Optimizing Cognitive-Behaviorial Therapy for Childhood Psychiatric Disorders

ObjectiveThe pathophysiology of attention-deficit/hyperactivity disorder (ADHD) is complicated by high rates of psychiatric comorbidities; thus, delineating unique vs shared functional brain perturbations is critical in elucidating illness pathophysiology. We investigated resting-state functional magnetic resonance imaging (rsfMRI)–complexity alterations among children with ADHD, oppositional defiant disorder (ODD), and obsessive-compulsive disorder (OCD), respectively, and comorbid ADHD, ODD, and OCD, within the cool and hot executive function (EF) networks.MethodWe leveraged baseline data from 9- to 10-year-old children in the Adolescent Brain and Cognitive Development (ABCD) Study. Data for children who singularly met all DSM-5 behavioral criteria for ADHD (n = 61), ODD (n = 38), and OCD (n = 48), respectively, were extracted, alongside data for children with comorbid ADHD, ODD, OCD, and/or other psychiatric diagnoses (n = 833). Data for a control sample of age-, sex-, and developmentally matched children were also extracted (N = 269). Voxel-wise sample entropy (SampEn) was computed using the LOFT Complexity Toolbox. Mean SampEn within all regions of interest (ROIs) of the EF networks was calculated for each participant. Hierarchical models with generalized estimating equations compared SampEn of comorbidity-free and comorbid ADHD, ODD, and OCD within the EF networks.ResultsSampEn was reduced in comorbidity-free ADHD and ODD in overlapping regions of both EF networks compared with the healthy controls, including the bilateral superior frontal gyrus, anterior/posterior cingulate gyrus, and bilateral caudate (Wald statistic = 5.682-10.798, p < .05, and Benjamini–Hochberg [BH] corrected), with ADHD additionally affected in the right inferior/middle frontal gyrus and bilateral frontal orbital cortex (Wald statistic = 7.231-9.420, p < 0.05, and BH corrected). Among comorbid presentations, the presence of ADHD symptomatology was associated with significantly lower SampEn in every ROI (z = −3.973 to −2.235, p < .05, and BH corrected).ConclusionADHD and ODD shared common impairments underlying the EF networks in the comorbidity-free presentations, with ADHD showing more widespread complexity reduction. When ADHD co-occurred with other psychiatric disorders, the reduction in SampEn extended beyond the regions affected in comorbidity-free ADHD, indicating that comorbidities amplify neural complexity deficits. In contrast, no significant SampEn alterations were observed in OCD, whether presented alone or in combination with ADHD.

Obsessive-Compulsive Disorder and Tourette's Disorder: Where Are We Now?

Obsessive-compulsive disorder (OCD) is common in children with rates of 1% to 4% in children and adolescents. A prominent first-line treatment for pediatric OCD is cognitive-behavioral therapy (CBT) using exposure and response prevention (ERP). However, it has also been suggested that family therapy be used as an adjunct treatment in pediatric OCD cases, as family members often accommodate or contribute to the maintenance of OCD symptoms. The following case study reviews the successful treatment of a 7-year-old with comorbid OCD and oppositional defiant disorder, in which traditional CBT and ERP for OCD was integrated with family-based approaches utilizing a family systems theory framework.

Clinical expression and treatment response among children with comorbid obsessive compulsive disorder and attention-deficit/hyperactivity disorder

Patients with Gilles de la Tourette syndrome have widespread personality differences

ABSTRACTObjectives: To investigate the prevalence of attention deficit hyperactivity disorder (ADHD) and obsessive-compulsive disorder (OCD) symptoms in adult patients with primary restless legs syndrome (RLS) and to determine the iron biological correlates of these comorbidities. Participants and Methods: We obtained demographic and clinical data from consecutive 105 outpatients with idiopathic RLS who answered validated questionnaires designed to assess the presence of ADHD and OCD symptoms. In these patients, iron blood parameters were routinely checked. Results: Of the total sample, 42.86% of the patients with RLS showed symptoms reminiscent either of ADHD or OCD. Prevalence of ADHD and OCD symptoms was 27.62% and 7.62%, respectively. Compared to other groups, a significantly higher percentage of RLS patients with ADHD symptoms was on antidepressant (p = 0.012); and women with ADHD symptoms, either alone or combined with OCD symptoms, showed significant reduced ferritin concentrations compared to men with either isolated ADHD symptoms or with combined ADHD and OCD symptoms (p = 0.028 and p = 0.025, respectively). Conclusions: Our findings highlight the high prevalence of ADHD and OCD symptoms in adult patients with primary RLS and independently of serum iron stores decrease, except for women with ADHD symptoms either alone or in combination with OCD symptoms. This may suggest an overlapping neurobiological dopaminergic and serotoninergic dysfunction in ADHD, OCD, and RLS, and question the expression of different RLS phenotypes. The efficacy of dopamine agonists in these groups of patients should be questioned in future studies.

Tourette syndrome (TS) is characterized by the presence of vocal and motor tics with an onset in childhood. In almost 80% of patients psychiatric comorbidities coexist, particularly, attention deficit/hyperactivity disorder (ADHD), obsessive-compulsive disorder (OCD) or behavior (OCB), depression, anxiety, rage attacks, and self-injurious behaviour (SIB). In this review, we discuss current state of the art regarding diagnosis and assessment of tics and OCD in patients with TS as well as challenges related to differential diagnosis between tics and OCD-related phenomena based on a systematic literature search. While in most cases clinical symptoms can be easily classified as either tics or OCB/OCD, some phenomena lay on the frontier between tics and compulsions/obsessions. For example, compulsions may resemble tics and, vice versa, sequences of motor tics may be misdiagnosed as compulsions. Accordingly, the terms “compulsive tics” and “cognitive tics” have been introduced. The most common and typical OCD symptom in patients with TS are “just right” phenomena, which also may show an overlap with tics, since patients may perform tics repeatedly until this feeling is achieved. Similarly, repetitive behaviors in patients with TS may manifest in a more “tic-like” or a more “OCD-like” type. Furthermore, SIB shows similarities with both tics and OCD. Until today, it is unclear how to classify this symptom best, although from most recent research a closer relationship between SIB and tics is suggested. In this review, in addition, we illustrate differences of the clinical spectrum of OCD in patients with TS compared to those with “pure OCD” without tics. To assess tics, the revised version of the Yale Global Tic Severity Scale (YGTSS-R) should be used, while for the assessment of OCD, the Yale Brown Obsessive Compulsive Disorder Scale (Y-BOCS) is recommended. Finally, we briefly summarize treatment strategies for tics and OCB/OCD in patients with TS.

Obsessive-Compulsive Disorder (OCD) comorbid with Recurrent Depressive Disorder is a complex clinical combination and often worsens the patient's psychological well-being. Cognitive Behavioral Therapy (CBT) has been shown to be effective in treating OCD, but its application to patients with comorbid Recurrent Depressive Disorder requires a more integrated approach. This study explores the effectiveness of CBT in treating cases of OCD comorbid with Recurrent Depressive Disorder, with a focus on interventions specifically designed to address both disorders simultaneously. Through a CBT approach that includes techniques such as exposure and response prevention, as well as cognitive management of negative thought patterns associated with depression, this therapy aims to significantly reduce the symptoms of OCD and Recurrent Depressive Disorder. The results of this case report show that CBT is not only effective in reducing obsessive-compulsive symptoms, but also improves mood and depressive affect in patients. This case report also highlights the importance of adapting CBT techniques to address the dynamics of these dual disorders, as well as the need for an approach that is holistic and focuses on the integration of cognitive and behavioral techniques for optimal outcomes. These findings support the use of CBT as a therapeutic method in the management of patients with comorbid OCD and Recurrent Depressive Disorder, and pave the way for further management of similar cases in the development of more effective therapeutic strategies. ABSTRAKGangguan Obsesif-Kompulsif (OCD) berkomorbid dengan Gangguan Depresif Berulang merupakan kombinasi klinis yang kompleks dan sering kali memperburuk kesejahteraan psikologis pasien. Terapi Perilaku Kognitif (CBT) telah terbukti efektif dalam mengatasi OCD, tetapi penerapannya pada pasien dengan komorbiditas Gangguan Depresif Berulang memerlukan pendekatan yang lebih terintegrasi. Studi ini mengeksplorasi efektivitas CBT dalam menangani kasus OCD yang berkomorbid dengan Gangguan Depresif Berulang, dengan fokus pada intervensi yang dirancang khusus untuk mengatasi kedua gangguan secara bersamaan. Melalui pendekatan CBT yang mencakup teknik seperti paparan dan respons pencegahan, serta pengelolaan kognitif terhadap pola pikir negatif yang terkait dengan depresi, terapi ini bertujuan untuk mengurangi gejala OCD dan Gangguan Depresif Berulang secara signifikan. Hasil laporan kasus ini menunjukkan bahwa CBT tidak hanya efektif dalam mengurangi gejala obsesif-kompulsif, tetapi juga memperbaiki mood dan afek depresif pada pasien. Laporan kasus ini juga menyoroti pentingnya penyesuaian teknik CBT untuk menangani dinamika gangguan ganda ini, serta perlunya pendekatan yang holistik dan berfokus pada integrasi teknik kognitif dan perilaku untuk hasil yang optimal. Temuan ini mendukung penggunaan CBT sebagai metode terapi dalam manajemen pasien dengan OCD dan Gangguan Depresif Berulang yang berkomorbid, serta membuka jalan bagi penatalaksaan kasus serupa lebih lanjut dalam pengembangan strategi terapeutik yang lebih efektif.

Intervention cost-effectiveness for pediatric anxiety and OCD: A systematic review and integrated database model

Aggressive behaviour, defined as sudden, explosive outbursts of rage, has been reported as a clinical problem in approximately 23% to 40% of Tourette syndrome (TS) patients (1-5). Attention-deficit hyperactivity disorder (ADHD) and obsessive-compulsive disorder (OCD) are also reported in 50% to 70% of TS patients (6). To investigate whether aggressive behaviour was associated with TS directly or found primarily in TS with comorbid ADHD or OCD. Aggressive behaviour in 33 nonmedicated patients with TS (ages 6 to 14 years) and 6 healthy control subjects (ages 7 to 12 years) was examined by semistructured interview and multiinformant questionnaires. Aggression subscales on Achenbach's Child Behavior Checklist (CBCL) completed by parents and Teacher's Report Form (TRF) completed by teachers distinguished the TS-only and control groups from the group with TS + Comorbidity (P < 0.046, and P < 0.016) after adjusting for tic severity and age. The conduct disorder subscale on the Conners Parent Rating Scale (CPRS) was also significantly higher (P < 0.005) in the TS + comorbidity group than in the TS-only or control groups, with more problems reported in the older children. These findings provide additional evidence that aggressive behaviour observed in children with TS may be associated with comorbid ADHD or OCD (6), independent of tic severity or age. This is consistent with the clinical observation that most TS patients have only minimal symptoms, which do not interfere with their daily functioning.

Quality of life (QoL) is a well-established outcome measure. In contrast to adult obsessive-compulsive disorder (OCD), little is known about the effects of treatment on QoL in children with OCD. This study aimed to assess QoL after cognitive behavioural therapy (CBT) in children and adolescents with OCD compared with the general population and to explore factors associated with potential changes in QoL after treatment. QoL was assessed in 135 children and adolescents (ages 7-17; mean 13 [SD 2.7] years; 48.1% female) before and after 14 CBT sessions, using self-report and a caregivers proxy report of the Questionnaire for Measuring Health-related Quality of Life in Children and Adolescents (KINDL-R). QoL was compared with an age- and gender-matched sample from the general population. Before treatment, QoL was markedly lower in children with OCD compared with the general population. QoL improved significantly in CBT responders (mean score change 7.4), to the same range as QoL in the general population. Non-responders reported no QoL changes after treatment, except for one patient. Comorbidity, family accommodation and psychosocial functioning were not associated with changes in QoL after treatment. To our knowledge, this is the first study of the changes in QoL after treatment of paediatric OCD. The assessment of QoL beyond symptoms and function in children with OCD has been shown to be reliable and informative. The results of this study support the application of QoL assessment as an additional measure of treatment outcome in children and adolescents with OCD.

The relationship between Obsessive Compulsive Disorder (OCD) and Obsessive Compulsive Personality Disorder (OCPD) has been the subject of interest for some time due to the historical assumption that OCPD causes OCD. This study systematically examined the association between OCD and OCPD in terms of prevalence and clinical presentation. The specificity of the association between OCD and OCPD was investigated relative to another axis I anxiety disorder (Panic disorder). Data for this study were drawn from measures taken at initial assessment at a specialist treatment centre for anxiety disorders. Of the 359 participants included in this study, 189 had a principal diagnosis of OCD, while 170 had a principal diagnosis of Panic disorder. Measures included SCID I and II interview modules and self-report measures of anxiety, depression, and OCD syptomatology. Significantly elevated rates of OCPD were found in OCD relative to Panic disorder. Regardless of axis I disorder, individuals with comorbid OCPD reported more severe depression relative to those without. Participants with both OCD and OCPD had greater self-reported OCD symptom severity, doubting, ordering, and hoarding symptoms at assessment relative to those without OCPD. Participants with OCD and comorbid OCPD also reported significantly higher levels of alcohol consumption. There appears to be a significant and specific association between OCD and OCPD. Co-occurring OCD and OCPD is associated with greater severity of impairment in terms of certain OCD symptoms. The significant and specific association between OCD and OCPD suggests that OCPD occurs more frequently with OCD than previously suggested. A comorbid OCPD diagnosis is associated with a greater degree of depression, regardless of axis I disorder, either OCD or Panic disorder. This is an important consideration, as depression can interfere with therapeutic progress (Foa, 1979). Participants with OCD and OCPD had greater self-reported OCD severity, along with doubting, ordering, and hoarding symptoms, relative to those without OCPD. In clinical practice, where OCD symptoms are severe, and the primary OCD symptoms include doubting, ordering, and hoarding, this may indicate a need to assess for comorbid OCPD. This may be useful in terms of including relevant information in formulation with the patient, and in addressing these issues in treatment. There may have been a sampling issue, as the study compared patients from a specialist clinic for the treatment of OCD and Panic disorder. Furthermore, OCD referrals were primary, secondary, or tertiary, whereas Panic disorder referrals were primary or secondary from the immediate catchment area only. This suggests the possibility of greater severity of the OCD sample relative to Panic disorder patients. All participants who met criteria for OCD were assessed for OCPD regardless of whether or not this was indicated by the SCID II screener self-report measure, while participants with Panic disorder were interviewed for OCPD only if indicated by the SCID-II screener. Had participants with Panic disorder been assessed for OCPD regardless of whether or not this was indicated by the SCID-II screener, there is a possibility that a higher rate of OCPD in the Panic disorder sample may have been found.

O1-E-25. The effect of obsessive compulsive disorder on saccade performance in Gilles de la Tourette (GTS) syndrome

Rates for tic disorders and obsessive compulsive symptomatology in families of children and adolescents with Gilles de la Tourette syndrome

Pediatric obsessive-compulsive disorder (OCD) is a severely impairing disorder, associated with high levels of family accommodation (FA). Approximately 40% of youth do not benefit from first-line treatment options (cognitive behavioral therapy or pharmacotherapy). Supportive Parenting for Anxious Childhood Emotions (SPACE) is a parent-based treatment, teaching parents to reduce FA and increase supportive parenting, thereby aiming to improve the child's OCD. This article presents the protocol of a multiple baseline single-case experimental design (SCED) study to test the efficacy of SPACE in reducing OCD severity and FA in youth with OCD. This SCED consists of a baseline, treatment, and follow-up phase. In total 25 youth (7-18 years) with OCD, who previously received cognitive behavioral therapy (CBT) unsuccessfully, aborted treatment early, or were not able to receive CBT due to too high levels of OCD/anxiety, and their parents will be included. They will be randomly allocated to one of three baseline phase options (4, 6 or 8 weeks). The treatment phase consists of 12 weekly sessions of SPACE with parents. Throughout all phases, OCD severity and FA will be briefly assessed thrice a week. Standard clinical measurements assessing OCD severity and FA and secondary parameters will be conducted at six timepoints, till 6 months follow-up. Combining the innovative SPACE treatment with a SCED provides detailed insight into the relationship between OCD and FA over time. Studying this in clinical practice in complex cases that are normally understudied, helps to improve more personalized care for youth with OCD.