The Society for Clinical Child and Adolescent Psychology (SCCAP): Initiative for Dissemination of Evidence-based Treatments for Childhood and Adolescent Mental Health Problems

With additional support from Florida International University and The Children’s Trust. Keynote Evidence-based Treatment of Obsessive Compulsive Disorder in Children and Adolescents

John Piacentini, Ph.D., ABPP Child OCD, Anxiety, and Tic Disorders Program UCLA Semel Institute for Neuroscience and Human Behavior Disclosure

Royalties for Treatment Manual and Child Workbook from Oxford University Press OCD Diagnostic Criteria

OBSESSIONS • Unwanted, repetitive, intrusive thoughts, impulses, images • Cause marked distress • Not simply excess worries about everyday topics • Individual attempts to ignore, neutralize or suppress • Usually recognized as product of one’s own mind

Obsessions – Adult

I just know I left the oven on. Obsessions – Child

I just know I left the computer on. OCD Diagnostic Criteria

COMPULSIONS

• Repetitive behaviors or mental acts conducted in response to obsession

• Typically performed in stereotypic or rule-bound fashion

• Behavior logically unrelated to obsessive fear or else completed in manner out of proportion to fear

• Aimed at reducing stress or preventing dreaded event OCD Diagnostic Criteria Features in Childhood

Obsessions • May be less well-formed in children than adults • “Bizarre” easily misdiagnosed

Accompanying Feelings • Fear/Anxiety, Doubt, Disgust, Unacceptable urges, Sensory Incompleteness

Checking Compulsions

Strike a match, Ernie. I need to check and see if I remembered to turn off the lights. OCD Diagnostic Criteria

Children and adolescents do not need to recognize that symptoms are excessive or unrealistic

Symptoms must be: • Distressing, • Interfering, or • Time consuming

Not due to another Axis I disorder or general medical condition

Obsessions and Compulsions

OBSESSION COMPULSION

 Contamination Washing / Cleaning

 Concern about Harm Checking / Others

 Need for Symmetry Arranging / Tapping

 Fear of losing things Hoarding

 Fear of embarrassment Avoidance

 “Just Right” Phenomenon Repeating

 Moral obsessions Confessing / Telling Clustering of Symptoms

Hasler et al. (2007) Major Symptom Factors of OCD

• Aggressive / harm obsessions & checking compulsions • Contamination obsessions & cleaning compulsions • Symmetry / order obsessions & arranging / precision compulsions • Saving / collecting obsessions & hoarding / saving compulsions • Sexual/religious obsessions & mental compulsions

(Leckman et al, 1997; Summerfeldt et al, 1999; Calamari et al, 1999) Childhood OCD

• 1-3% prevalence • More common in boys prepubertally • Onset may be abrupt or gradual • Onset or exacerbation may be related to psychosocial trauma or stress in some cases • Symptoms may wax and wane or be chronic and progressive • Child may be able to ignore/resist symptoms at times (e.g., with friends, at school) • Symptoms worse when child sick, stressed, or tired • Variable course: 41% full-OCD after 1-15yr FU; 60% at least some symptoms (Stewart et al., 2004)

OCD-Related Functional Impairment

• One of 10 most disabling medical conditions worldwide (Murray and Lopez, 1996)

• 151 OCD youngsters and their parents completed parallel self-report rating scale (COIS) assessing OCD-related dysfunction in three areas: home/family, school, and social

• 88% of parents and 85% of children reported at least one area of significant OCD-related dysfunction.

• Half of sample reported significant OCD-related dysfunction at home, in school, and socially.

• Parents more likely to report home/family problems, children more likely to report problems related to mental rituals.

Piacentini et al., 2003 Most Common Problems Parent Report

Concentrating on school work 72 % Doing homework 68 Doing assigned chores at home 67 Getting ready for bed at night 66 Getting along with parents 66 Bathing / grooming in the morning 62 Getting dressed in the morning 60 Getting to school on time 59 Taking tests 59 Completing in-class work 57 Sleeping at night 56 Getting along with sibs 55

Piacentini et al., 2003 Most Common Problems Child Report

Concentrating on school work 64 % Letting others touch / use things 62 Doing homework 60 Being with a group of strangers 56 Completing in-class work 55 Getting ready for bed at night 54 Bathing/grooming in morning 52 Doing assigned chores at home 52 Sleeping at night 49 Getting along with parents 49 Getting to school on time 48 Writing in class 48 Taking tests 46 Piacentini et al., 2003 OCD-Related Impairment Parent-Child Differences

Child-Report Parent-Report ______

No Slight Significant No Slight Significant Parent- Problem Problem Problem Problem Problem Problem Child Diff

% % % % % % t (P>C)

GLOBAL PROBLEM RATINGS

Problems at School 20 36 44 20 33 47 1.52

Problems socially with friends 46 35 19 24 42 33 4.33 ***

Prevented from going places 48 32 20 43 32 25 1.50

Problems at home/with family 23 29 48 8 27 66 4.28 ***

*** p < .001

Piacentini et al., 2003 Comorbidity in Childhood OCD

N % Other Anxiety Disorders 47 42.0 ADHD 22 19.6 ODD/CD 10 8.9 Tic Disorders 12 10.7 MDE/Dysthymia 12 10.7 One Comorbid Disorder 82 73.2 Multiple Comorbid 35 31.3

(N=112) UCLA Child OCD Program OCD Neurobiology

 Serotonin Hypothesis: SSRI efficacy, but 5-HT and metabolites not found to consistently differ between OCD and normals in CSF or peripherally

 5-HT binding studies suggest impaired 5-HT binding may play a role in OCD pathogenesis

 Mixed evidence for dopaminergic involvement. Increased dopamine transmission in basal ganglia may relate to hyperactivity of cortico-striato-thalamo-cortico circuit.

Cortico-Striatal-Thalamic Model

 Circuit possibly involved in regulation of repetitive thoughts and behaviors: underactive caudate nuclei so that thoughts, actions generated by orbitofrontal cortex are not suppressed Baseline Glucose Metabolism in OCD

NORMAL OCD Schwartz, 1996 OCD Neuroanatomy

 Increased glucose metabolism or other indices of activation in the orbitofrontal cortex and caudate nuclei

 Normalizes with behavioral and pharmacological treatment (Schwartz et al., 1996)

 Part of a circuit possibly involved in regulation of repetitive thoughts and behaviors: underactive caudate nuclei so that thoughts, actions generated by orbitofrontal cortex are not suppressed Change in Glucose Metabolism Pre/Post CBT

Schwartz, 1996 OCD Neuropsychology

 Deficits in systems subserved by dorsal and ventral corticostriatal circuitry

 Executive function: set-shifting, spatial working memory (DLPFC); alternation tasks, decision-making (OFC)

 Cognitive flexibility, reversal learning ?

 Methodologic problems (small N, heterogeneous samples) limit conclusions that can be drawn

OCD Genetics

 Family studies show rates of OCD significantly greater in relatives of probands vs. controls (12% vs 2%) (Pauls et al., 1995)

 Familiality increases with increased homogeneity of proband symptom type (e.g., cleaning, hoarding, etc.)

 GAD and agoraphobia show strong association to OCD phenotype (family rates remain elevated when dx controlled for in probands)

 Major depression elevated in relatives but likely secondary to OCD

 Perhaps predisposition for anxiety, not specific dx, is inherited

 Tics and earlier onset age associated with higher rates (esp in combination)

Nicolini et al (2009) OCD Genetics

 Segregation analyses suggest evidence for both single and polygenic inheritence

 Ordering and symmetry, OCD with eating disorder, early onset age – Autosomal Dominant

 Candidate gene studies:

 COMT, MAO-A, Dopamine transporters and receptors – studies typically small with mixed results.

 More evidence for SERT (serotonin transporter) and 5-HT receptor genes

 Glutamate transporter SLC1A1 has been associated with OCD in multiple studies Nicolini et al (2009)

Pediatric Autoimmune Neuropsychiatric Disorders Associated with Strep PANDAS Diagnostic criteria

• Presence of obsessive-compulsive disorder and/or a tic disorder • Pediatric onset of symptoms (age 3 years to puberty) • Episodic course of symptom severity • Association with group A Beta-hemolytic streptococcal infection (a positive throat culture for strep or history of Scarlet Fever) • Association with neurological abnormalities (motoric hyperactivity, or adventitious movements, such as choreiform movements)

http://www.nimh.nih.gov Strep + OCD = PANDAS ?

• NO • Almost all school aged children get strep throat at some point in their lives. • The average child has 2-3 strep throat infections each year. • PANDAS is considered only when there is a very close relationship between the abrupt onset or worsening or OCD and/or tics, and a preceding strep infection. • If strep is found in conjunction with two or three episodes of OCD/tics, then it may be that the child has PANDAS.

• PANDAS IS NOT A VALIDATED DISORDER

http://www.nimh.nih.gov What to do for PANDAS

OCD • Treat the OCD symptoms according to best practice standards

Strep infection • Treat the strep infection according to best practice standards

http://www.nimh.nih.gov What not to do for PANDAS

• Steroids • Plasmapheresis • Intravenous immunoglobulin • Antibiotic prophylaxis

http://www.nimh.nih.gov Cognitive Aspects

of OCD Intrusive Mental Processes

 80-90% community experience occasional intrusive thoughts

 Similar in content to obsessions from patient samples (e.g., Rachman & de Silva, 1978)

 Exacerbated by stress but subside Cognitive Biases in Adult OCD

Thought-Action Fusion Individuals with TAF:

 Experience thoughts and actions about harm as equivalent (thinking it is same as doing it)

 Believe that having an intrusive negative thought is as wrong as acting it out (thinking it is as bad as doing it)

Exaggerated Responsibility

 Failing to prevent or trying to prevent harm to others is the same as having caused harm

 Responsibility is not attenuated by low probability of occurrence

(Rachman, 1993) Cognitive Processses in Child OCD

Barrett & Healy, 2002

 OCD children report higher levels of responsibility, probability of harm and severity, thought action fusion, and less cognitive control compared to nonclinic comparison children.

 OCD children only reported less cognitive control than anxious comparison children.

 Specificity of cognitive biases to OCD is questionable in children. May be developmental phenomenon Cognitive Processses in Child OCD

Barrett & Healy, 2004

 Experimental manipulation of responsibility during BAT.

 Manipulation inflated perceived responsibility for harm in OCD children

 However, this did not lead to increases in estimated probability or severity of harm or distress.

 CBT led to significant decreases in perceived responsibility for harm, probability and severity of harm, and distress.

 Although CBT effective in addressing responsibility, this bias may not be as important in child OCD versus adult disorder. Obsessive Compulsive Cycle Obsessive Compulsive Cycle

Obsessions Distress Trigger Intrusive, repetitive Anxiety, fear, disgust or negative images shame or impulses

Relief Compulsions Distress subsides Repetitive thoughts temporarily images or actions

Negative Reinforcement Assessment of

Childhood OCD Accurate Diagnosis of OCD in Youth

• Young children tend to think in the moment and hence misrepresent symptoms or severity • Adolescents may under-report symptoms (especially boys) • The nature of certain symptoms (otherwise normative behaviors) leads to misdiagnosis or being missed completely • Accurate diagnosis in youth is dependent upon both child/adolescent AND parent report (DiBartolo, Albano, Barlow & Heimberg, 1998) Assessment of Childhood OCD

GOALS • Determine baseline severity • Identify comorbidities and other complicating factors • Monitor response to treatment

CONSIDERATIONS • Secretive nature of symptoms • Multiple informants • Developmental issues • Family assessment

Assessment of OCD

Diagnostic Interview Schedules • Provides reliable differential diagnoses Behavioral Assessment Techniques • Fear and Avoidance Hierarchies • Behavioral Avoidance Tasks Questionnaires • Self-Report; Parent-Report; Teacher Ratings Differential Diagnosis

Other Anxiety Disorders

GAD, SAD, Panic Pervasive Developmental Disorders

Asperger’s Syndrome Tic Disorders Compulsion vs. Complex Motor Tic Other Disorders Children’s Yale-Brown Obsessive Compulsive Scale (CYBOCS)

10 Items 5 items on Obsessions Subscale 5 items on Compulsions Subscale

Each item scored 0 - 4 20 Point Maximum for Obsessions 20 Point Maximum for Compulsions

Total Score ranges from 0-40

CYBOCS ge 15 clinically significant OCD CY-BOCS: Checklist Categories

• Washing/Cleaning • Checking • Repeating • Counting • Ordering/Arranging • Hoarding/Saving • Excessive Games/Superstitious Behaviors • Rituals Involving other persons • Sexual Obsessions • Somatic obsessions • Aggressive Obsessions • Miscellaneous Child OC Impairment Scale (COIS-R)

• Measure of OCD-specific impairment • Parallel Child/Adult Versions • Covers School, Social, Home • Good psychometrics • Useful in helping break down child resistance to treatment

Piacentini et al., 2007 Summary of Child Assessment

Multi-informant: • child, parent, teacher Multi-method: • Self-report, clinician driven, behavioral, observational Developmentally sensitive Ongoing through treatment

OCD Treatment Planning

Assessment 1. OCD Symptoms, Severity, Impairment 2. Comorbid Disorders

Treatment Planning 1. Effective vs. ineffective treatments 2. Assess insight and motivation 3. Determine most appropriate treatment setting 4. Assess need for combined medication and CBT 5. Prioritze treatment of comorbid disorders 6. Address family and environmental factors

Education: patient, family, etc.

Cognitive Behavioral Treatment of Childhood OCD

CBT Program for Childhood OCD

• Psychoeducation - to reduce blame, stigma, anxiety • Assessment - “Fear Thermometer” to create sx hierarchy • Graded Exposure to address “core” OCD symptoms • Response Prevention • Use of Graphics - visual record of progress • Reward Program - motivation and address comorbidity • Cognitive Restructuring - to manage anxiety and obsessions • Homework - to foster generalization • Family Work - to foster maintenance of tx gains CBT Program for Childhood OCD

• Psychoeducation - to reduce blame, stigma, anxiety • Assessment - “Fear Thermometer” to create sx hierarchy • Graded Exposure to address “core” OCD symptoms • Response Prevention • Use of Graphics - visual record of progress • Reward Program - motivation and address comorbidity • Cognitive Restructuring - to manage anxiety and obsessions • Homework - to foster generalization • Family Work - to foster maintenance of tx gains Psychoeducation

GOALS: Reduce stigma, blame, and anxiety

Prevalence • Common Disorder (0.5 - 2%)

Neurobiological Framework • “Asthma” analogy

Ethological Perspective • Anxiety as “False Alarm” Ethological Perspective

Anxiety has been conserved as an evolutionary trait across species because it serves a protective function OCD as a False Alarm

Fire Drill Analogy

The fire alarm is scary sounding to get your attention and make you leave the school building in case there’s a fire. But sometimes the alarm goes off when there’s no fire (a false alarm). It still sounds scary, even though there’s no real danger. OCD is like a false fire alarm. It makes you scared even when there’s no real danger. In treatment you will learn how to ignore your OCD false alarm so it doesn’t bother you anymore OCD Habituation - 1

10

9

8

7 S 6 U D 5 S 4

3

2

1

0 Time OCD Symptom Hierarchy

Fear Thermometer (SUDS)

Hardest to Resist (Most Scary or Upsetting)

10 OCD Symptom Hierarchy

9 Situation SUDS 8 7 Walking through kitchen door 10 6 Checking locks at night 9

5 Turning TV on and off (3 times) 6 4 Flipping lightswitch (3 times) 6 3 Erasing/Rewriting Homework 4 2 Brushing teeth 3 1

0 Throwing away old homework 2

Easiest to resist (Least Scary or Upsetting) Negative Reinforcement Cycle

Obsessions Distress Repetitive negative, Anxiety, fear, disgust or images or impulses shame X Relief Compulsions Distress subsides Repetitive thoughts temporarily images or actions

Negative Reinforcement Exposure Plus Response Prevention (ERP)

EXPOSURE • Begin with item low on Symptom Hierarchy • Therapist models behavior first

RESPONSE PREVENTION • Individual encouraged to resist ritualizing • Assess SUDS (anxiety) level at frequent intervals • Continue exposure until anxiety decreases > 50% from peak • Repeat exercise as often as possible in session Exposure Graph Writing Crooked Optimizing Exposure Efficacy Craske et al., 2008; BRAT

Within and between session habituation does not predict anxiety reduction over time in adults Length of fear expression predicts extinction learning

Treatment Implications • Exposure goal - sustained fear tolerance not fear reduction • Patient expectations about exposure • Unpredictability of exposure (e.g., symptom grab bag) • Sustained exposure • Developmental considerations

Unclear if this applies to younger children Cognitive Restructuring

Externalize: Recognize and Relabel Fears as OCD • “I won’t get sick if I touch this, its just my OCD talking” Reality Testing • Challenge irrational beliefs Mindfulness-based Approaches • Neutral, non-affective reaction to symptoms and fear Learn to Tolerate Uncertainty • Bad things do happen, just not very often Exposing Obsessive Thoughts Homework

NAME: DATE:

SYMPTOM:

EXPOSURE INSTRUCTIONS: How Often

HOW OFTEN: • Daily for 30-45 minutes or HOW LONG:

until anxiety disappears WAYS TO FIGHT OCD THOUGHTS:

What is Practiced REWARD:

• Situations covered in session 10 9 • Situations unable to be covered 8 7 in session 6 5 4 Reviewed in Session 3

Feeling ThermometerFeeling 2 1 Covered by Reward Program 0 1 2 3 4 5 6 7 8 Time or Trial Reward Program

How Often • Younger children or more difficult tasks require more frequent rewards What Gets Rewarded • Effort not results • Clearly defined behaviors Selecting a Reward • Desired, strong, realistic Family Factors in Childhood OCD Treatments for child OCD typically do not lead to symptom remission POTS I: Symptomatic at Post-Tx (CYBOCS > 10)

80 70 Combo 46% 60 CBT 61% SSRI 79% 50 % 40 30 20 10 0 Combined CBT Meds

TREATMENT GROUP POTS Team, 2004 Predictors of Worse CBT Response

Adult Studies

• Comorbidity • Motivation • Fixity of Beliefs • Family Factors – Expressed Emotion – Patient expectation of criticism

Abramowitz et al. (2000); Chambless et al. (1999); Foa et al. (1997) Predictors of Worse CBT Response

Child/Adolescent Studies

• More severe OCD • Poorer psychosocial functioning • Family history of OCD • Family factors – Overall family dysfunction – Parental blame/criticism – Poorer family cohesion – Higher family conflict

Barrett et al. (2005); Piacentini et al. (2002); Peris et al. (submitted); Mars Garcia et al. (2010) Family environment may be an important intervention target Family Factors in Child OCD

• Family Distress/Dysfunction (66 – 90%)

• Elevated rates of parental OCD (20 – 50%) • Elevated rates of Parental Blame • Elevated rates of Expressed Emotion

• Family Accommodation (62 – 100%)

• Actual participation in OCD rituals (50 – 75%)

Allsopp & Verduyn, 1990; Apter et al., 1984; Bolton et al., 1983; Cooper et al. 1996; Peris et al., 2008; Piacentini et al. 2003; Storch et al., 2007; Van Noppen et al., 1991 Family Accommodation

Family accommodation is thought to be a barrier to treatment inasmuch as it reinforces avoidance behaviors and undermines exposure-based exercises Family Accommodation

Calvocoressi et al. (1995; 1999) • High rates of family accommodation • Associated with increased family distress Amir et al. (2000) • Modification of family routine linked with depression • Refusal to accommodate linked to anxiety • Accommodation not linked to severity of child’s OCD Storch et al. (2007) • Family accommodation may mediate the relationship between • OCD symptom severity and associated functional impairment Family Accommodation

Less than Participation in OCD 1x/month Weekly Daily reassure patient 14% 30% 56% participate in rituals 41 14 45

Consequences of not participating pt becomes distressed/anxious 19 47 34 pt becomes angry/abusive 48 29 22

Mild Modification of family routine None Moderate Severe modified family routine 33 55 13

Distress when OCD not accomodated 27 60 13

Peris et al., 2008 Family Context of Childhood OCD

• FAMILY ACCOMMODATION very common • 60-90% report participating in child’s OCD via reassurance or worse • 50-80% report child reacts negatively when accommodation is resisted • positively correlated with OCD severity and presence of comorbid externalizing symptoms

• 75% of parents report distress when giving in to their child’s OCD • given parental resistance is key part of CBT, this needs to be addressed in treatment

Peris et al., 2008 Parental OCD and Family Context

Parent YBOCS > 15 YES NO

FES Organization 3.2 5.4 **

FA Distress 2.1 1.1 **

FA Consequences 5.8 3.6 *

* p < .05, ** p < .01, *** p < .001 Parental OCD - Associated with less family organization - More negative consequences of OCD limit setting - Greater distress when limit setting Peris et al., 2008 Family Accommodation

• Higher child CYBOCS scores associated with greater family participation in child rituals, greater modification of family routine, and more negative child response to OCD-related limit setting

• Higher family conflict associated with more negative child response to limit setting and greater parental distress when accommodating child symptoms

• Higher family cohesion associated with opposite pattern

Family Context of Childhood OCD

Asking families of OCD children – especially distressed families - to resist accommodating child symptoms likely to lead to:

- Emotional distress on part of family

- Negative reaction on part of child Individual vs. Family CBT ??

FCBT: Individual child+family interventions which specify structured weekly intervention sessions focused on changing family dynamics

ICBT: Primarily individual child treatments which include family members in a less-structured or less-frequent manner, often as a brief check-in at the end of individual sessions

Barrett, Farrell, Pina, Peris, & Piacentini, 2008 Family Intervention

Goals of Family Intervention • Reduce level of conflict and feelings of anger, blame, guilt • Enhance family problem solving • Facilitate disengagement from child’s OCD symptoms • Rebuild normal (OCD-free) family interaction patterns • Foster environment conducive to maintaining treatment gains Evidence-base For Treatment Of Childhood OCD Controlled Medication Trials

• Clomipramine - DeVeaugh-Geiss et al., 1992

• Fluoxetine - Riddle et al., 1992; Geller, 2001; Liebowitz, 2003

• Fluvoxamine - Riddle et al., 2001

• Sertraline - March et al., 1998

• Paroxetine – Geller et al., 2004 Meta-Analysis of SRIs for OCD Geller et al. (2003)

Methods • All published placebo-controlled medication trials • Twelve studies with 1,044 total participants • Four outcome measures: CYBOCS, LOI, NIMH, CGI • CMI, PAR, FLUV, FLX, SER

Findings • Mean ES = 0.46 (95% CI = 0.37 - 0.55) (p<.001) • Overall ES is modest • CMI > PAR=FLUV=FLX=SER • No relationship between ES and publication date Psychosocial Treatment Of Childhood OCD Psychosocial Tx of Child OCD

# of Studies Design Description 2 Type 1 Rigorously designed RCTs 4 Type 2 One or more design limitations 10 Type 3 Open trials

Barrett, Farrell, Pina, Peris, & Piacentini, 2008 JCCAP Special issue on EBTs for Childhood Disorders Controlled Efficacy Trials for Child OCD

N Outcome

De Haan (1998) 22 CBT > CMI

Barrett et al. (2004) 77 Ind-CBT = Group-CBT > WL

POTS I (POTS Team, 2004) 112 COMBO >? CBT >= SER > PBO

Barrett, Farrell, Pina, Peris, & Piacentini, 2008 JCCAP Special issue on EBTs for Childhood Disorders Controlled Efficacy Trials for Child OCD

N Outcome

De Haan (1998) 22 CBT > CMI

Barrett et al. (2004) 77 Ind-CBT = Group-CBT > WL

POTS (March et al, 2004) 112 COMBO >? CBT >= SER > PBO

POTS II (March et al, under review) 124 MM+Full CBT > MM+CBT-lite > MM

UCLA (Piacentini et al, under review) 71 CBT > PsychoEd/Relax Training

Comparison across trials complicated by methodological differences Comparison of CBT and CMI DeHaan et al. (1998)

25

20

15 CBT CMI 10

5

CYBOCS Total CYBOCS Score Effect Size CBT = 1.56 0 CMI = .86 Pre Post Comparison of Individual & Group CBT Barrett et al. (2004)

I-CBT = G-CBT > WL

25

20

15 I-CBT G-CBT 10 WL

5 CYBOCS Total CYBOCS Score 0 0 14 Effect Size

Week ICBT = 2.84 GCBT = 2.63 Pediatric OCD Treatment Study (POTS) Duke (J. March), Penn (E. Foa, M. Franklin), Brown (H. Leonard)

128 OCD youngsters randomized to: - CBT - SER - COMBO - Pill PBO

SAMPLE CHARACTERISTICS Gender (female): 50% Mean age: 11.7 (2.7) Age range: 7-17 Ethnicity (Caucasian): 93% Any Comorbid Disorder 80% • Internalizing Disorder 63% • Externalizing Disorder 27% - ADD/ADHD and on Psychostimulant 10%

POTS (2004) Change in CYBOCS Total Score POTS STUDY

COMB > CBT = SER > PBO 30 25

20 Effect Size

CBT = .98 15 COMB Comb = 1.46 10 CBT SER 5

CYBOCS Total CYBOCS Score PBO 0 0 4 8 14 Week Lower Med Doses in Combo Group POTS STUDY

250 Median 200 Mean

150

100 Sertraline (mg) Sertraline 50

0 PBO SER COMB Treatment x Site Interaction DUKE-PENN (POTS) STUDY

2 Penn 1.8 Duke 1.6 1.4 1.2 1 0.8 0.6

Effect Size (Btw Ss) Effect 0.4 0.2 0 SER CBT COMB UCLA CBT for Child OCD Study

Randomized Controlled Trial comparing:

• F/CBT – CBT (ERP+Cog Restructuring) plus a structured family component • P/RT – Psychoeducation plus Relaxation Training F/CBT included weekly manualized family CBT component Twelve sessions therapy delivered over 14 weeks

Piacentini et al. (under review) Supported by NIMH R01 MH58549 Treatment Response Rate UCLA STUDY

60

50 Intent to Treat 40

30 ERP

20 RT % Responded %

10

0 4 8 14 p < .05 Week Excellent Responder POTS and UCLA Studies

60 (CY-BOCS < 10) 54 50

39 40 40

30 21

20 17 PercentResponse 10 3 0 PBO LA - RT SER CBT LA - CBT COMB Family Accommodation as Outcome Mediator

Storch et al. (2007): Families receiving intensive FCBT showed greater reduction in family accommodation compared to those receiving weekly treatment.

Merlo et al. (2009): In a partially-overlapping sample of children receiving FCBT through one of two separate open-label studies, decreases in family accommodation over the course of treatment predicted reduced symptom severity and OCD-related impairment post-treatment.

Piacentini et al. (under review): FCBT was associated with a marginally greater reduction in parent-reported accommodation of OCD symptoms (p=.05). Reduction in family accommodation temporally preceded improvement in OCD severity across treatment groups and child functional status for FCBT only

Effectiveness of CBT for Child OCD Valderhaug, Larsson, Gotestam, & Piacentini, 2006

28 Norwegian youth treated in community clinics by community practitioners.

60.6% response rate post-tx

68.8% response rate at 6 mo FU

Intensive CBT for Child OCD

Franklin al. (1998) 14 Ss age 10-17 nonrandom assignment to outpatient (16wks) or intensive (18 days) CBT. Groups didn’t differ post-tx

Storch et al. (2006) 40 Ss age 7-17 randomized to 14 sessions outpatient (14 wks) or intensive (3wks) CBT c/ family component. Intensive > outpatient post-tx but not at 3 mo FU

Excellent response rates to intensive CBT, but differences in baseline severity differences (sicker kids in intensive tx) complicate comparison with outpatient samples. Diversity in Child OCD Treatment Research

Limited available data suggests treatment outcome not related to gender or ethnicity, but this has not been systematically evaluated in controlled trials. Classification of Psychosocial Treatments for OCD in Children and Adolescents

Treatment Citation

Well-Established Treatments None — Probably Efficacious Treatments Individual CBT POTS (2004) Individual CBT + sertraline POTS (2004) Possibly Efficacious Treatments Family-Focused Individual CBT Barrett et al. (2004) Family-Focused Group CBT Barrett et al. (2004) Experimental Treatments Group CBT Multiple authors

Barrett et al., JCCAP, 2008

For more information, please go to the main website and browse for workshops on this topic or check out our additional resources. Additional Resources Online resources: 1. National Institute of Mental Health: http://nimh.nih.gov/health/topics/obsessive-compulsive-disorder-ocd/index.shtml 2. Society of Clinical Child and Adolescent Psychology website: http://effective childtherapy.com Books: 1. Albano, A. M., March, J.S., Piacentini, J. (1999). Obsessive-compulsive disorder. In in R. T., Ammerman, M. Hersen, & C. G. Last (Eds.), Handbook of prescriptive treatments for children and adolescents (pp. 193-213). Needham Heights: Allyn & Bacon. 2. Franklin, M.E., Freeman, J., & March, J.S. (2010). Treating pediatric obsessive-compulsive disorder. In J.R. Weisz & A.E. Kazdin. (Eds.), Evidence-based psychotherapies for children and adolescents (pp. 80-92). New York: Guilford Press. Peer-reviewed Journal Articles: 1.Barrett, P.M., Farrell, L., Pina, A.A., Peris, T.S. & Piacentini, J. (2008). Evidence-based psychosocial treatments for child and adolescent obsessive–compulsive disorder. Journal of Clinical Child & Adolescent Psychology, 37 (1), 131-155. 2. Garcia, A.M., Sapyta , J.J., Moore, P.S. Freeman, J.B., Franklin, M.E., March, J.S., Foa, E.B. (2010). Predictors and moderators of treatment outcome in the pediatric obsessive compulsive treatment study (POTS I). Journal of the American Academy of Child & Adolescent Psychiatry 49 (10), 1024-1033. 3. Geller, D.A., Biederman, J., Stewart, S.E., Mullin, B., Martin, A., Spencer, T. & Faraone, S.V. (2003). Which SSRI? A meta-analysis of pharmacotherapy trials in pediatric obsessive-compulsive disorder. American Journal of Psychiatry, 160, 1919-1928. 4. Peris, T.S., Bergman, R.L., Langley, A., Chang, S., McCracken, J.T., & Piacentini, J. (2008). Correlates of accommodation of pediatric obsessive-compulsive disorder: Parent, child, and family characteristics. Journal of the American Academy of Child and Adolescent Psychiatry. 47 (10), 1173-1181 5. Piacentini J., Bergman L., Keller M., & McCracken J. (2003). Functional impairment in children and adolescents with obsessive- compulsive disorder. Journal of Child and Adolescent Psychopharmacology, 13, S61–S69.

Full Reference List

Keynote: Evidence-based Treatment of Obsessive Compulsive Disorder in Children and Adolescents

Websites: National Institute of Mental Health: http://nimh.nih.gov/health/topics/obsessive-compulsive-disorder- ocd/index.shtml

Books: Albano, A. M., March, J.S., Piacentini, J. (1999). Obsessive-compulsive disorder. In in R. T., Ammerman, M. Hersen, & C. G. Last (Eds.), Handbook of prescriptive treatments for children and adolescents (pp. 193-213). Needham Heights: Allyn & Bacon. Murray CJL, Lopez AD, eds. The Global Burden of Disease: a comprehensive assessment of mortality and disability from diseases, injuries, and risk factors in 1990 and projected to 2020. Cambridge: Harvard University Press, 1996. Van Noppen, B.L., Rasmussen, S.A., Eisen, J., & McCartney, L. (1991). A multifamily group approach as an adjunct to treatment of obsessive-compulsive disorder. In M.T.Pato (Ed.), Current treatments of obsessive-compulsive disorder (pp. 115–134). Washington, DC: American Psychiatric Press.

Peer-reviewed Journal Articles: Abramowitz, J., Franklin, M., Street, G., Kozak, M., & Foa, E. (2000). Effects of comorbid depression on response to treatment for obsessive-compulsive disorder. Behavior Therapy, 31, 517-28. Allsopp, M. & Verduyn, C. (1990). Adolescents with obsessive-compulsive disorder: a case note review of consecutive patients referred to a provincial regional adolescent psychiatry unit. Journal of Adolescence, 13 (2), 157-169. Amir, N., Freshman, M., & Foa, E.B. (2000). Family distress and involvement in relatives of obsessive- compulsive disorder patients. Journal of Anxiety Disorders. 14 (3), 209-217. Apter A., Bernhout, E., & Tyano, S. (1984). Severe obsessive compulsive disorder in adolescence: a report of eight cases. Journal of Adolescence, 7 (4), 349-35 Barrett, P. M., & Healy L.J. (2003). An examination of the cognitive processes involved in childhood obsessive–compulsive disorder. Behavior Research and Therapy, 41 (3), 285-299 Barrett P.M., & Healy-Farrell, L. (2003) Perceived responsibility in juvenile obsessive-compulsive disorder: an experimental manipulation. Journal of Clinical Child and Adolescent Psychology. 32(3), 430-41. Barrett, P., Healy-Farrell, L., & March, J.S. (2004). Cognitive-behavioral family treatment of childhood obsessive-compulsive disorder: A controlled trial. Journal of the American Academy of Child & Adolescent Psychiatry, 43 (1), 46-62. Barrett, P.M, Farrell, L., Dadds, M., & Boutler, N. (2005). Cognitive-behavioral family treatment of childhood obsessive-compulsive disorder: long-term follow-up and predictors of outcome. Journal of the American Academy of Child and Adolescent Psychiatry, 44, 1005–1014. Barrett, P.M., Farrell, L., Pina, A.A., Peris, T.S., & Piacentini, J. (2008). Evidence-based psychosocial treatments for child and adolescent obsessive–compulsive disorder. Journal of Clinical Child & Adolescent Psychology, 37 (1), 131-155. Bolton D., Collins S., & Steinberg D. (1983). Treatment of OCD in adolescence: report of 15 cases. British Journal of Psychiatry, 142, 456–64. Calamari, J., Wiegartz, P., & Janeck, A. (1999). Obsessive-compulsive disorder subgroups: A symptom- based cluster approach. Behavior Research and Therapy, 37,113-125. Calvocoressi L., Calvocoressi, B., Lewis, M., Harris, S.J., Trufan, W.K., Goodman, C.J., McDougle and L.H. Price, (1995). Family accommodation in obsessive-compulsive disorder. American Journal of Psychiatry, 152, 441–443. Full Reference List

Cooper, M. (1996). Obsessive-compulsive disorder: Effects on family members. American Journal of Orthopsychiatry, 66, 296–304 Craske, M. G., Kircanski, K., Zelikowsky, M., Mystkowski, J., Chowdhury, N., & Baker, A. (2008). Optimizing inhibitory learning during exposure therapy. Behavior Research and Therapy, 46, 5- 27. De Haan, E., Hoogduin, K.A.L., Buitelaar, J.L., & Keijsers, G.P.J. (1998). Behavior therapy versus clomipramine for the treatment of obsessive-compulsive disorder in children and adolescents. Journal of the American Academy of Child & Adolescent Psychiatry, 37 (10), 1022-1029. DeVeaugh-Geiss J., Moroz G., Biederman J., et al. (1992). Clomipramine hydrochloride in childhood and adolescent obsessive-compulsive disorder—a multicenter trial. Journal of the American Academy of Child and Adolescent Psychiatry, 31(1), 45-49. DiBartolo, P. M., Albano, A. M., Barlow, D. H., & Heimberg, R. G. (1998). Cross-informant agreement in the assessment of social phobia in youth. Journal of Abnormal Child Psychology, 26, 213-220. Foa, E., Abramowitz, J., Franklin, M., & Kozak, M. (1999). Feared consequences, fixity of belief, and treatment outcome in patients with obsessive-compulsive disorder. Behavior Therapy, 30, 223- 231. Franklin, M., Kizak, M.J., Cashman, L.A., Coles, M., Rheingold, A.A., Foa, E. (1998), Cognitive behavioral treatment of pediatric obsessive compulsive disorder: An Open Clinical Trial. Journal of the American Academy of Child & Adolescent Psychiatry, 37 (4), 412-419 Garcia, A.M., Sapyta , J.J., Moore, P.S., Freeman, J.B., Franklin, M.E., March, J.S., Foa, E.B. (2010). Predictors and moderators of treatment outcome in the pediatric obsessive compulsive treatment study (POTS I). Journal of the American Academy of Child & Adolescent Psychiatry 49 (10), 1024-1033. Geller, D.A., Biederman, J., Stewart, S.E., Mullin, B., Martin, A., Spencer, T. & Faraone, S.V. (2003). Which SSRI? A meta-analysis of pharmacotherapy trials in pediatric obsessive-compulsive disorder. American Journal of Psychiatry, 160, 1919-1928. Geller, D., Hoog, S., Heiligenstein, J., Ricardi, R., Tamura, R., et al. (2001). Fluoxetine treatment for obsessive–compulsive disorder in children and adolescents: A placebo-controlled clinical trial. Journal of the American Academy of Child & Adolescent Psychiatry, 40, 773-779. Hasler, G., Pinto, A., Greenberg, B.D., Samuels, J., Fyerd, A.J., Pauls, D., …Murphy, D.L. (2007). Familiality of factor analysis-derived YBOCS dimensions in OCD-affected sibling pairs from the OCD collaborative genetics study. Biological Psychiatry, 61(5), 617-625. Leckman, J. F., Orice, D. E., Boardman, J., Zhang, H., Vitale, A., Bondi, C., … Pauls, D. L. (1997). Symptoms of obsessive-compulsive disorder. American Journal of Psychiatry, 154, 911-917. Liebowitz, M., Turner, S., Piacentini, J., Beidel, D., Clarvit, S., et al. (2002 ). Fluoxetine in children and adolescents with OCD: A placebo-controlled trial. Journal of the American Academy of Child & Adolescent Psychiatry, 41, 1431-1438. Nicolini H, Arnold P, Nestadt G, Lanzagorta N, Kennedy JL. (2008). Overview of genetics and obsessive- compulsive disorder. Psychiatry Research, 170 (1) 7-14. Pauls D.L., Alsobrook J.P., Goodman W., et al. (1995). A family study of OCD. American Journal of Psychiatry 152, 76-84. Peris, T.S., Bergman, R.L., Langley, A., Chang, S., McCracken, J.T., & Piacentini, J. (2008). Correlates of accommodation of pediatric obsessive-compulsive disorder: Parent, child, and family characteristics. Journal of the American Academy of Child and Adolescent Psychiatry. 47 (10), 1173-1181 Piacentini, J., Bergman, R. L., Chang, S., Langley, A., Peris, T., Wood, J.J., McCracken, J. (2011). Controlled Comparison of Family Cognitive Behavioral Therapy and Psychoeducation/Relaxation Training Full Reference List

for Child Obsessive-Compulsive Disorder. Journal of the American Academy of Child & Adolescent Psychiatry 50(11), 1149-1161 Piacentini, J., Bergman, R.L., Jacobs, C., McCracken, J.T., & Kretchman, J. (2002). Open trial of cognitive behavior therapy for childhood obsessive–compulsive disorder. Journal of Anxiety Disorders, 16, (20), 207-219 Piacentini, J., Bergman, L., Keller M., & McCracken J. (2003). Functional impairment in children and adolescents with obsessive-compulsive disorder. Journal of Child and Adolescent Psychopharmacology, 13, S61–S69. Piacentini, J., Peris, T.S., Bergman, R.L., Chang, S., & Jaffer, M. (2007), Functional impairment in childhood OCD: Development and psychometrics properties of the Child Obsessive-Compulsive Impact Scale-Revised (COIS-R). Journal of Clinical Child and Adolescent Psychology, 36, 645–653. Pediatric OCD Treatment Study Team (2004). Cognitive-behavior therapy, sertraline, and their combination for children and adolescents with obsessive-compulsive disorder: the Pediatric OCD Treatment Study (POTS) randomized controlled trial. Journal of the American Medical Association, 292, 1969–1976. Rachman, S. (1993). A critique of cognitive therapy for anxiety disorders. Journal of Behavior Therapy and Experimental Psychiatry, 24 (4). 279-288. Rachman S., & de Silva P. (1978) Abnormal and normal obsessions. Behavior Research Therapy, 16, 233– 248. Riddle, M.A., Reeve, E.A., Yaryura-Tobias, J.A., Yang, H.M., Claghorn, J.L., & Gaggney, G.,… Walkup, J. (2001). Fluvoxamine for Children and Adolescents with Obsessive-Compulsive Disorder: A Randomized, Controlled, Multicenter Trial. Journal of the American Academy of Child & Adolescent Psychiatry, 40 (2), 222-229. Riddle M.A., Scahill, L., King, R.A. et al. (1992), Double-blind, crossover trial of fluoxetine and placebo in children and adolescents with obsessive-compulsive disorder. Journal of the American Academy of Child and Adolescent Psychiatry, 31, 1062-1069 Schwartz J. M., Stoessel, P.W., Baxter, L.R., Martin, K.M., & Phelps, M.E. (1996). Systematic changes in cerebral glucose metabolic rate after successful behavior modification treatment of obsessive- compulsive disorder. Archives of General Psychiatry, 3(2), 109-113. Stewart, S. E., Geller, D. A., Jenike, M., Pauls, D., Shaw, D., Mullin, B. & Faraone, S. V. (2004), Long-term outcome of pediatric obsessive–compulsive disorder: a meta-analysis and qualitative review of the literature. Acta Psychiatrica Scandinavica, 110: 4–13. Storch, E. A., Geffken, G. R., & Merlo, L. J. (2007), Family-based cognitive-behavioral therapy for pediatric obsessive-compulsive disorder: Comparison of intensive and weekly approaches. Journal of the American Academy of Child and Adolescent Psychiatry, 46 (4), 469-78 Summerfeldt, L. J., Richter, M. A., Antony, M. M., & Swinson, R. P. (1999). Symptom structure in obsessive-compulsive disorder: A confirmatory factor-analytic study. Behavior Research and Therapy, 37, 297-311. Valderhaug, R., Larsson, B., Gotesam, G., Piacentini J. (2006), An open clinical trial with cognitive behavior therapy administered in outpatient psychiatric clinics to children and adolescents with OCD. Behavior Research and Therapy, 45, 577–589.

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