However, these results were attenuated compared with previous trials. Patients with a long history of poor response to medication may have poor insight and/or not put sufficient effort into treatment; these factors are likely to diminish treatment outcome.     

Cognitive-behavioral therapy for obsessive-compulsive disorder: a non-randomized comparison of intensive and weekly approaches

This study examined the relative efficacy of intensive versus weekly cognitive-behavioral therapy (CBT) for adults with obsessive-compulsive disorder (OCD). Sixty-two adults with OCD received either 14 sessions of weekly (n=30) or intensive CBT (n=32; daily psychotherapy sessions) in a non-randomized format. Assessments were conducted at Pre-treatment, Post-treatment, and 3-month Follow-up by raters who were blind to treatment group at the Pre-treatment assessment. Intensive and weekly CBT were similar in efficacy at Post-treatment and Follow-up and associated with large treatment effect sizes. Since many people with OCD do not have access to trained CBT providers, intensive treatment may be a viable option in such cases.     

A review of obsessive-compulsive disorder in children and adolescents

This article is a review of recent literature on obsessive-compulsive disorder in the pediatric population. Areas covered include: a brief historical perspective, clinical presentation in relation to symptoms found in different age groups, epidemiology, psychiatric comorbidity, etiology (with regards to genetics, neuroimaging, and familial factors), clinical course and prognosis, and treatment, with special emphasis on individual and family-based cognitive-behavioral therapy and psychopharmacology.     

Impulse-control disorders in children and adolescents with obsessive-compulsive disorder

The aim of this study was to examine current prevalences, clinical correlates and patterns of co-occurrence of impulse-control disorders (ICDs) in children and adolescents with obsessive-compulsive disorder (OCD). We examined rates and clinical correlates of comorbid ICDs in 70 consecutive child and adolescent subjects with lifetime DSM-IV OCD (32.9% females; mean age = 13.8 ± 2.9 years). Comorbidity data were obtained with structured clinical interviews using DSM-IV criteria. OCD severity was assessed with the Child Yale-Brown Obsessive-Compulsive Scale. All variables were compared in OCD subjects with and without current ICDs. 12 (17.1%) subjects met criteria for a current ICD. Pathological skin picking and compulsive nail biting were the most common ICDs with current rates of 12.8% and 10.0%, respectively. OCD subjects with current ICDs were significantly more likely to have a co-occurring tic disorder (66.7% vs. 20.7%). Although having an ICD was associated with greater numerical scores of OCD symptomatology, these differences were not statistically significant. There were no sex-specific patterns of ICD occurrence in children and adolescents with OCD. Certain ICDs are common among children and adolescents with OCD. Better identification of ICDs in children and adolescents with OCD is needed, as are empirically validated treatments for youth with co-occurring ICDs.     

Cognitive-behavioral therapy for weight management and eating disorders in children and adolescents

Eating disorders and obesity in children and adolescents involve harmful behavior and attitude patterns that infiltrate daily functioning. Cognitive-behavioral therapy (CBT) is well suited to treating these conditions, given the emphasis on breaking negative behavior cycles. This article reviews the current empirically supported treatments and the considerations for youth with weight control issues. New therapeutic modalities (ie, enhanced CBT and the socioecologic model) are discussed. Rationale is provided for extending therapy beyond the individual treatment milieu to include the family, peer network, and community domains to promote behavior change, minimize relapse, and support healthy long-term behavior maintenance.     

Group cognitive-behavioral therapy versus sertraline for the treatment of children and adolescents with obsessive-compulsive disorder

OBJECTIVE: To compare the effectiveness of group cognitive-behavioral therapy (GCBT) and of sertraline in treatment-na?ve children and adolescents with obsessive-compulsive disorder. METHOD: Between 2000 and 2002, 40 subjects between 9 and 17 years old were randomized to receive GCBT (n = 20) or sertraline (n = 20). GCBT consisted of a manual-based 12-week cognitive-behavioral protocol adapted for groups, and treatment with sertraline involved medication intake for 12 weeks. Subjects were assessed before, during, and after treatment (at 1, 3, 6, and 9 months after treatment conclusion). Primary outcome measure was the Children's Yale-Brown Obsessive-Compulsive Scale. Repeated-measures analyses of variance were done. RESULTS: Both GCBT and sertraline conditions had significant improvement in obsessive-compulsive disorder symptoms as measured by the Children's Yale-Brown Obsessive-Compulsive Scale after 12 weeks of treatment. After the 9-month follow-up period, subjects in the GCBT condition had a significantly lower rate of symptom relapse than those in the sertraline group. CONCLUSIONS: The treatment with GCBT may be effective in decreasing obsessive-compulsive symptoms in childhood obsessive-compulsive disorder and should be considered as an alternative to either individual cognitive-behavioral therapy or a medication, such as sertraline. Results support the effectiveness and the maintenance of gains of GCBT in the treatment of youngsters with obsessive-compulsive disorder.     

The epidemiology of obsessive-compulsive disorder in children and adolescents.

Epidemiologic studies show that by late adolescence OCD has a lifetime prevalence of 2% to 3%. The age of onset is earlier in boys than in girls, and has a first peak around puberty and another in early adulthood. The natural course of the disorder is fairly stable, with a complete remission rate of 10% to 15%, although fluctuations in symptom level may make short-term apparent outcome unreliable. Comorbid conditions include depression, movement disorders, and anxiety disorders. Although the prevalence of OC symptoms and of OCD are not different for boys and girls, there may be gender differences in the symptom types. The boundary of the diagnosis of OCD is not always easy to determine, and individuals may meet threshold and subthreshold criteria at different times.     

The effect of fluvoxamine and behavior therapy on children and adolescents with obsessive-compulsive disorder

OBJECTIVE: The efficacy of medications, consisting of serotonin partial and specific reuptake blockers, and behavior therapy, consisting of exposure and response prevention in addition to social skills training, cognitive therapy, and habit reversal, in the treatment of obsessive-compulsive disorder are well documented. The purpose of the study was to explore if adding behavior therapy to medication would enhance treatment efficacy. METHODS: Ten children/adolescents who had not previously responded to behavior therapy were randomly assigned to two groups: fluvoxamine alone or fluvoxamine with behavior therapy. All 10 patients received fluvoxamine for 10 weeks-five continued solely on fluvoxamine for one year and five engaged in behavior therapy for 20 sessions along with fluvoxamine and then continued solely on medication until the end of the year. RESULTS: Eight of 10 patients improved significantly on fluvoxamine at week 10 on the primary outcome variable, the Children's Yale-Brown Obsessive Compulsive Scale (CY-BOCS). According to the other measurements-National Institute of Mental Health-Global Obses-sive-Compulsive Scale, Clinical Global Impression-Improvement (assessing level of im-provement from week to week), and Clinical Global Impression-Severity of Illness Scale (as-sessing how ill the patient is from week to week)-improvement was not as evident. According to the CY-BOCS, those who received a combination of fluvoxamine and exposure with response prevention showed significantly more improvement than those who only took medication. At two-year follow-up, all patients continued to improve, with those in the combined approach improving more than those in the medication-alone group. CONCLUSIONS: Future studies should determine the specific effect of each treatment group, combined and singularly. Reasons for discrepancy in improvement ratings as noted by the different instruments are discussed. The addition of behavior therapy to fluvoxamine seems to enhance treatment efficacy, according to the CY-BOCS.     

Brain SPECT imaging in children and adolescents with obsessive-compulsive disorder

Summary. Objective: To evaluate the patterns of regional cerebral blood flow (rCBF) in cortical and subcortical regions by Brain SPECT imaging, in children and adolescents with obsessive-compulsive disorder (OCD) before and after treatment.Method: Fourteen OCD patients (6 to 17 years old) underwent brain SPECT; ten of those subjects were reexamined after successful treatment. rCBF ratios were correlated with clinical parameters on the 14 patients in symptomatic state, and we compared rCBF ratios of the ten patients before and after treatment.Results: There was no statistically significant difference in average ratios of rCBF before and after treatment. There were significant clinical correlations between current age and age of onset of OCD and rCBF in the bilateral superior frontal, and bilateral parietal cortical regions.Conclusions: Further investigations on abnormal neurodevelopment of cortical-subcortical circuits possibly involved in symptomatology of paediatric OCD are warranted.     

Group behavioral therapy for adolescents with tic-related and non-tic-related obsessive-compulsive disorder

Prior research supports the distinction between tic-related and non-tic-related obsessive-compulsive disorder (OCD) based on phenomenologic, etiologic, and neurobehavioral data. The present study examines whether response to psychosocial treatment differs in adolescents, depending on the presence of comorbid tics. Nineteen adolescents, 12-17 years of age, participated in 7-week, uncontrolled trial of group cognitive-behavioral treatment (CBT) for OCD. Eight of the patients had tic-related and eleven had non-tic-related OCD. The group CBT program included psycho-education, exposure and response prevention, cognitive strategies, and family involvement. Significant improvement was observed for all subjects on the Yale-Brown Obsessive Compulsive Scale ratings of obsessions, compulsions, and total OCD symptoms. Outcomes were similar for subjects with tic-related and non-tic-related OCD. These preliminary results suggest that the presence of comorbid tic disorders may not attenuate response to behavioral group treatment among adolescents.     

Cognitive-behavioral therapy for PANDAS-related obsessive-compulsive disorder: findings from a preliminary waitlist controlled open trial

OBJECTIVE: To provide preliminary estimates of the effectiveness of cognitive-behavioral therapy (CBT) in treating pediatric obsessive-compulsive disorder (OCD) of the pediatric autoimmune neuropsychiatric disorders associated with streptococcus (PANDAS) subtype. METHOD: Seven children with OCD of the PANDAS subtype (range 9-13 years) were treated in a 3-week intensive CBT program conducted at a university clinic. Six of seven children were taking selective serotonin reuptake inhibitor medication(s) upon presentation. Assessments were conducted at four time points: baseline, pretreatment approximately 4 weeks later, posttreatment, and 3-month follow-up. Raters were blind to the nature of the study treatment. RESULTS: Six of seven participants were classified as treatment responders (much or very much improved) at posttreatment, and three of six remained responders at follow-up. Clinician severity ratings, as measured by the Children's Yale-Brown Obsessive-Compulsive Scale and Anxiety Disorder Interview Schedule for DSM-IV Child Interview Schedule-Parent version, decreased significantly following intervention, with effect sizes of 3.38 and 2.29, respectively. Self-reported general anxiety and depression symptoms were not significantly reduced. CONCLUSIONS: This study provides preliminary support for CBT in treating the PANDAS subtype of pediatric OCD. This approach is also considered a safe and minimally invasive treatment approach.     

Cerebrospinal fluid neurochemistry in children and adolescents with obsessive-compulsive disorder.

Cerebrospinal fluid hormones, monoaminergic metabolites, and dynorphin A (1-8 sequence) were examined in 43 children with severe, primary obsessive-compulsive disorder. Cerebrospinal fluid levels of 5-hydroxyindoleacetic acid were positively correlated with one of eight obsessive-compulsive disorder severity ratings and three of seven measures of improvement following 5 weeks of treatment with clomipramine hydrochloride. Arginine vasopressin concentration was significantly and negatively correlated with several ratings of obsessive-compulsive disorder symptom severity, while oxytocin concentration was positively correlated with depressive symptoms. The ratio of arginine vasopressin to oxytocin was also negatively correlated with obsessive-compulsive disorder and depressive symptoms. Comorbid affective disorder was associated with decreased arginine vasopressin concentrations, while concomitant anxiety disorder was associated with increased oxytocin. Dynorphin A (1-8 sequence), homovanillic acid, corticotropin, 3-methoxy-4-hydroxyphenylglycol, and corticotropin releasing hormone were not significantly related to obsessive-compulsive disorder symptoms. These results seem to indicate that arginine vasopressin may be related to obsessive-compulsive disorder symptom severity, while 5-hydroxyindoleacetic acid might be associated with drug response.     

Long-term sertraline treatment of children and adolescents with obsessive-compulsive disorder

OBJECTIVE: To evaluate the safety and effectiveness of sertraline in the long-term treatment of pediatric obsessive-compulsive disorder (OCD). METHOD: Children (6-12 years; n= 72) and adolescents (13-18 years; n = 65) with DSM-III-R-defined OCD who had completed a 12-week, double-blind, placebo-controlled sertraline study were given open-label sertraline 50 to 200 mg/day in this 52-week extension study. Concomitant psychotherapy was allowed during the extension study Outcome was evaluated by the Children's Yale-Brown Obsessive Compulsive Scale (CY-BOCS), National Institute of Mental Health Global Obsessive-Compulsive Scale, and Clinical Global Impression Severity (CGI-S) and Improvement (CGI-I) scores. RESULTS: Significant improvement (p < .0001) was demonstrated on all four outcome parameters on an intent-to-treat analysis for the overall study population (n = 132), as well as the child and the adolescent samples. At endpoint, 72% of children and 61% of adolescents met response criteria (>25% decrease in CY-BOCS and a CGI-I score of 1 or 2). Significant (p < .05) improvements were also demonstrated from the extension study baseline to endpoint on all outcome parameters in those patients who received sertraline during the 12-week, double-blind acute study. Long-term sertraline treatment was well tolerated, and there were no discontinuations due to changes in vital signs, laboratory values, or electrocardiograms. CONCLUSION: Sertraline (50-200 mg/day) was effective and generally well tolerated in the treatment of childhood and adolescent OCD for up to 52 weeks. Improvement was seen with continued treatment.