Watson, C., Purdon, C.

Attention training in the reduction and reappraisal of intrusive thoughts

Attention Training (ATT) is an auditory attention-focusing technique that attempts to reduce the perseverative self-focused processing characteristic of anxiety and mood disorders. The present study investigated the effects of one session of ATT in the reduction and reappraisal of intrusive thoughts in a university sample reporting high levels of obsessive-compulsive symptoms. One-hundred and eight participants identified their most distressing intrusive thought and spent 7 minutes monitoring their stream of consciousness while recording occurrences of the identified thought. They then rated the unpleasantness of the intrusive thought, their attempts to dismiss the thought from consciousness, and their perceived success in reducing the frequency of the thought. Participants were then randomly assigned to receive one session of ATT, thought replacement instructions (TR), distraction instructions (DI), or no intervention (CONT). Participants then repeated the thought monitoring interval and ratings. ATT was expected to be the most effective in decreasing the frequency and unpleasantness of intrusive thoughts. However, contrary to hypotheses, all groups reported similar decreases across intervals. Implications of these findings are discussed. copyright 2007 British Association for Behavioural and Cognitive Psychotherapies.

Behavioural & Cognitive Psychotherapy., 36(1) : 61-70

Freeman, Jennifer B., Choate-Summers, Molly L., Moore, Phoebe S., Garcia, Abbe M., Sapyta, Jeffrey J., Leonard, Henrietta L., Franklin, Martin E.

Cognitive behavioral treatment for young children with obsessive-compulsive disorder

Obsessive-compulsive disorder (OCD) is a distressing and functionally impairing disorder that can emerge as early as age 4. Cognitive behavior therapy (CBT) for OCD in youth shows great promise for amelioration of symptoms and associated functional impairment. However, the empirical evidence base for the efficacy of CBT in youth has some significant limitations, particularly as related to treating the very young child with OCD. This report includes a quantitative review of existing child CBT studies to evaluate evidence for the efficacy of CBT for OCD. It identifies gaps in the literature that, when addressed, would enhance the understanding of effective treatment in pediatric OCD. Finally, it presents a proposed research agenda for addressing the unique concerns of the young child with OCD. [References: 68]

Biological Psychiatry, 61(3) : 337-43

Storch, Eric A., Geffken, Gary R., Merlo, Lisa J., Mann, Giselle, Duke, Danny, Munson, Melissa, Adkins, Jennifer, Grabill, Kristen M., Murphy, Tanya K., Goodman, Wayne K.

Family-based cognitive- behavioral therapy for pediatric obsessive-compulsive disorder: comparison of intensive and weekly approaches.[see comment]

OBJECTIVE: To examine the relative efficacy of intensive versus weekly cognitive-behavioral therapy (CBT) for children and adolescents with obsessive-compulsive disorder (OCD). METHOD: Forty children and adolescents with OCD (range 7-17 years) were randomized to receive 14 sessions of weekly or intensive (daily psychotherapy sessions) family-based CBT. Assessments were conducted at three time points: pretreatment, posttreatment, and 3-month follow-up. Raters were initially blind to randomization. Primary outcomes included scores on the Children's Yale-Brown Obsessive- Compulsive Scale, remission status, and ratings on the Clinical Global Impression-Severity and Clinical Global Improvement scales. Secondary outcomes included the Child Obsessive Compulsive Impact Scale-Parent Rated, Children's Depression Inventory, Multidimensional Anxiety Scale for Children, and Family Accommodation Scale. Adjunctive pharmacotherapy was not an exclusion criterion. RESULTS: Intensive CBT was as effective as weekly treatment with some advantages present immediately after treatment. No group differences were found at follow-up, with gains being largely maintained over time. Although no group x time interaction was found for the Children's Yale-Brown Obsessive-Compulsive Scale (F(1,38) = 2.2, p = .15), the intensive group was rated on the Clinical Global Impression-Severity as less ill relative to the weekly group (F(1,38) = 9.4, p < .005). At posttreatment, 75% (15/20) of youths in the intensive group and 50% (10/20) in the weekly group met remission status criteria. Ninety percent (18/20) of youths in the intensive group and 65% (13/20) in the weekly group were considered treatment responders on the Clinical Global Improvement (chi1(2) = 3.6, p = .06). CONCLUSIONS: Both intensive and weekly CBT are efficacious treatments for pediatric OCD. Intensive treatment may have slight immediate advantages over weekly CBT, although both modalities have similar outcomes at 3-month follow-up.

Journal of the American Academy of Child & Adolescent Psychiatry, 46(4) : 469-78

O'Kearney, R.

Benefits of cognitive-behavioural therapy for children and youth with obsessive-compulsive disorder: Re- examination of the evidence

The aim of the present paper was to critically examine evidence about the benefits of cognitive-behavioural therapy (CBT) for pediatric obsessive-compulsive disorder (OCD) from controlled and single group studies, including its benefits relative to medication are critically reviewed. Selected studies were categorized by study type and by risk of bias classification. Standardized mean differences (Hedges' g or Cohen d) and, where appropriate, weighted mean difference (WMD) were calculated. All five comparison and 14 one-group studies showed a significant benefit for CBT within a wide range (ES = .78 to 4.38). Low risk of bias studies produced the lower adjusted effect sizes. The best available estimate of CBT efficacy relative to no treatment is about 1 standardized mean difference, equivalent to a treatment effect of 8 points on the Children's Yale-Brown Obsessive-Compulsive Scale. This represents a reduction in the risk of continuing to have OCD post-treatment of about 37% (95% CI 14% to 54%). Evidence from 3 studies indicates that the efficacy of CBT and medication do not differ significantly. CBT combined with medication is significantly more efficacious than non-active controls or medication alone but not relative to CBT alone. CBT should be regarded as a first line equivalent to anti-OCD medication with the potential to lead to better outcomes when combined with medication than medication alone can provide. Additional studies are needed to further clarify CBT's benefits and to investigate how it can be made more available as a treatment option for children and youth who suffer from OCD.

Australian & New Zealand Journal of Psychiatry., 41(3) : 199- 212

O'Kearney, RT., Anstey, K., von-Sanden, C., Hunt, A.

Behavioural and cognitive behavioural therapy for obsessive compulsive disorder in children and adolescents

Background: This is an update of a Cochrane Review first published in The Cochrane Library in Issue 4, 2006.Obsessive-compulsive disorder (OCD) in children and adolescents is characterised by persistent intrusive thoughts, inappropriate impulses or images which cause marked anxiety, and/or by persistent repetitive behaviours such as hand washing, checking and ordering. Along with antidepressant medication, behavioural or cognitive-behavioural therapy (BT/CBT) is recommended as the treatment of choice for paediatric obsessive-compulsive disorder (OCD).Objectives: This review examines the overall efficacy of BT/CBT for paediatric OCD, its relative efficacy against medication and whether there are benefits in using BT/CBT combined with medication.Search methods: We searched CCDANCTR-Studies,CCDANCTR-References (16/3/2009), MEDLINE, EMBASE, PsycINFO, national trials registers, reference lists of all selected studies and handsearched journals related to cognitive behavioural treatment of OCD.Selection criteria: Included studies were randomised or quasi-randomised controlled trials trials with participants 18 years of age or younger with a diagnosis of OCD, established by clinical assessment or standardised diagnostic interview. Reviewed studies included standard behavioural or cognitive- behavioural techniques, either alone or in combination, compared with wait-list, attention placebo, pill placebo or medication.Data collection and analysis: The quality of selected studies was assessed independently by two review authors. Using Review Manager software, weighted mean differences were calculated for the total severity of OCD symptoms at post treatment and relative risks for having OCD at post treatment.Main results: Eight studies with 343 participants were included. The review found evidence for lower post-treatment OCD severity and reduced risk of continuing with OCD for the BT/CBT group compared to pill placebo or wait-list comparisons. There was no evidence found that the efficacy of BT/CBT alone and medication alone differ in terms of post treatment symptom severity or in the risk of having OCD. There was some evidence of a benefit for combined BT/CBT and medication compared to medication alone but not relative to BT/CBT alone. The low rates of drop out suggested BT/CBT is an acceptable treatment to child and adolescent patients and their families.Authors' conclusions: Although only based on a small number of studies which vary in quality, behavioural or cognitive-behaviour therapy alone appears to be an effective treatment for OCD in children and adolescents. It is as effective as medication alone and may lead to better outcomes when combined with medication compared to medication alone. Additional higher quality trials are needed to confirm these findings.

Cochrane Database of Systematic Reviews, (4) :

Simons, Michael, Schneider, Silvia, Herpertz-Dahlmann, Beate

Metacognitive therapy versus exposure and response prevention for pediatric obsessive-compulsive disorder

Background: Exposure with ritual prevention (ERP) is the psychotherapeutic treatment of choice for pediatric obsessive-compulsive disorder (OCD). In the present study, a new treatment rationale - metacognitive therapy (MCT) for children - was developed and evaluated. Methods: Ten children and adolescents with OCD were randomly assigned to either MCT or ERP therapy condition. Patients were assessed before and after treatment and at the 3-month and 2-year follow-up by means of symptom severity interviews. Depressive symptoms were also assessed. Manualized treatment involved up to 20 sessions on a weekly basis. Results: We found clinically and statistically significant improvements in symptom severity after treatment. At the 3-month and 2-year follow-up, the attained improvements during treatment were retained. Conclusions: Despite some methodological limitations, results showed that MCT proved to be a promising psychotherapeutic alternative to the well-established ERP in the treatment of pediatric OCD. Further investigations into the efficacy of MCT are necessary to answer questions as to the working mechanisms underlying therapy for OCD. (PsycINFO Database Record (c) 2008 APA, all rights reserved) (journal abstract).

Psychotherapy & Psychosomatics, 75(4) : 257-264

Abramowitz, Jonathan S., Whiteside, Stephen P., Deacon, Brett J.

The effectiveness of treatment for pediatric obsessive-compulsive disorder: A meta- analysis

The last decade has seen a noticeable increase in the number of treatment outcome studies for pediatric obsessive-compulsive disorder (OCD). The present article describes a meta-analysis of this literature with the aim of quantifying treatment effects and examining the extent to which various patient or treatment variables are related to outcome. Results showed that pharmacotherapy with serotonergic antidepressants and cognitive-behavioral therapy involving exposure and response prevention are each effective in reducing OCD symptoms. Cognitive-behavioral therapy produced larger effect sizes and greater rates of clinically significant improvement compared to medication, although there were methodological differences between medication and psychotherapy studies. (PsycINFO Database Record (c) 2008 APA, all rights reserved) (journal abstract).

Behavior Therapy, 36(1) : 55-63

Asbahr, Fernando Ramos, Castillo, Ana Regina, Ito, Ligia Montenegro, Latorre, Maria Rosario Dias de Oliveira, Moreira, Michele Nunes, Lotufo-Neto, Francisco

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-naive 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.

Journal of the American Academy of Child & Adolescent Psychiatry, 44(11) : 1128 -36

Pediatric, OCD

Cognitive-behavior therapy, sertraline, and their combination for children and adolescents with obsessive-compulsive disorder: the Pediatric OCD Treatment Study (POTS) randomized controlled trial

JAMA, 292(16) : 1969

Geller, Daniel A., Biederman, Joseph, Stewart, S. Evelyn, Mullin, Benjamin, Martin, Andres, Spencer, Thomas, Faraone, Stephen V.

Which SSRI? A meta-analysis of pharmacotherapy trials in pediatric obsessive- compulsive disorder.[see comment]

OBJECTIVE: The authors conducted a meta-analysis of published randomized, controlled medication trials in children and adolescents with obsessive-compulsive disorder (OCD) to assess evidence for differential efficacy based on type of drug, study design, and outcome measure. METHOD: A systematic literature search was performed for articles pertaining to the pharmacological treatment of pediatric and/or adolescent OCD. All baseline, posttreatment, and change scores with standard deviations reported in each study were included in the analyses. Effect sizes for dependent measures were expressed as standardized mean differences. The analysis included data on efficacy for four selective serotonin reuptake inhibitors (SSRIs) (paroxetine, fluoxetine, fluvoxamine, and sertraline) and clomipramine, four study designs, four dependent outcome measures, and two types of outcome scores (change and posttreatment scores). Multivariate regression was performed to assess the degree to which the effect sizes varied with the methodological features of each study. RESULTS: Twelve studies with a total of 1,044 participants met all inclusion criteria for the analysis. The pooled standardized mean difference for the results of all studies was 0.46 and showed a highly significant difference between drug and placebo treatment. Only one of the four outcome measures evaluated was not sensitive to change with treatment. A multivariate regression analysis of drug effect with other variables controlled showed that clomipramine was significantly superior to each of the SSRIs but that the SSRIs were comparably effective. CONCLUSIONS: Although highly significant, the overall effect sizes for medication were modest. Similarities and differences between the variables studied that emerged in the meta-analysis may have implications for both clinical care and future research.

American Journal of Psychiatry, 160(11) : 1919- 28

Liebowitz, Michael R., Turner, Samuel M., Piacentini, John, Beidel, Deborah C., Clarvit, Susan R., Davies, Sharon O., Graae, Flemming, Jaffer, Margaret, Lin, Shu-Hsing, Sallee, Floyd R., Schmidt, Andrew B., Simpson, H.

Fluoxetine in children and adolescents with OCD: A placebo-controlled trial

Examined the safety and efficacy of fluoxetine in child and adolescent obsessive-compulsive disorder (OCD). Between 1991 and 1998, 43 patients (aged 6-18 years) were randomly assigned to fluoxetine or placebo for 8 weeks. Dosing was fixed for the first 6 weeks (up to 60 mg/day) and then could be increased to 80 mg/day. Responders entered an 8-week maintenance phase. The primary outcome measures were the Children's Yale-Brown Obsessive Compulsive Scale (CY-BOCS) and the Clinical Global Impression-Improvement (CGI-I) scale. Analyses were done on the intent-to-treat sample. Fluoxetine patients (n=21) had significantly lower CY-BOCS scores than placebo patients (n=22) after 16 (but not 8) weeks. Fluoxetine responders (n=11) had significantly lower CY-BOCS scores than placebo responders (n=7) after an additional 8 weeks of treatment. After 16 weeks, 57% of fluoxetine (versus 27% of placebo) patients were much or very much improved on the CGI-I scale (p<.05). No patient terminated the study because of adverse medication effects. It is concluded that fluoxetine was well tolerated and effective for the treatment of child and adolescent OCD, but fluoxetine's full effect took more than 8 weeks to develop. (PsycINFO Database Record (c) 2008 APA, all rights reserved).

Journal of the American Academy of Child & Adolescent Psychiatry, 41(12) : 1431-1438

Geller, D. A., Hoog, S. L., Heiligenstein, J. H., Ricardi, R. K., Tamura, R., Kluszynski, S., Jacobson, J. G., FluoxetinePediatricOCDStudyTeam

Fluoxetine treatment for obsessive-compulsive disorder in children and adolescents: a placebo-controlled clinical trial.[see comment]

OBJECTIVE: This study assesses the efficacy and tolerability of fluoxetine in the acute treatment of child and adolescent obsessive-compulsive disorder (OCD) during a 13-week, double-blind, placebo-controlled study. METHOD: Eligible patients aged 7 to 17 (N = 103) were randomized at a ratio of 2:1 to receive either fluoxetine or placebo. Dosing was initiated at 10 mg daily for 2 weeks, then increased to 20 mg daily. After 4 weeks of treatment, and again after 7 weeks of treatment, non-responders could have their dosage increased by 20 mg daily, for a maximum possible dosage of 60 mg daily. Primary measure of efficacy was improvement in OCD symptoms as measured by the Children's Yale-Brown Obsessive Compulsive Scale (CY-BOCS). All analyses were intent-to-treat. RESULTS: Fluoxetine was associated with significantly greater improvement in OCD as assessed by the CY-BOCS (p = .026) and other measures than was placebo. Fluoxetine was well tolerated and had a rate of discontinuation for adverse events similar to that of placebo (p = 1.00). CONCLUSIONS: Fluoxetine 20 to 60 mg daily was effective and well tolerated for treatment of OCD in this pediatric population.

Journal of the American Academy of Child & Adolescent Psychiatry, 40(7) : 773- 9