Search

Background: Widely used psychotropic medications for obsessive-compulsive disorder (OCD) may change the volumes of subcortical brain structures, and differently in children vs. adults. We measured subcortical volumes cross-sectionally in patients finely stratified for age taking various common classes of OCD drugs. Methods: The ENIGMA-OCD consortium sample (1081 medicated/1159 unmedicated OCD patients and 2057 healthy controls aged 6–65) was divided into six successive 6–10-year age-groups. Individual structural MRIs were parcellated automatically using FreeSurfer into 8 regions-of-interest (ROIs). ROI volumes were compared between unmedicated and medicated patients and controls, and between patients taking serotonin reuptake inhibitors (SRIs), tricyclics (TCs), antipsychotics (APs), or benzodiazepines (BZs) and unmedicated patients. Results: Compared to unmedicated patients, volumes of accumbens, caudate, and/or putamen were lower in children aged 6–13 and adults aged 50–65 with OCD taking SRIs (Cohen's d = −0.24 to −0.74). Volumes of putamen, pallidum (d = 0.18–0.40), and ventricles (d = 0.31–0.66) were greater in patients aged 20–29 receiving APs. Hippocampal volumes were smaller in patients aged 20 and older taking TCs and/or BZs (d = −0.27 to −1.31). Conclusions: Results suggest that TCs and BZs could potentially aggravate hippocampal atrophy of normal aging in older adults with OCD, whereas SRIs may reduce striatal volumes in young children and older adults. Similar to patients with psychotic disorders, OCD patients aged 20–29 may experience subcortical nuclear and ventricular hypertrophy in relation to APs. Although cross-sectional, present results suggest that commonly prescribed agents exert macroscopic effects on subcortical nuclei of unknown relation to therapeutic response.

Objective: Cognitive-behavioral therapy (CBT) is considered a first-line treatment for obsessive-compulsive disorder (OCD) in pediatric and adult populations. Nevertheless, some patients show partial or null response. The identification of predictors of CBT response may improve clinical management of patients with OCD. Here, we aimed to identify structural magnetic resonance imaging (MRI) predictors of CBT response in 2 large series of children and adults with OCD from the worldwide ENIGMA-OCD consortium. Method: Data from 16 datasets from 13 international sites were included in the study. We assessed which variations in baseline cortical thickness, cortical surface area, and subcortical volume predicted response to CBT (percentage of baseline to post-treatment symptom reduction) in 2 samples totaling 168 children and adolescents (age range 5-17.5 years) and 318 adult patients (age range 18-63 years) with OCD. Mixed linear models with random intercept were used to account for potential cross-site differences in imaging values. Results: Significant results were observed exclusively in the pediatric sample. Right prefrontal cortex thickness was positively associated with the percentage of CBT response. In a post hoc analysis, we observed that the specific changes accounting for this relationship were a higher thickness of the frontal pole and the rostral middle frontal gyrus. We observed no significant effects of age, sex, or medication on our findings. Conclusion: Higher cortical thickness in specific right prefrontal cortex regions may be important for CBT response in children with OCD. Our findings suggest that the right prefrontal cortex plays a relevant role in the mechanisms of action of CBT in children.

ObjectivesThe present study aimed to: 1) identify possible latent class trajectories of OCD-related functional impairment over 3 years after stepped-care treatment in children and adolescents with OCD; 2) describe these classes according to pretreatment characteristics; and 3) identify predictors of trajectory class membership.MethodsThe sample consisted of 246 children and adolescents (aged 7-17 years) with OCD participating in the Nordic long-term OCD treatment study (NordLOTS). Latent class growth analysis (LCGA) was conducted using Children’s Obsessive-Compulsive Impact Scale-Revised (COIS-R) data from children and parents on 7 points of assessment: pretreatment, week 7, week 14, 6-month follow-up, 12-month follow-up, 24-month follow-up, and 36-month follow-up.ResultsFor both the parent and child versions of the COIS-R, a 5-cluster quadratic solution had the best fit as determined by the Bayesian information criterion (BIC). For children and parents, the 2 largest clusters were comprised of participants who steadily declined in their levels of functional impairment throughout treatment and follow-up but had different levels of severity at baseline. For both parents and children, the 3 smaller clusters were comprised of participants who showed no or limited improvement in functional impairment as well as a class that improved initially and then relapsed during follow-up. Higher levels of contamination and cleaning symptoms, somatic and illness symptoms, and comorbid ADHD predicted membership for the nonresponse and relapse clusters.ConclusionsMost children and adolescents undergoing stepped-care treatment for OCD show improvements in functional impairment continuously throughout a 3-year follow-up period. However, distinct subgroups do not respond to treatment or relapse after treatment. These subgroups can be distinguished by symptom and comorbidity profiles.

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

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

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

Introduction Obsessive–compulsive disorder (OCD) is a disabling mental health disorder affecting 1–3% of children and adolescents. Cognitive behavioral therapy (CBT) is recommended as the first-line treatment, but is limited by accessibility, availability, and, in some cases, response to treatment. Enhancement with Internet technologies may mitigate these challenges. Methods We developed an enhanced CBT (eCBT) treatment package for children and adolescents with OCD to improve treatment effect as well as user-friendliness. This study aims to explore the feasibility, acceptability, and preliminary effectiveness of the eCBT intervention. The eCBT protocol consists of 10 face-to-face and 12 webcam sessions delivered in 14 weeks. CBT is enhanced by a smartphone application (app) for children and parents to support and monitor treatment, psychoeducative videos, and therapist-guided webcam exposure exercises conducted at home. Assessments were performed at baseline, post-treatment, and at 3- and 6-month follow-up. Primary measures of outcomes were the the Client Satisfaction Questionnaire-8 (CSQ-8) (acceptability), treatment drop-out (feasibility) and the Children’s Yale-Brown Obsessive–Compulsive Scale (CY-BOCS) (preliminary effectiveness). Results This paper describes 25 patients with OCD (aged 8–17 years) treated with eCBT. Results indicated that children and parents were satisfied with eCBT, with CSQ-8 mean scores of 27.58 (SD 0.67) and 29.5 (SD 3.74), respectively (range 8–32). No patients dropped out from treatment. We found a mean of 63.8% symptom reduction on the CY-BOCS from baseline to post-treatment. CY-BOCS scores further decreased during 3-month and 6-month follow-up. Conclusion In this explorative study, eCBT for pediatric OCD was a feasible, acceptable intervention demonstrating positive treatment outcomes.

The major aim of this manuscript is to bring together two important topics that have recently received much attention in child and adolescent research, albeit separately from each other: single‐case experimental designs and statistical mediation analysis. Single‐case experimental designs (SCEDs) are increasingly recognized as a valuable alternative for Randomized Controlled Trials (RCTs) to test intervention effects in youth populations. Statistical mediation analysis helps provide understanding about the most potent mechanisms of change underlying youth intervention outcomes. In this manuscript we: (i) describe the conceptual framework and outline desiderata for methods for mediation analysis in SCEDs; (ii) describe the main aspects of several data‐analytic techniques potentially useful to test mediation in SCEDs; (iii) apply these methods to a single‐case treatment data set from one clinically anxious client; and (iv) discuss pros and cons of these methods for testing mediation in SCEDs, and provide future directions.

Reframing cognitions is assumed to play an important role in treatment for obsessive–compulsive disorder (OCD). However, there hardly is any empirical support for this assumption, especially for children. The aim of this study was to examine if changing dysfunctional beliefs is a mediating mechanism of cognitive behavioral therapy (CBT) for childhood OCD. Fifty-eight children (8–18 years) with OCD received CBT. Dysfunctional beliefs (OBQ-CV) and OCD severity (CY-BOCS) were measured pre-treatment, mid-treatment, post-treatment, and at 16-week follow-up. Results showed that OCD severity and dysfunctional beliefs decreased during CBT. Changes in severity predicted changes in beliefs within the same time interval. Our results did not support the hypothesis that changing dysfunctional beliefs mediates treatment effect. Future studies are needed to replicate these findings and shed more light on the role of explicit and implicit cognitions in treatment for childhood OCD.

Introduction: This article presents two international pilot studies examining brief intensive group cognitive behavioral therapy (BIG-CBT) for pediatric OCD. Aims: 1) to examine treatment outcome of BIG-CBT in two countries, 2) to explore the influence of potential predictors on treatment outcome. Methods: Study 1 (n = 59) was a retrospective study executed in the Netherlands, study 2 (n = 17) was a prospective study performed in Switzerland (total: 76 participants). The pilot studies were carried out in academic centers for child and adolescent psychiatry. BIG-CBT consisted of 5-day CBT in a group format, with exposure and response prevention as the main element. Results: Both studies showed a significant decrease from pre-to post-treatment on the Children's Yale-Brown Obsessive Compulsive Scale mean scores. In study 1, 44% of participants met the criterion for treatment responder at post-treatment (≥35% improvement), in study 2 this was 59% at post-treatment and 41% at 3-month-follow-up. In both studies, age, gender and baseline OCD severity did not significantly predict treatment outcome. Conclusion: The results of these two international pilots of BIG-CBT indicate that brief, intensive treatment has the potential to become a valuable addition to standard clinical care for pediatric OCD.

Hoewel in de leerboeken dwanggedachten vrijwel altijd als eerste genoemd worden, en dwanghandelingen beschreven worden als een reactie op die gedachten, hebben de meeste kinderen vooral last van dwanghandelingen. Gevraagd naar hun problemen zullen zij die als eerste noemen. Hun dwanggedachten zijn eerder de verklaring voor hun rituelen dan de aanleiding daarvoor, in hun beleving. Een klein aantal kinderen klaagt over de typische dwanggedachten zoals die in de DSM worden genoemd: steeds terugkerende gedachten of beelden die zij niet willen hebben. Zij hebben soms ook dwanghandelingen in reactie hierop, maar beleven deze als minder belangrijk. Vaak kunnen ze die handelingen ook achterwege laten zonder dat de dwanggedachten veranderen.

Dit protocol is geschikt voor de behandeling van kinderen en jongerenmet een dwangstoornis. Voor jongere kinderen zijn aanpassingen beschreven. Vanzelfsprekend kunnen deze aanpassingen ook gebruikt worden bij jongeren voor wie de eerst beschreven technieken te ingewikkeld zijn.

Background Although the evidence base of cognitive behavioral therapy (CBT) for pediatric obsessive-compulsive disorder (OCD) has been broadly established, the treatment is hampered by limited access, poor compliance, and nonresponse. New technologies offer the opportunity to improve the accessibility, user friendliness, and effectiveness of traditional office-based CBT. By employing an integrated and age-appropriate technologically enhanced treatment package, we aim to execute a more focused and attractive application of CBT principles to increase the treatment effect for pediatric OCD. Objective The aim of this open study is to explore the acceptability, feasibility, and effectiveness of a newly developed enhanced CBT (eCBT) package for pediatric OCD. Methods This study is an open trial using a historical control design conducted at the outpatient clinic of the Department of Child and Adolescent Psychiatry at St. Olavs University Hospital (Trondheim) or at BUP Klinikk (Aalesund). Participants are 30 children (age 7-17 years) with a primary Diagnostic and Statistical Manual of Mental Disorders (DSM)-5 diagnosis of OCD, and their parents. All participants receive eCBT. eCBT consists of the usual evidence-based CBT for pediatric OCD in an “enhanced” format. Enhancements include videoconferencing sessions (supervision and guided exposure exercises at home) in addition to face-to-face sessions; an app system of interconnected apps for the child, the parents, and the therapist; psychoeducative videos; and frequent online self-assessments with direct feedback to patients and the therapist. Primary outcome measures are the Children’s Yale-Brown Obsessive Compulsive Scale (CY-BOCS) (effectiveness), the Client Satisfaction Questionnaire-8 (acceptability), and treatment drop out (feasibility). Assessments are conducted pretreatment, posttreatment, and at 3- and 6-month follow-ups. A 12-month follow-up assessment is envisioned. The treatment outcome (CY-BOCS) will be compared to traditional face-to-face CBT (data collected in the Nordic Long-term OCD Treatment Study). Results Ethical approval has been obtained (2016/716/REK nord). Inclusion started on September 04, 2017. Data collection is ongoing. Conclusions This study is the first step in testing the acceptability, feasibility, and preliminary effectiveness of eCBT. In case of positive results, future steps include improving the eCBT treatment package based on feedback from service users, examining cost-effectiveness in a randomized controlled trial, and making the package available to clinicians and other service providers treating OCD in children and adolescents. Trial Registration ISRCTN, ISRCTN37530113; registered on January 31, 2020 (retrospectively registered); https://www.isrctn.com/ISRCTN37530113. International Registered Report Identifier (IRRID) DERR1-10.2196/24057

BACKGROUND Although the evidence base of cognitive behavioral therapy (CBT) for pediatric obsessive-compulsive disorder (OCD) has been broadly established, the treatment is hampered by limited access, poor compliance, and nonresponse. New technologies offer the opportunity to improve the accessibility, user friendliness, and effectiveness of traditional office-based CBT. By employing an integrated and age-appropriate technologically enhanced treatment package, we aim to execute a more focused and attractive application of CBT principles to increase the treatment effect for pediatric OCD. OBJECTIVE The aim of this open study is to explore the acceptability, feasibility, and effectiveness of a newly developed enhanced CBT (eCBT) package for pediatric OCD. METHODS This study is an open trial using a historical control design conducted at the outpatient clinic of the Department of Child and Adolescent Psychiatry at St. Olavs University Hospital (Trondheim) or at BUP Klinikk (Aalesund). Participants are 30 children (age 7-17 years) with a primary Diagnostic and Statistical Manual of Mental Disorders (DSM)-5 diagnosis of OCD, and their parents. All participants receive eCBT. eCBT consists of the usual evidence-based CBT for pediatric OCD in an “enhanced” format. Enhancements include videoconferencing sessions (supervision and guided exposure exercises at home) in addition to face-to-face sessions; an app system of interconnected apps for the child, the parents, and the therapist; psychoeducative videos; and frequent online self-assessments with direct feedback to patients and the therapist. Primary outcome measures are the Children’s Yale-Brown Obsessive Compulsive Scale (CY-BOCS) (effectiveness), the Client Satisfaction Questionnaire-8 (acceptability), and treatment drop out (feasibility). Assessments are conducted pretreatment, posttreatment, and at 3- and 6-month follow-ups. A 12-month follow-up assessment is envisioned. The treatment outcome (CY-BOCS) will be compared to traditional face-to-face CBT (data collected in the Nordic Long-term OCD Treatment Study). RESULTS Ethical approval has been obtained (2016/716/REK nord). Inclusion started on September 04, 2017. Data collection is ongoing. CONCLUSIONS This study is the first step in testing the acceptability, feasibility, and preliminary effectiveness of eCBT. In case of positive results, future steps include improving the eCBT treatment package based on feedback from service users, examining cost-effectiveness in a randomized controlled trial, and making the package available to clinicians and other service providers treating OCD in children and adolescents. CLINICALTRIAL ISRCTN, ISRCTN37530113; registered on January 31, 2020 (retrospectively registered); https://www.isrctn.com/ISRCTN37530113. INTERNATIONAL REGISTERED REPORT DERR1-10.2196/24057

Bij een dwangstoornis heeft iemand last van dwanghandelingen en/of dwanggedachten; ook is er vaak sprake van vermijding. De evidencebased behandeling is cognitieve gedragstherapie. Het belangrijkste element van deze therapie is exposure met responspreventie. Hierbij wordt geoefend om situaties die met dwanghandelingen gepaard gaan, zonder het uitvoeren van dwanghandelingen aan te gaan. Cognitieve interventies, gericht op het veranderen van onhandige, disfunctionele (dwang)gedachten, kunnen een belangrijke aanvulling zijn op de gedragstherapie.

Clinical consensus exists on the recommendation to add medication to cognitive behavioral therapy (CBT) for children with moderate to severe obsessive compulsive disorder (OCD). However, it has never been examined if CBT monotherapy indeed is less effective for this subgroup. In addition, CBT is often expected to be less suitable in case of an autism spectrum disorder. The aim of the present study was to examine if CBT monotherapy is an effective treatment for children with severe OCD and for children with co-morbid autistic symptoms. Methods: Participants were 58 children (8-18 years) with OCD. They were randomized over two conditions: a waitlist followed by CBT, and directly starting CBT. After CBT, participants were followed during a one-year period. Linear mixed model analyses were performed to examine if severity and autistic symptoms were predictors of treatment effect. Results: Results showed that neither baseline severity, F(2,196.52)=.29, p=.75, nor autistic symptoms, F (1, 182.72)=2.09, p=.15, were predictive of treatment effect. Conclusion: Results suggest that the majority of children with OCD, including children with severe OCD and with autistic symptoms, can be treated effectively with CBT. Therefore, the recommendation to combine CBT and medication for children with moderate to severe OCD may need refinement. (C) 2016 Elsevier Inc. All rights reserved

Initial internet-based cognitive behavioral therapy (iCBT) programs for anxiety disorders in children and young people (CYP) have been developed and evaluated, however these have not yet been widely adopted in routine practice. The lack of guidance and formalized approaches to the development and dissemination of iCBT has arguably contributed to the difficulty in developing iCBT that is scalable and sustainable beyond academic evaluation and that can ultimately be adopted by healthcare providers. This paper presents a consensus statement and recommendations from a workshop of international experts in CYP anxiety and iCBT (#iCBTLorentz Workshop Group) on the development, evaluation, engagement and dissemination of iCBT for anxiety in CYP., Highlights • This paper gives a consensus statement and recommendations for research on iCBT for anxiety in youth • We discuss considerations regarding the development, evaluation, engagement and dissemination of iCBT for anxiety in youth • ICBT for youth anxiety should be initially evaluated with a RCT, while further iterations could use other research designs • Consistent measures relating to youth anxiety and iCBT usage should be employed, as well as precise reporting of iCBT programs • Dissemination of iCBT for youth anxiety into routine clinical practice should be considered from the start of development

Inleiding: Hoewel de symptomen van een dwangstoornis duidelijk zijn, is het niet bekend wat het essentiële probleem ervan is. Kennis hierover kan consequenties hebben voor het behandelbeleid.Methode: Twee psychologische verklaringsmodellen en recent onderzoek naar behandeleffectiviteit worden besproken.Resultaten: Het cognitieve verklaringsmodel is niet aangetoond juist, maar heeft een invloedrijke vorm van behandeling gegenereerd (cognitieve therapie). Het model dat gedrag (met name herhalen) als het centrale probleem ziet, is experimenteel aangetoond. Op grond van dit model is de belangrijkste behandelstrategie exposure en responspreventie. Uit een recente meta-analyse blijkt dat cognitieve gedragstherapie (CGT) en de combinatie van CGT met medicatie effectieve behandelvormen zijn (grote effect size hebben). Als CGT wordt uitgevoerd door gespecialiseerde behandelaars is er geen verschil in effect tussen CGT en CGT gecombineerd met medicatie. Cognitive Bias Modification (CBM) en korte intensieve therapie zijn nieuwe vormen van behandeling.Conclusie: Onderzoek naar verklaringsmodellen voor de dwangstoornis is van belang voor het verbeteren van de behandeling. CGT is effectief maar zou uitgevoerd moeten worden door gespecialiseerde behandelaars. Dat het combineren van CGT met medicatie het effect van CGT vergroot is niet aangetoond. Ouders betrekken bij de behandeling is essentieel.

Om meer zicht te krijgen op de effectieve bestanddelen van cognitieve gedragstherapie bij kinderen en adolescenten met een angststoornis, werd door middel van een longitudinaal design met meerdere meetmomenten onderzocht of een verandering in een aantal beoogde mediatoren (negatieve en positieve gedachten, coping-strategieën en ervaren controle) vooraf ging aan een verandering in (ouder- en kindgerapporteerde) angstsymptomen.

The purpose is to investigate whether a change in putative mediators (negative and positive thoughts, coping strategies, and perceived control over anxious situations) precedes a change in anxiety symptoms in anxiety-disordered children and adolescents receiving cognitive behavioral therapy (CBT). Participants were 145 Dutch children (8-18 years old, M = 12.5 years, 57% girls) with a primary anxiety disorder. Assessments were completed pretreatment, in-treatment, posttreatment, and at 3-month follow-up. Sequential temporal dependencies between putative mediators and parent- and child-reported anxiety symptoms were investigated in AMOS using longitudinal Latent Difference Score Modeling. During treatment an increase of positive thoughts preceded a decrease in child-reported anxiety symptoms. An increase in three coping strategies (direct problem solving, positive cognitive restructuring, and seeking distraction) preceded a decrease in parent-reported anxiety symptoms. A reciprocal effect was found for perceived control: A decrease in parent-reported anxiety symptoms both preceded and followed an increase in perceived control. Using a longitudinal design, a temporal relationship between several putative mediators and CBT-outcome for anxious children was explored. The results suggest that a change in positive thoughts, but not negative thoughts, and several coping strategies precedes a change in symptom reduction and, therefore, at least partly support theoretical models of anxiety upon which the anxiety intervention is based.

Dysfunctional beliefs are assumed to play an important role in OCD. A new type of treatment is the Cognitive Bias Modification of Interpretation (CBM-I) training: a computerized paradigm developed to modify dysfunctional interpretations in for example OCD, anxiety, and depression. A meta-analysis focusing on adult samples revealed that CBM-I training was successful in increasing positive interpretations and decreasing negative mood states (Menne-Lothmann et al., 2014). A recent meta-analysis on the effect of CBM in child samples also shows a positive effect on interpretations, but not on mental health outcomes (Cristea, Mogoase, David, & Cuijpers, 2015). However, effects of CBM-I in children are not unequivocal. Due to a lack of studies in this field, and methodological differences and limitations it is too early to draw conclusions about the effect of CBM-I for children and adolescents with emotional disorders. Our pilot study (Salemink, Wolters, & de Haan, 2015) was the first study examining the effect of a CBM-I in children with clinical OCD. The results of this study showed that patients who received eight sessions of CBM-I training reported fewer obsessive compulsive symptoms after training, and clinicians’ ratings showed fewer obsessive symptoms, in contrast to the placebo group. As a next step, we improved the training and conducted a larger randomized controlled trial to further examine the effectiveness of a CBM-I training in children and adolescents with OCD. Participants were 79 children and adolescents between 8 and 18 years old ( M 13.7; SD 3.0) referred for outpatient treatment of OCD. Participants were randomly assigned to 12 sessions of CBM-I in 4 weeks ( N = 39) or to a waitlist of 4 weeks ( N = 40). In the second part of the study, all participants received manualized cognitive behavioral therapy. Among other measurements, the CY-BOCS, a clinician-rated semi-structured interview, was used to assess severity of OC symptoms. Results showed a significant decrease of OCD severity (CY-BOCS score) in the CBM-I condition, but not in the waitlist condition. These results are promising and possible applications of the CBM-I training in the treatment of pediatric OCD will be discussed.

Introduction Half of all patients with obsessive compulsive disorder (OCD) have their disease onset in childhood and adolescence of which up to 40 percent shows persistence of symptoms into adulthood [1]. In addition to their clinical symptoms, patients also show an underperformance in neurocognitive functioning that may hamper the efficacy of cognitive behavioral therapy (CBT) [2]. Previous studies showed changes after CBT in prefrontal cortex function and cognitive performance in pediatric OCD [3]. It remains unknown whether these changes are short lasting or persistent during a period of brain maturation. Here, we investigated the long-term effects of CBT on planning performance and brain function in pediatric OCD using a longitudinal design. Methods Fifteen pediatric OCD patients and sixteen matched healthy controls ranging from the ages of 8-18 years performed the Tower of London planning paradigm during functional magnetic resonance imaging (fMRI) at three time points; before treatment, after 16 sessions of CBT and after two years of naturalistic follow up. The task consisted of six conditions: a baseline condition and five planning conditions with increasing difficulty. Weighted contrasts for each subject for the effect of all planning moves versus baseline and for the linear effect of the increasing task load were computed. Voxel-wise statistical tests were family wise error (FWE) rate corrected (P Results Pediatric OCD patients performed the planning task significantly slower than healthy controls at baseline (pre-treatment), but with the same accuracy. After two years of follow up, reaction times were at the level of healthy controls. Imaging results at baseline showed that increasing task difficulty was associated with stronger recruitment of the left inferior frontal gyrus, middle frontal gyrus and anterior insula in patients than controls. With increasing age, activity in the left insula and right cingulum decreases, opposed to increasing activity in the parietal lobe. Normalization of the anterior insula and inferior frontal gyrus that occurred shortly after CBT continued during the two-year follow-up. Conclusion Pediatric OCD patients showed longer reaction times and additional recruitment of frontal brain regions during planning complexity compared with healthy controls. These differences tended to normalize after CBT and the process continued during two years of follow-up. This longitudinal study shows long-lasting changes in cognitive performance and prefrontal cortex function after CBT during a period of ongoing brain maturation. In addition, the temporary effects of this longitudinal study suggest that modest planning dysfunction in pediatric OCD is a state rather than a trait characteristic of the disorder.

The Anxiety Severity Interview for Children and Adolescents (ASICA) was developed for the repeated assessment of the impact of anxiety and control over anxiety symptoms. The ASICA incorporates three main components of anxiety: physical response, avoidant behaviour and anxious thoughts. The objective of this study was to evaluate the psychometric properties of the ASICA in children with anxiety disorder (n = 139, age 8–18 years) and a non‐anxious control group (n = 40, age 8–18 years). A confirmatory factor analysis confirmed the intended factor structure. Internal reliability was moderate to good; inter‐rater reliability was excellent. Four‐week test‐retest reliability was good. The ASICA discriminated between anxious and non‐anxious children and appeared sensitive to treatment change. A cut‐off score of 13 was determined. Convergent validity with anxiety symptoms was moderate; discriminant validity with depressive symptoms was less strong. The results suggest that the ASICA is a reliable instrument that could be used in clinical practice to repeatedly monitor anxiety severity. Copyright © 2013 John Wiley & Sons, Ltd.KEY PRACTITIONER MESSAGE: The ASICA was developed to repeatedly assess anxiety severity in children.The clinician assesses anxious feelings, avoidant behaviour and anxious thoughts.The ASICA discriminates well between anxious and non-anxious children.The ASICA has good psychometric properties and is treatment sensitive.The ASICA can be used in clinical practice to repeatedly monitor anxiety severity.

Background: Perceived control is thought to play an important role in the development and maintenance of anxiety disorders in children. The objective of the present study was to further investigate the Perceived Control Implicit Association Procedure (IAP, Hogendoorn et al., 2008) as an indirect measure of perceived control in children.Methods: The IAP was completed by 136 anxiety disordered children (aged 8-18 years old, M = 12.51) and 31 non-selected children (8-15 years old. M = 11.65). A second control group of 38 non-selected children (aged 8-18 years old, M = 12.08) was used to validate the pictorial stimuli in the computer task.Results: First, children were able to correctly classify the pictures into Control and No control categories. Second, as predicted, anxious children reported less perceived control than the control group on both the direct measure (the ACQ-C) and the indirect measure (IAP). For the No Control score however, this was only the case for children younger than twelve years old. Third, test-retest correlation in the anxious group was fair to good (ICCs .57.58).Conclusions: These results suggest that the perceived control IAP is still quite experimental, but could be an interesting departure point for future research on perceived control in children. (c) 2012 Elsevier Ltd. All rights reserved.

Background: Heightened error and conflict monitoring are considered central mechanisms in obsessive-compulsive disorder (OCD) and are associated with anterior cingulate cortex (ACC) function. Pediatric obsessive-compulsive patients provide an opportunity to investigate the development of this area and its associations with psychopathology. Methods: Repeated measures were carried out using functional magnetic resonance imaging (fMRI) during the performance of an interference task, the arrow version of the Flanker paradigm, before and after cognitive-behavioral treatment of 25 medication-free pediatric obsessive-compulsive patients compared with age- and gender-matched healthy controls. Results: During error trials compared to correct trials, pediatric OCD patients and controls showed an interaction effect of Group × Time × Age in the ACC and insula. This effect was mainly driven by an increased activation in older OCD subjects, which was also present after treatment. During high-conflict trials compared with low-conflict trials, a Group × Time × Age interaction effect was found in bilateral insula. This effect was driven by an increase of BOLD (blood oxygen level dependent) signal in older OCD patients before but not after treatment. In addition, a Group × Time interaction effect in dorsomedial prefrontal cortex, premotor region and ACC was found. This effect was driven by an increase of BOLD signal in OCD subjects relative to controls over time. Conclusions: Compared to healthy controls, children and adolescents with OCD show increased activation of the ACC during error responses and in bilateral insular cortex during high-conflict tasks, which is age dependent and which is only partially affected by cognitive-behavioral therapy (CBT). Therefore, we suggest that ACC functioning is a vulnerability marker in pediatric OCD, whereas insular dysfunction may be state dependent.

To improve research in cognitive theories of childhood OCD, a child version of the Obsessive Beliefs Questionnaire (OBQ-CV) has been developed (Coles et al., 2010). In the present study, psychometric properties of the Dutch OBQ-CV were examined in a community sample (N=547; 8-18 years) and an OCD sample (N=67; 8-18 years). Results revealed good internal consistency and adequate retest reliability (retest interval 7-21 weeks and 6-12 weeks, respectively). Children with OCD reported more beliefs than non-clinical children. Obsessive beliefs were related to self-reported OCD symptoms, but not to clinician-rated OCD severity. Beliefs were also related to anxiety and depression. This is the first study examining the factor structure of the OBQ-CV. Confirmatory factor analyses revealed best fit for four factors representing Perfectionism/Certainty, Importance/Control of Thoughts, Responsibility, and Threat, and a higher-order factor. This is in line with results from adult samples. These results support the reliability and validity of the Dutch OBQ-CV.

The present study first examined the links between reactive temperament (negative affectivity), regulative temperament (effortful control [EC]) and internalizing problems in adolescents (12-18 years) with anxiety disorders (ANX; N=39) and without anxiety disorders (nANX; N=35). Links differed between ANX and nANX participants. Negative affectivity predicted internalizing problems, with almost no role of EC in nANX, but a protective role of EC was found in ANX youth. Second, we investigated the role of attentional bias as a mediator between temperament and internalizing problems. Strategic threat-related bias was predicted by initial attention and EC, but these relations differed in both groups. In nANX participants, higher initial bias scores were predictive for lower strategic bias scores and higher levels of EC were associated with higher bias scores. In ANX participants, there was almost no effect of initial bias or EC on strategic attention. Internalizing problems were predicted by strategic attention, but again differently in ANX and nANX participants. High strategic bias scores were associated with an increase in anxiety in ANX and a decrease in anxiety in nANX participants.

A perceived lack of control over negative events is assumed central to the development of anxiety disorders. So far, only questionnaires were used to test this theory, but they have several disadvantages.In this study, the Implicit Association Procedure (IAP) was adapted to measure anxiety-related perceived control in an indirect way. IAP data of 33 non-selected children were compared to a direct measure of perceived control, the Anxiety Control Questionnaire for Children (ACQ-C). Results showed that higher anxious children had lower perceived control over anxiety-related events than lower anxious children, on both the indirect and the direct measure.

Voor de behandeling van de dwangstoornis bij kinderen zijn, net als voor veel andere stoornissen, duidelijke en bruikbare richtlijnen beschreven. Behandelprotocollen zijn echter in de meeste gevallen gericht op kinderen met een IQ boven de 80 zonder al te veel comorbide problematiek. In dit artikel wordt de semigeprotocolleerde behandeling van de dwangstoornis beschreven bij een tienjarige jongen met autisme en een lichte verstandelijke beperking. Voor de therapeut werd het een zoektocht door behandelrichtlijnen naar bruikbare cognitieve en gedragstherapeutische technieken. Er moest regelmatig worden geimproviseerd. Belangrijke ingredienten van de therapie waren onder meer het betrekken van de ouders bij de oefeningen, het gebruik van beloningen, duidelijke, concrete opdrachten, het varieren van technieken en bovenal lang volhouden en een onverwoestbaar vertrouwen tonen in het kind.

Single-case experimental designs are useful methods in clinical research practice to investigate individual client progress. Their proliferation might have been hampered by methodological challenges such as the difficulty applying existing statistical procedures. In this article, we describe a data-analytic method to analyze univariate (i.e., one symptom) single-case data using the common package SPSS. This method can help the clinical researcher to investigate whether an intervention works as compared with a baseline period or another intervention type, and to determine whether symptom improvement is clinically significant. First, we describe the statistical method in a conceptual way and show how it can be implemented in SPSS. Simulation studies were performed to determine the number of observation points required per intervention phase. Second, to illustrate this method and its implications, we present a case study of an adolescent with anxiety disorders treated with cognitive-behavioral therapy techniques in an outpatient psychotherapy clinic, whose symptoms were regularly assessed before each session. We provide a description of the data analyses and results of this case study. Finally, we discuss the advantages and shortcomings of the proposed method.

BACKGROUND AND OBJECTIVES: Cognitive Behavioral Therapy for children and adolescents with Obsessive Compulsive Disorder (OCD) is effective. However, since almost half of patients remain symptomatic after treatment, there remains room for improvement. Cognitive Bias Modification training of Interpretations (CBM-I) is a promising new intervention, as it targets misinterpretation of intrusions, which is seen as an important characteristic in OCD. To date, there have been no published studies of CBM-I in adolescents with OCD. The aim of the current pilot study was to examine the added value of online CBM-I training as an adjunctive treatment to the Treatment As Usual (TAU; that included CBT and pharmacotherapy) in adolescents with OCD.METHODS: Patients receiving TAU were randomly assigned to either an additional CBM-I training (n = 9), or to an additional placebo variant of this procedure (n = 7).RESULTS: Immediate, on-line interpretations changed in response to the CBM-I training, while no such effects were observed on slower retrospective off-line interpretations. Patients in the CBM-I training condition reported fewer obsessive compulsive symptoms after training, and clinicians rated them as having fewer obsessive symptoms (corresponding to medium-large effect sizes). No such changes were observed in the placebo group.LIMITATIONS: The small sample size precludes strong conclusions and replication is necessary to test the robustness of the findings.CONCLUSIONS: This small randomized controlled trial is suggestive, although not conclusive, regarding the promising additive value of OC-related CBM-I training as an adjunctive intervention to TAU in an adolescent clinical population.

Objectives: To identify neurodevelopmental differences in regional brain volume between medication-free paediatric obsessive-compulsive disorder (OCD) patients and controls at 2-year follow-up after cognitive behavioural therapy.Methods: We assessed 17 medication-free paediatric OCD patients (mean age 13.8 years; SD = 2.8; range 8.2-19.0) and 20 controls, matched on age and gender, with T1-weighted MR scans in a repeated measures design at three time points with intervals of 6 months and 2 years. Voxel based morphometry (VBM) was used to test whole brain voxel-wise for the effects of diagnosis and time on regional grey matter (GM) and white matter volumes.Results: GM volume of the orbitofrontal cortex showed a group × time interaction effect, driven by an increase of GM volume over the whole time period in OCD patients and a decrease in controls. When splitting the groups in two age groups (8-12 and 13-19 years) this interaction effect was only seen in the youngest age group.Conclusions: Neuroimaging findings in paediatric OCD after 6 months of CBT in the GM volume of the orbital frontal cortex are still present at 2-year follow-up.

A lack of perceived control over anxiety-related situations is theorized to be characteristic of anxiety disorders in children and adolescents. In the current study we tested several theoretical predictions and developmental variation with the Dutch translation of the Anxiety Control Questionnaire for Children (ACQ-C). The theoretical factor structure of anxiety control was tested using Confirmatory Factor Analysis (CFA) in 548 non-referred children (8-18 years old, M = 12.5 years; 50.7 % girls). The incremental predictive validity of perceived control for anxiety status was assessed using logistic regression in 141 clinically anxious children (age M = 12.6 years; 56.7 % girls) and 298 non-referred non-anxious children (age M = 12.6 years; 52.7 % girls). CFA showed that both a one-factor model and two-factor model (perceived control over internal reactions and external events) fit well. The one-factor model proved invariant across age and gender. Internal consistency was excellent (Cronbach's alpha = .93). Two-month test-retest reliability was adequate. The ACQ-C was able to incrementally predict diagnostic status, even after controlling for age, gender and self-reported anxiety symptoms. Finally, both younger children and girls reported less perceived control, independent of anxiety level. Findings advance the understanding of the psychometric properties of the ACQ-C, the role of control in childhood anxiety and point to the potential utility of the ACQ-C in both clinical and community samples. The Dutch translation of the ACQ-C demonstrated sound psychometric properties

Identify differences in regional brain volume between medication-free pediatric OCD patients and controls and examine changes after cognitive behavioural therapy. We assessed 29 medication-free paediatric OCD patients (Age: M = 13.78 years; SD = 2.58; range 8.2-19.0) and 29 controls, matched on age and gender, with T1-weighted MR scans in a repeated measures, pre-post treatment design. Voxel based morphometry (VBM) following diffeomorphic anatomical registration through exponential lie algebra (DARTEL) was used to test voxel-wise for the effects of diagnosis and treatment on regional gray matter (GM) and white matter (WM) volumes. After cognitive behavioural therapy, orbitofrontal GM and capsula externa WM increased in paediatric OCD relative to controls. In patients, changes in symptom severity (delta CY-BOCS) correlated positively with GM volume in the orbitofrontal cortex after treatment. Furthermore, before treatment, paediatric OCD patients, compared to the controls, showed larger GM volume in left frontal pole and left parietal cortex and larger WM volume in cingulum and corpus callosum. Our findings underscore the involvement of the ventral frontal-striatal circuit in paediatric OCD and the plasticity of this circuit in response to the modulatory effects of CBT. The possible relation to brain development is discussed

Although the meta-cognitive model (Wells, 1997, 2000) for obsessive-compulsive disorder (OCD) has clearly influenced research and treatment of OCD, little research has been performed in youth samples. In the present study the psychometric properties of the Dutch Meta-Cognitions Questionnaire-Adolescent Version (MCQ-A; Cartwright-Hatton et al., 2004) were examined in a clinical sample of adolescents with OCD (N = 40, 12-18 years) and a non-clinical sample (N = 317: 12-18 years). Results provided support for the 5-factor structure, and showed fair to good internal consistency and generally good retest reliability. Overall, adolescents with OCD reported more meta-cognitive beliefs than non-clinical adolescents. Several subscales were associated with self-reported obsessive-compulsive symptoms, anxiety and depression, but not with clinician-rated OCD severity. In conclusion, results suggest that the Dutch MCQ-A is a reliable and valid questionnaire to examine meta-cognitive beliefs in adolescents. (C) 2011 Elsevier Ltd. All rights reserved

Although selective attention to threatening information is an adaptive mechanism, exaggerated attention to threat may be related to anxiety disorders. However, studies examining threat processing in children have obtained mixed findings. In the present study, the time-course of attentional bias for threat and behavioral interference was analyzed in a community sample of 8-18-year-old children (N = 33) using a pictorial dot probe task. Threatening and neutral stimuli were shown during 17 ms (masked), 500 ms, and 1250 ms. Results provide preliminary evidence of an automatic attentional bias for threat at 17 ms that persists during later, more controlled stages of information processing (500 and 1250 ms). Furthermore, participants showed a delayed response to threat-containing trials relative to neutral trials in the 500 and 1250 ms condition, which may indicate interference by threat. Together, these results suggest that an attentional bias for threat precedes behavioral interference in children. Furthermore, results indicate that performance in daily life can be temporarily interrupted by the processing of threatening information. In addition, results of earlier studies into selective attention in children using tasks based on behavioral responses may have been confounded by interference effects of threat. For future studies, we recommend to take behavioral interference into account

Heightened error and conflict monitoring are considered central mechanisms in obsessive-compulsive disorder (OCD) and are associated with anterior cingulate cortex (ACC) function. Pediatric obsessive-compulsive patients provide an opportunity to investigate the development of this area and its associations with psychopathology.Repeated measures were carried out using functional magnetic resonance imaging (fMRI) during the performance of an interference task, the arrow version of the Flanker paradigm, before and after cognitive-behavioral treatment of 25 medication-free pediatric obsessive-compulsive patients compared with age- and gender-matched healthy controls.During error trials compared to correct trials, pediatric OCD patients and controls showed an interaction effect of Group × Time × Age in the ACC and insula. This effect was mainly driven by an increased activation in older OCD subjects, which was also present after treatment. During high-conflict trials compared with low-conflict trials, a Group × Time × Age interaction effect was found in bilateral insula. This effect was driven by an increase of BOLD (blood oxygen level dependent) signal in older OCD patients before but not after treatment. In addition, a Group × Time interaction effect in dorsomedial prefrontal cortex, premotor region and ACC was found. This effect was driven by an increase of BOLD signal in OCD subjects relative to controls over time.Compared to healthy controls, children and adolescents with OCD show increased activation of the ACC during error responses and in bilateral insular cortex during high-conflict tasks, which is age dependent and which is only partially affected by cognitive-behavioral therapy (CBT). Therefore, we suggest that ACC functioning is a vulnerability marker in pediatric OCD, whereas insular dysfunction may be state dependent.

Negatively valenced thoughts are assumed to play a central role in the development and maintenance of anxiety. However, the role of positive thoughts in anxiety is rather unclear. In the current study we examined the role of negative and positive self-statements in the anxiety level of anxious and non-anxious children. Participants were 139 anxiety disordered children and 293 non-anxious children (8-18 years). Compared to non-anxious children, anxious children reported more negative thoughts, less positive thoughts and lower State of Mind (SUM) ratios (ratio of positive to negative thoughts). Negative thoughts and SOM ratios were the strongest predictors of anxiety level in anxious children; whereas both negative and positive thoughts were the strongest predictors of anxiety level in non-anxious children. To conclude, a lack of positive thoughts might be more than just an epiphenomenon of anxiety level and might deserve a place in the cognitive model of anxiety. (C) 2011 Elsevier Ltd. All rights reserved.

Objective: Pediatric obsessive compulsive disorder (OCD) has been associated with cognitive abnormalities, in particular executive impairments, and dysfunction of frontal-striatal-thalamic circuitry. The aim of this study was to investigate if planning as an executive function is compromised in pediatric OCD and is associated with frontal-striatal-thalamic dysfunction, and if this dysfunction would normalize after successful treatment.Method: Twenty-five medication-free pediatric patients (mean ± SD 13.95 ± 2.52 years old, range 9 to 19 years) with OCD and 25 healthy controls, matched by age and gender, were scanned twice using a self-paced pseudo-randomized event-related functional magnetic resonance imaging version of the Tower of London. Patients were rescanned after 16 sessions of protocol-based cognitive behavioral therapy; healthy controls were rescanned after a similar interval.Results: Patients performed the task significantly slower but with similar accuracy compared with controls. Neuroimaging results showed less recruitment of frontal and parietal regions in patients with OCD compared with controls during the planning versus control task. With increasing task load patients compared with controls showed more recruitment of ventrolateral and medial prefrontal cortex and insula and anterior cingulate cortex. After treatment, these differences ceased to be significant, with time by group by task load interaction analyses showing a significant decrease in right posterior prefrontal activity in patients with OCD compared with healthy controls.Conclusion: Pediatric patients with OCD showed subtle planning impairments and decreased dorsolateral prefrontal and parietal recruitment that normalized after cognitive behavioral treatment. Planning dysfunction is likely to be a state rather than a trait feature of pediatric OCD.

Automatic evaluations of clinically anxious and nonanxious children (n=40, aged 8-16, 18 girls) were compared using a pictorial performance-based measure of automatic affective associations. Results showed a threat-related evaluation bias in clinically anxious but not in nonanxious children. In anxious participants, automatic evaluations of anxiety-relevant stimuli were more negative than those of negative stimuli. In nonanxious participants, evaluations of negative and anxiety-relevant stimuli did not differ. Furthermore, anxious youth had stronger negative evaluations of anxiety-relevant stimuli than nonanxious children. Automatic evaluations of positive, neutral, and negative stimuli did not differ between groups. Threat-related evaluations were predictive of parent-reported, but not child-reported, anxiety.