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The Children's Yale-Brown Obsessive Compulsive Scale-Symptom Checklist (CY-BOCS-SC; Scahill, L., Riddle, M. A., McSwiggin-Hardin, M., Ort, S. I., King, R. A., Goodman, W. K., et al. (1997). Children's Yale-Brown Obsessive Compulsive Scale: Reliability and validity. Journal of the American Academy of Child and Adolescent Psychiatry, 36, 844-852) is widely used to assess the presence of obsessions and compulsions in youth. Although factor analytic studies have established symptom dimensions of the CY-BOCS-SC, little is known of its psychometric properties. The present study sought to examine the convergent and discriminant validity of the CY-BOCS-SC. Eighty-six youth with obsessive compulsive disorder (OCD) and their parents were administered the CY-BOCS-SC, the CY-BOCS severity items, and the Anxiety Disorders Interview Schedule for DSM-IV: Parent Version (ADIS-IV-P). Children completed the Children's Depression Inventory and Multidimensional Anxiety Scale for Children. Internal consistency of CY-BOCS-SC symptom dimensions ranged from poor to good. The CY-BOCS-SC demonstrated good to excellent convergent validity, as demonstrated by large correlations with conceptually similar items on the ADIS-IV-P. The discriminant validity of the CY-BOCS-SC was also good, as evidenced by small, generally non-significant, correlations between the CY-BOCS-SC dimensions and depressive and anxiety symptoms, OCD symptom severity, and trichotillomania symptoms. These results provide initial psychometric support for the CY-BOCS-SC and support its use as a clinical and research instrument for assessing presence of a range of obsessive and compulsive symptoms in youth with OCD.

We examined parental experience of having a child with obsessive-compulsive disorder (OCD) in 62 parent–child dyads. Youth with a primary diagnosis of OCD and their parent(s) were administered the CY-BOCS jointly by a trained clinician. Parents completed several measures about their child’s OCD-related impairment and accommodation, emotional and behavioral functioning, parental distress, caregiver stress, and parental experiences of having a child with OCD. Results indicated that parents of children with OCD are considerably distressed about their child’s condition. As expected, negative parental experiences (e.g., anxiety about child’s condition, uncertainty about their future) were directly related to OCD symptom severity and impairment, as well as child internalizing and externalizing problems, family accommodation of symptoms, and caregiver strain. The presence of emotional resources was negatively related to most outcomes, although some of these relationships did not achieve statistical significance. The presence of internalizing symptoms mediated the relationship between parental experiences and parental distress. Given these findings, addressing parental experiences as part of a family based cognitive-behavioral treatment program for pediatric OCD may help reduce parental distress and improve patient prognosis.

Objective To examine the impact of psychiatric comorbidity on cognitive-behavioral therapy response in children and adolescents with obsessive-compulsive disorder. Method Ninety-six youths with obsessive-compulsive disorder (range 7-19 years) received 14 sessions of weekly or intensive family-based cognitive-behavioral therapy. Assessments were conducted before and after treatment. Primary outcomes included scores on the Children's Yale-Brown Obsessive-Compulsive Scale, response rates, and remission status. Results Seventy-four percent of participants met criteria for at least one comorbid diagnosis. In general, participants with one or more comorbid diagnoses had lower treatment response and remission rates relative to those without a comorbid diagnosis. The number of comorbid conditions was negatively related to outcome. The presence of attention-deficit/hyperactivity disorder and disruptive behavior disorders was related to lower treatment response rates, and the presence of disruptive behavior disorders and major depressive disorder were related to lower remission rates. Conclusions The presence of a comorbid disorder, particularly disruptive behavior, major depressive, and attention-deficit/hyperactivity disorders, has a negative impact on treatment response. Assessing for psychiatric disorders before treatment entry and treating these comorbid conditions before or during cognitive-behavioral therapy may improve final outcome. Comorbid anxiety or tic disorders do not seem to negatively affect response.

Obsessive-compulsive disorder (OCD) is a debilitating psychiatric condition with a heterogeneous array of obsessions and compulsions. Although factor analytic studies have identified symptom dimensions comprising the clinical presentation of OCD, many frequently reported miscellaneous symptoms are not considered in factor analytic studies because they do not fit conceptually within a particular symptom category, despite being functionally related. In the present study, we examined the associations between miscellaneous symptoms and OCD symptom dimensions in a sample of 111 adults with OCD. Overall, most miscellaneous symptoms were associated with one or more symptom dimensions in previously identified four- (14 of the 22 symptoms) and five-factor models (12 of the 22 symptoms). In both models, Contamination/Cleaning was the only dimension not related to any miscellaneous symptom. The present results provide information about which miscellaneous symptoms may be related to particular symptom dimensions, which will assist in clinical evaluations and help planning behavioral psychotherapy (e.g., hierarchy development).

Obsessive–compulsive disorder (OCD) in children and adults is a heterogeneous disorder associated with significant psychosocial impairment. Although factor analytic studies have identified symptom dimensions, these analyses do not capture the varied miscellaneous symptoms that fail to load on a specific dimension despite being functionally related. The present study sought to extend the findings of previous research in adults to a sample of youth with OCD (n=131). Logistic regression analyses were used to examine the predictive value of each of the four symptom factors (contamination symptoms, obsessions and checking, symmetry and ordering, and hoarding) to the miscellaneous OCD symptoms. The vast majority of miscellaneous symptoms (17 of the 18 symptoms) were associated with one or more symptoms factors (i.e., contamination symptoms, obsessions and checking, symmetry, and ordering). Hoarding was not related to any miscellaneous symptom. In addition to improving our understanding about the clinical presentation of pediatric OCD, findings also have important assessment (e.g., understanding which miscellaneous symptoms relate to certain dimensions) and treatment implications (e.g., hierarchy development).

This study explored the impact of comorbidity on symptom severity and treatment outcome in a sample of 75 pediatric Obsessive–Compulsive Disorder (OCD) patients. Forty received cognitive–behavioral therapy (CBT). Overall, 56% had a comorbid disorder. Results revealed that youth with comorbid disorders (anxiety or otherwise) endorsed significantly more anxiety symptoms than youth with OCD only. Youth with comorbidities instead of or in addition to anxiety exhibited more severe OCD symptoms than youth with OCD alone or an anxiety-only comorbidity. Youth in the comorbidities instead of or in addition to anxiety group had the poorest CBT response relative to the other groups. These results suggest that relative to those with OCD alone or with an anxiety disorder comorbidity, youth with comorbidities instead of or in addition to anxiety have a differing clinical presentation (e.g., more severe symptoms) and worse psychotherapy outcome.

The present study analyzed rates of peer victimization in children with a chronic tic disorder as compared to children with type 1 diabetes and healthy controls. The associations among peer victimization, tic symptom severity, and psychological symptoms, as well as the potential mediating relationship between peer victimization, tic severity, and child internalizing symptoms, were also explored. Children with tics displayed higher rates of peer victimization than control groups, and peer victimization in children with tics was positively correlated with tic symptom severity, loneliness, anxiety symptoms, and parent report of child internalizing symptoms. Results also supported the hypothesis that peer victimization mediates the relationship between tic symptom severity and loneliness. Findings highlight the importance of the assessment and treatment of psychosocial variables in children with chronic tic disorders, including social functioning and peer relationships.

Objective: This study was conducted to examine whether pediatric patients with obsessive-compulsive disorder (OCD) and hoarding symptoms differed in terms of clinical characteristics from pediatric OCD patients without hoarding symptoms. Method: Eighty children and adolescents with OCD (range, 7-17 years) completed clinician-administered and parent- and child-report measures of OCD symptom severity, impairment, and emotional and behavioral symptoms. Results: Twenty-one youth endorsed significant hoarding symptoms. Relative to nonhoarders, youth with hoarding symptoms had worse insight, more magical thinking obsessions, and ordering/arranging compulsions than nonhoarders, higher levels of anxiety, aggression, somatic complaints, and overall externalizing and internalizing symptoms. Higher rates of panic disorder were found in youth with hoarding symptoms although other comorbidity rates did not differ. Conclusions: These findings in children are partially consistent with studies in adults, and suggest that pediatric patients with hoarding symptoms may exhibit a unique clinical presentation.

Objective Tourette's Syndrome (TS) during childhood is linked to varied behavioral and psychological difficulties and functional impairment. The current study was undertaken to examine both tic-related impairment and impairment from other psychological problems in 59 youth (mean age 11.4 years, 69% male) with TS. Methods Caretakers completed a checklist about the impact of tics and other psychological difficulties on family, school, and social functioning. In addition, a clinician administered a measure of tic severity to families. Results Over half of the sample reported one significant problem area due to the presence of tics, with over a third reporting two or more problem areas. Problems were heterogeneous in nature, with no report of a particular problem area in more than 25% of the children. The rate of nontic-related impairment was very high, with 70% of parents reporting at least one problem area. Conclusions Treating both tic and nontic-related impairments concurrently may improve functioning more so than treating the symptoms separately.

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

The Florida Obsessive-Compulsive Inventory (FOCI) is a new self-report questionnaire that has separate scales for symptom enumeration (The Checklist) and evaluation of symptom severity (Severity Scale). The present research investigated the FOCI in a sample of 113 patients with obsessive-compulsive disorder (OCD). The results indicated that the FOCI Severity Scale is internally consistent (α = .89) and highly correlated with the total score from the Yale–Brown Obsessive-Compulsive Scale (Y-BOCS; Goodman et al., 1989a). The correlations of the FOCI Severity Scale with measures of depression and global severity of psychopathology were similar to those obtained with the Y-BOCS Total Severity Score. The FOCI Symptom Checklist had adequate reliability (K-R 20 = .83) and moderate correlations (rs < .45) with the FOCI Severity Scale, the Y-BOCS scales, and measures of depression and severity of psychopathology. These findings imply concurrent validity for the FOCI Severity Scale. A strength of the FOCI is that it offers a quick evaluation of both presence and severity of OCD symptoms. An important limitation is that the FOCI does not assess the severity of individual symptoms. © 2007 Wiley Periodicals, Inc. J Clin Psychol 63: 851–859, 2007.

Behavior therapy is an evidenced-based intervention with moderate-to-large treatment effects in reducing tic symptom severity among individuals with Persistent Tic Disorders (PTDs) and Tourette's Disorder (TD). This review describes the behavioral treatment model for tics, delineates components of evidence-based behavior therapy for tics, and reviews the empirical support among randomized controlled trials for individuals with PTDs or TD. Additionally, this review discusses several challenges confronting the behavioral management of tics, highlights emerging solutions for these challenges, and outlines new directions for treatment research.

This study reports an open trial of family-based cognitive-behavioral therapy (CBT) in children and adolescents with obsessive-compulsive disorder (OCD) exhibiting an onset pattern consistent with pediatric acute-onset neuropsychiatric syndrome (PANS).Eleven primarily Caucasian youth with PANS-related OCD (range=4-14 years; 6 boys) who were incomplete responders to antibiotic treatment, received family-based CBT delivered either face-to-face or via web camera.All participants completing treatment (8 of 8) were considered improved at posttreatment, and average obsessive-compulsive symptom severity was reduced by 49%. Significant reductions in obsessive-compulsive symptom severity and in clinician- and parent-rated OCD-related impairment were noted. Reductions in parent- and child-rated anxiety, child-rated OCD-related impairment, and comorbid neuropsychiatric symptoms were not statistically significant.Gains were maintained at follow-up, with 100% (6 of 6) of those assessed remaining improved. Implications for treatment and further research are discussed.

Background: Studies have noted immunological disruptions in patients with tic disorders, including increased serum cytokine levels. This study aimed to determine whether or not cytokine levels could be correlated with tic symptom severity in patients with a diagnosed tic disorder. Methods: Twenty-one patients, ages 4–17 years (average 10.63±2.34 years, 13 males), with a clinical diagnosis of Tourette's syndrome (TS) or chronic tic disorder (CTD), were selected based on having clinic visits that coincided with a tic symptom exacerbation and a remission. Ratings of tic severity were assessed using the Yale Global Tic Severity Scale (YGTSS) and serum cytokine levels (interleukin [IL]-2, IL-4, IL-5, IL-10, IL-12p70, IL-13, interferon [IFN]-γ, tumor necrosis factor [TNF]-α, and granulocyte macrophage-colony stimulating factor [GM-CSF]) were measured using Luminex xMAP technology. Results: During tic symptom exacerbation, patients had higher median serum TNF-α levels (z=−1.962, p=0.05), particularly those on antipsychotics (U=9.00, p=0.033). Increased IL-13 was also associated with antipsychotic use during exacerbation (U=4.00, p=0.043) despite being negatively correlated to tic severity scores (ρ=−0.599, p=018), whereas increased IL-5 was associated with antibiotic use (U=6.5, p=0.035). During tic symptom remission, increased serum IL-4 levels were associated with antipsychotic (U=6.00, p=0.047) and antibiotic (U=1.00, p=0.016) use, whereas increased IL-12p70 (U=4.00, p=0.037) was associated with antibiotic use. Conclusions: These findings suggest a role for cytokine dysregulation in the pathogenesis of tic disorders. It also points toward the mechanistic involvement and potential diagnostic utility of cytokine monitoring, particularly TNF-α levels. Larger, systematic studies are necessary to further delineate the role of cytokines and medication influences on immunological profiling in tic disorders.

Sudden onset clinically significant eating restrictions are a defining feature of the clinical presentation of some of the cases of pediatric acute-onset neuropsychiatric syndrome (PANS). Restrictions in food intake are typically fueled by contamination fears; fears of choking, vomiting, or swallowing; and/or sensory issues, such as texture, taste, or olfactory concerns. However, body image distortions may also be present. We investigate the clinical presentation of PANS disordered eating and compare it with that of other eating disorders.We describe 29 patients who met diagnostic criteria for PANS. Most also exhibited evidence that the symptoms might be sequelae of infections with Group A streptococcal bacteria (the pediatric autoimmune neuropsychiatric disorder associated with streptococcal infections [PANDAS] subgroup of PANS).The clinical presentations are remarkable for a male predominance (2:1 M:F), young age of the affected children (mean=9 years; range 5-12 years), acuity of symptom onset, and comorbid neuropsychiatric symptoms.The food refusal associated with PANS is compared with symptoms listed for the new Diagnostic and Statistical Manual of Mental Disorders, 5th ed. (DSM-V) diagnosis of avoidant/restrictive food intake disorder (ARFID). Treatment implications are discussed, as well as directions for further research.

Clinically elevated anxiety is a common, impairing feature of autism spectrum disorders (ASD). A modular CBT program designed for preteens with ASD, Behavioral Interventions for Anxiety in Children with Autism (BIACA; Wood et al., 2009) was enhanced and modified to address the developmental needs of early adolescents with ASD and clinical anxiety. Thirty-three adolescents (11-15 years old) were randomly assigned to 16 sessions of CBT or an equivalent waitlist period. The CBT model emphasized exposure, challenging irrational beliefs, and behavioral supports provided by caregivers, as well as numerous ASD-specific treatment elements. Independent evaluators, parents, and adolescents rated symptom severity at baseline and posttreatment/postwaitlist. In intent-to-treat analyses, the CBT group outperformed the waitlist group on independent evaluators' ratings of anxiety severity on the Pediatric Anxiety Rating Scale (PARS) and 79% of the CBT group met Clinical Global Impressions-Improvement scale criteria for positive treatment response at posttreatment, as compared to only 28.6% of the waitlist group. Group differences were not found for diagnostic remission or questionnaire measures of anxiety. However, parent-report data indicated that there was a positive treatment effect of CBT on autism symptom severity. The CBT manual under investigation, enhanced for early adolescents with ASD, yielded meaningful treatment effects on the primary outcome measure (PARS), although additional developmental modifications to the manual are likely warranted. Future studies examining this protocol relative to an active control are needed.

This article reviews evidence that led the Food and Drug Administration to issue a “black box” warning about the risk of “suicidality” (suicidal thoughts and behavior) in children and adolescents during treatment with antidepressants. Re-analysis of data from randomized clinical trials of antidepressants in the pediatric population revealed a significantly greater overall (all drugs across all indications) risk ratio for drug 1.95 (95% Cl, 1.28–2.98) compared to placebo in this sample of approximately 4,000 subjects. The essential message of the “black box” is to remind prescribers and consumers about the importance of monitoring closely for adverse behavioral changes during the initiation of (or changes in) antidepressant therapy. Possible mechanisms that might account for this phenomenon, particularly the so-called activation syndrome, are discussed. Empirical studies are needed to identify the precursors of suicidality and to predict which individuals are most susceptible to adverse behavioral side effects of antidepressants.

This case study describes the application of intensive cognitive-behavioral treatment (CBT), focusing on extinction and differential reinforcement of other behaviors (DRO), in an adolescent girl with primarily obsessional obsessive-compulsive disorder (OCD). “Abby,” a 13-year-old, Caucasian female, showed meaningful changes in OCD symptomatology during five consecutive sessions of intensive treatment. Abby’s mother also reported dramatic improvements in Abby’s functioning and in the mother-child relationship. Improvements continued to be reported by Abby and her mother and observed by therapists during follow-up sessions. The results of this case study provide preliminary support that intensive CBT incorporating extinction, cognitive restructuring skills, and DRO may be an effective treatment for pediatric OCD.

The Tourette's Disorder Scales (Shytle et al., 2003) are parent- (Tourette's Disorder Scales-Parent Rated; TODS-PR) and clinician-rated (Tourette's Disorder Scales-Clinician Rated; TODS-CR) measures that assess tics, obsessions, compulsions, inattention, hyperactivity, aggression, and emotional disturbances among children with tics. Although the TODS-PR/CR are being increasingly used in clinical trials, relatively little psychometric data have been reported. Subjects were 44 children and adolescents recruited in a university tic specialty clinic. Families were administered the TODS-CR and Yale Global Tic Severity Scale. Completion of the TODS-PR and Child Behavior Checklist were counterbalanced. Results indicated adequate to excellent internal consistency for the TODS-PR/CR scores. Excellent inter-rater agreement and convergent and divergent validity was found. These results provide further psychometric support for the TODS-PR and TODS-CR.

This study examined the frequency of peer victimization and psychological symptom correlates among youth with obsessive-compulsive disorder (OCD). The Schwartz Peer Victimization Scale, Children's Depression Inventory, and Asher Loneliness Scale were administered to 52 children and adolescents diagnosed with OCD. The child's parent or guardian completed the Child Behavior Checklist, and a trained clinician administered the Children's Yale-Brown Obsessive-Compulsive Scale (CY- BOCS). Fifty-two healthy controls and 52 children with Type 1 diabetes (T1D) who were administered the Schwartz Peer Victimization Scale as part of another study were included for comparison purposes. Greater rates of peer victimization were reported in youth with OCD relative to healthy controls and children with Type 1 diabetes (T1D). Peer victimization in the OCD sample was positively related to loneliness, child-reported depression, parent-reported internalizing and externalizing symptoms, and clinician-rated OCD severity. Peer victimization fully mediated the relation between OCD severity and both depression and parent reports of child externalizing behaviors and partially mediated the relation between OCD severity and loneliness. Recognition of the magnitude of the problem and contribution problematic peer relations may play in comorbid psychological conditions is important for clinicians who see children with OCD.

Childhood OCD often develops into a chronic illness that lasts decades. Proof that some type of immunotherapy (such as antibiotic prophylaxis) could significantly reduce recurrence or exacerbation of symptoms of OC or tics would suggest a supportive role for immune triggers in the onset or worsening of these conditions and provide additional tools for improving outcome. The validity of PANDAS will continue to be questioned, however,because demonstrating a clear causation will be difficult on a background ofa common childhood illness. Along with the previously mentioned immuno-therapy study, validation of the PANDAS phenotype (broadly interpreted)would be advanced from new and continued research in the following areas: (1) prospective studies to identify infectious triggers in the onset and exacerbations of OCD spectrum disorders, (2) biological measures for immune and genetic susceptibility, and (3) large scale epidemiological studies demonstrating the relationship between infection and OCD spectrum disorders. The assimilation of these study results should allow for elucidation of the immune system's role in the onset and maintenance of OCD.

To develop a guide to clinical assessment and pharmacotherapy for children and adults with Tourette syndrome (TS), we reviewed published literature over the past 25 years to identify original articles and reviews on the assessment and pharmacological treatment of Tourette syndrome, attention-deficit/hyperactivity disorder (ADHD) and obsessive-compulsive disorder (OCD). The literature search also included a survey of reviews published in book chapters. The assessment section was compiled from several reviews. Pharmacological treatments were classified into those with strong empirical support (as evidenced by two positive placebo-controlled studies for tics, OCD, or ADHD in TS samples); modest empirical support (one positive placebo-controlled study), or minimal support (open-label data only). We conclude that accurate diagnosis, including identification of comorbid conditions, is an essential step toward appropriate treatment for patients with TS. In many patients with TS, symptom management requires pharmacotherapy for tics or coexisting conditions. The evidence supporting efficacy and safety for medications used in patients with TS varies. But this evidence offers the best guide to clinical practice.

The children's Yale-Brown obsessive-compulsive scale (CY-BOCS) is a commonly used, psychometrically sound clinician-rated instrument of pediatric obsessive-compulsive disorder (OCD) severity. Given the relatively direct rating format and potential benefits of alternative versions that could be easily administered to patients and parents, we developed and examined the psychometric properties of child- and parent-report formats of the CY-BOCS severity items. A total of 53 children and adolescents (8-17 years old) with OCD and their parents was administered the CY-BOCS, children's Yale-Brown obsessive-compulsive scale-child report (CY-BOCS-CR), children's Yale-Brown obsessive-compulsive scale-parent report (CY-BOCS-PR), and other measures of obsessive-compulsive symptoms, internalizing, and externalizing symptoms. In general, reliability and convergent and divergent validity of the CY-BOCS-CR/PR were satisfactory. Psychometric properties for the CY-BOCS-CR in those children and adolescents with externalizing behavior problems were lower relative to those without externalizing problems. Exploratory factor analyses identified a two-factor structure in both measures comprised of disturbance and severity factors. This study provides preliminary support for the use of child- and parent-report versions of the CY-BOCS.

This study examined the psychometric properties of the Obsessive-Compulsive Scale (OCS) of the Child Behavior Checklist (CBCL). Participants included 48 youth with obsessive-compulsive disorder (OCD), 41 with a non-OCD internalizing disorder, and 101 with an externalizing disorder. Confirmatory factor analysis of the 8-item OCS did not result in an adequate fit. Exploratory factor analysis identified a 1-factor model consisting of 6 items. Adequate internal consistency for the revised OCS (OCS-R) was obtained, and convergent validity was supported by moderate relationships with other OCD indices. The OCS-R had stronger associations with measures of OCD symptoms than with measures of depression and externalizing behaviors. Youth with OCD had significantly higher OCS-R scores than those with internalizing and externalizing disorders. Suggestions for cutoff scores are provided using results from ROC analyses. Overall, these findings suggest that the OCS-R is a reliable and valid instrument for the assessment of pediatric OCD.

Despite wide use, relatively little is known about sociodemographic and clinical characteristics that predict early fluoxetine response. What research has been conducted has produced inconsistent findings, which may be due to the statistical procedures used, and no studies to date have examined predictors of early fluoxetine treatment response. Sixty adults with obsessive-compulsive disorder (OCD) completed an open-label fluoxetine trial for 8 weeks (up to 40 mg) after a 1-week, single-blind, placebo run-in before baseline assessment. The baseline and posttreatment assessment battery included the Yale-Brown Obsessive Compulsive Scale, the Hamilton Rating Scale for Depression, and the Yale Global Tic Severity Scale. Patient characteristics included illness duration, age, age of onset, gender, and pharmacological treatment history. Independent t-tests and multiple logistic regression analysis showed that longer illness duration, older age, and greater symptom severity were associated with nonresponse. Our findings highlight the impact of functional psychiatric impairment on determining those who may respond to treatment. Furthermore, findings suggest early predictors of patients with certain characteristics who may ultimately need adjunctive care to facilitate response.

Obsessive-compulsive disorder (OCD) is a relatively common disorder among children and adolescents, and is associated with increased risk for concurrent and future distress and impairment. Many youth who suffer from OCD go undiagnosed or misdiagnosed, and do not attain appropriate treatment in a timely manner. As a result, researchers have focused greater attention to the assessment of pediatric OCD. This paper provides an overview of recent advances in this area, including an introduction to several new assessment instruments. Descriptions of new and commonly used instruments and their clinical/research utility are described. Psychometric properties are also reported. Finally, a critical review is offered of major trends in the assessment of pediatric OCD (e.g., diagnostic interviews, self-report and parent-report measures, and clinician-administered inventories).

This study examined the psychometric properties of the Children's Yale-Brown Obsessive-Compulsive Scale (CY-BOCS; Scahill et al., 1997). Participants were 82 children and adolescents diagnosed with obsessive-compulsive disorder (OCD). Confirmatory factor analyses of 2 previously found models (Obsessions and Compulsions; Disturbance and Severity) yielded poor fit indexes. Exploratory factor analysis supported a model of severity and disturbance with slightly different item content than found by McKay et al. (2003). The internal consistency of the factors was acceptable, and the convergent and divergent validity was supported vis-a-vis correlations with clinician ratings of impairment, self-report measures of depression and anxiety, and parent ratings of Tourette's disorder (TD) symptoms. These findings suggest that the CY-BOCS Total Score may represent an inaccurate assessment of symptom severity and supports the use of the revised Severity and Disturbance factors in assessing illness severity.

The authors describe a protocol for intensive cognitive behavioral therapy (I-CBT) for children and adolescents with obsessive–compulsive disorder (OCD). After a review of pediatric OCD and efficacious treatments, the rationale for an intensive approach to treatment is provided along with findings in the extant literature. Subsequently, a session by session outline of I-CBT for pediatric OCD is provided. Finally, a case example of this treatment approach is discussed.

The factor structure of the Yale-Brown Obsessive-Compulsive Scale (Y-BOCS) has been examined in a number of prior investigations; however, findings have not consistently yielded a stable factor solution. The present study therefore tested the fit of each previously reported factor structure. One hundred thirty-one adults with obsessive-compulsive disorder (OCD) were administered the Y-BOCS; a portion of these participants completed self-report measures of depression and obsessive-compulsive symptoms and were rated on a global impairment index. Consistent with the originally proposed structure, confirmatory factor analyses supported a factor structure comprised of obsession and compulsion factors. Reliability and convergent validity of these factors were generally satisfactory, although divergent validity was not entirely supported. Implications of these findings on scoring the Y-BOCS are discussed.

This study evaluated the psychometric properties of the Children's Yale-Brown Obsessive-Compulsive Scale (CY-BOCS). A total of 61 children and adolescents, aged 4-18 years, who were diagnosed with obsessive-compulsive disorder (OCD) participated. Thirty-seven of these children also participated in a second CY-BOCS administration by the same rater an average of 41 days later. Good internal consistency and test-retest reliability were found for the CY-BOCS Obsession and Compulsion Severity Scores and the Total Score. CY-BOCS scores demonstrated strong correlations with clinician-rated measures of impairment, obsessions, and compulsions. In addition, CY-BOCS scores were moderately related to measures of depression, aggressive behavior, and symptoms of attention deficit hyperactivity disorder, but were not significantly related to clinician ratings of tics or self-reports of general anxiety. Findings suggest that the CY-BOCS is a reliable and valid instrument for the assessment of childhood obsessions and compulsions.

Background A subgroup of children with obsessive-compulsive and tic disorders are proposed to have an infectious trigger. The purpose of this study was to investigate the relationship between group A streptococcal titers and symptom fluctuations in children with a clinical course resembling that described for pediatric autoimmune neuropsychiatric disorders associated with streptococcus. Methods Twenty-five children with obsessive-compulsive disorder and/or tic disorder were evaluated for neuropsychiatric severity and group A streptococcal antibody titers (streptolysin O, deoxyribonuclease B, and carbohydrate A) at 6-week intervals for ≥ six consecutive evaluations (total visits=277). Results Children with large symptom fluctuations ( n = 15) were compared with children without dramatic fluctuations ( n = 10). Co-movements of obsessive-compulsive/tic severity and group A streptococcal antibodies were assessed. In subjects with large symptom changes, positive correlations were found between streptococcal titers and obsessive-compulsive severity rating changes ( p = .0130). These subjects were also more likely to have elevated group A streptococcal titers during the majority of observations ( p = .001). Tic symptom exacerbations occurred more often in the fall/winter months than spring/summer months ( p = .03). Conclusions Patients with marked obsessive-compulsive/tic symptom changes may be characterized by streptococcal titer elevations and exhibit evidence of seasonal tic exacerbations.

[Author Affiliation]Diana M. Gerardi. 1 Division of Pediatric Neuropsychiatry, Rothman Center, Department of Pediatrics, University of South Florida, St. Petersburg, Florida.Joseph Casadonte. 2 Pediatric Neurology Associates, St. Petersburg, Florida. 3 Department of Neurology, All Children's Hospital, St. Petersburg, Florida.Priyal Patel. 1 Division of Pediatric Neuropsychiatry, Rothman Center, Department of Pediatrics, University of South Florida, St. Petersburg, Florida.Tanya K. Murphy. 1 Division of Pediatric Neuropsychiatry, Rothman Center, Department of Pediatrics, University of South Florida, St. Petersburg, Florida. 4 Department of Psychiatry, University of South Florida, Tampa, Florida.Address correspondence to: Tanya K. Murphy, MD, MS, Rothman Center for Pediatric Neuropsychiatry, University of South Florida, Department of Pediatrics, 880 6th St. South, Suite 460, St. Petersburg, FL 33701, E-mail: tmurphy@health.usf.eduTo The Editor:Kleine-Levin syndrome (KLS) is a sleep disorder of unknown etiology characterized by episodic hypersomnia, hyperphagia, cognitive and mood abnormalities, and abnormal behaviors. The average age of onset is 15 years, and males are more frequently affected than females (Gadoth et al. 2001; Arnulf et al. 2005, 2008). Active episodes have an average duration of 10-13 days with reoccurrences averaging every 3.5 months, with patients typically asymptomatic between episodes (Arnulf et al. 2005, 2008). Computed tomography (CT) and magnetic resonance imaging (MRI) of the brain are typically normal in patients with KLS (Servan et al. 1993; Poryazova et al. 2007; Huang et al. 2012b), and polysomnography tends to display impairment of slow wave sleep and rapid eye movement sleep at symptom onset (Huang et al. 2008). Studies of the long-term effects of KLS are limited, but short-term memory dysfunction, academic decline, and auditory-verbal attention deficits have been observed even during periods of remission (Fontenelle et al. 2000; Landtblom et al. 2003).Pediatric autoimmune neuropsychiatric disorder associated with streptococcus (PANDAS) is a disorder characterized by an acute, sudden onset of obsessive-compulsive disorder (OCD) and/or tics, often accompanied by attention deficit/hyperactivity, separation anxiety, oppositional behaviors, and emotional lability (Swedo et al. 1998). Personality changes, cognitive disturbances, motor abnormalities, sensory sensitivity, behavioral regression, and, occasionally, psychosis are also often present (Bernstein et al. 2010; Murphy et al. 2012). The pathogenesis of PANDAS is hypothesized to be related to group A streptococcal (GAS) infections via molecular mimicry, in that streptococcal antibodies target brain proteins of similar epitopic structure to that of GAS (Cunningham 2012). PANDAS exhibits immunological similarities to Sydenham's chorea (SC), a classic infection-triggered autoimmune disorder that also presents with a high degree of OCD comorbidity (Swedo et al. 1989). However, unlike SC, definitive evidence for autoantibody-mediated reactions in PANDAS has been less conclusive (Brilot et al. 2011; Morris-Berry et al. 2013). A newer iteration of acute-onset neuropsychiatric symptoms not dependent upon a GAS association is termed "pediatric acute-onset neuropsychiatric syndrome" (PANS) (Swedo et al. 2012). Given the dramatic phenotype and the potential for long-standing neuropsychiatric sequelae, PANS is perhaps a subtype of autoimmune encephalopathy affecting primarily psychiatric symptom domains rather than the neurological symptom domains typical of other encephalopathies. For a complete review of the clinical presentation, assessments, and proposed pathophysiology of PANDAS/PANS, please see our referenced reviews (Chang et al. forthcoming, Murphy et al. 2014).Our aim is to report a case of a 9-year-old boy who exhibited symptoms of both KLS and PANDAS. …

On May 23 and 24, 2013, the First PANS Consensus Conference was convened at Stanford University, calling together a geographically diverse group of clinicians and researchers from complementary fields of pediatrics: General and developmental pediatrics, infectious diseases, immunology, rheumatology, neurology, and child psychiatry. Participants were academicians with clinical and research interests in pediatric autoimmune neuropsychiatric disorder associated with streptococcus (PANDAS) in youth, and the larger category of pediatric acute-onset neuropsychiatric syndrome (PANS). The goals were to clarify the diagnostic boundaries of PANS, to develop systematic strategies for evaluation of suspected PANS cases, and to set forth the most urgently needed studies in this field. Presented here is a consensus statement proposing recommendations for the diagnostic evaluation of youth presenting with PANS.

Pediatric acute-onset neuropsychiatric syndrome (PANS) is a subtype of obsessive compulsive disorder (OCD) marked by an abrupt onset or exacerbation of neuropsychiatric symptoms. We aim to characterize the phenotypic presentation of youth with PANS.Forty-three youth (ages 4-14 years) meeting criteria for PANS were assessed using self-report and clinician-administered measures, medical record reviews, comprehensive clinical evaluation, and laboratory measures.Youth with PANS presented with an early age of OCD onset (mean=7.84 years) and exhibited moderate to severe obsessive compulsive symptoms upon evaluation. All had comorbid anxiety and emotional lability, and scored well below normative means on all quality of life subscales. Youth with elevated streptococcal antibody titers trended toward having higher OCD severity, and presented more frequently with dilated pupils relative to youth without elevated titers. A cluster analysis of core PANS symptoms revealed three distinct symptom clusters that included core characteristic PANS symptoms, streptococcal-related symptoms, and cytokine-driven/physiological symptoms. Youth with PANS who had comorbid tics were more likely to exhibit a decline in school performance, visuomotor impairment, food restriction symptoms, and handwriting deterioration, and they reported lower quality of life relative to youth without tics.The sudden, acute onset of neuropsychiatric symptoms, high frequency of comorbidities (i.e., anxiety, behavioral regression, depression, and suicidality), and poor quality of life capture the PANS subgroup as suddenly and severely impaired youth. Identifying clinical characteristics of youth with PANS will allow clinicians to diagnose and treat this subtype of OCD with a more strategized and effective approach.

Sleep-related problems (SRPs) are common and problematic among anxious youth but have not been investigated in anxious youth with autism spectrum disorder (ASD). Participants were 102 youth (ages 7-16 years) with ASD and comorbid anxiety. Youth and their primary caregiver were administered the Pediatric Anxiety Rating Scale. Parents completed the Multidimensional Anxiety Scale for Children-Parent (MASC-P) Report, Social Responsiveness Scale, and the Child Behavior Checklist (CBCL). A measure of SRPs was created from items from the CBCL and MASC-P. Results suggest SRPs were relatively common among youth with ASD and comorbid anxiety. The number of SRPs endorsed directly associated with parent ratings of social deficits, internalizing and externalizing symptoms, and anxiety symptoms, as well as with clinician-rated anxiety symptoms. Parent-rated internalizing symptoms predicted frequency of SRPs over and above social deficits, externalizing symptoms, and parent- and clinician-rated anxiety symptoms. A subset of 40 participants who completed family-based cognitive-behavioral therapy (CBT) experienced reduced SRPs following treatment. Implications, study limitations, and recommendations for future research are discussed.

Inter-rater agreement for symptom impairment associated with obsessive-compulsive disorder (OCD) varies between parents and children. However, extraneous variables that may influence these agreement differences have scarcely been examined. Therefore, the purpose of this paper was to examine moderators of parent and child agreement on ratings of overall OCD-related impairment and impairment across three domains (i.e., school, social, home) as measured by the Children's OCD Impact Scale - Child and Parent versions (COIS-C/P). One hundred sixty-six children with OCD and their parents completed ratings of symptom severity, impairment, and demographics, among other measures, prior to psychosocial treatment initiation. Overall parent-child agreement of impairment was in the moderate range. Age, OCD symptom severity, resistance and control, obsession and compulsion severity, and insight emerged as moderator variables, with the direction of moderation varying by domain. Results, implications, and study limitations are discussed.

Clinical studies in adults and children with obsessive–compulsive disorder (OCD) have shown that d-cycloserine (DCS) can improve treatment response by enhancing fear extinction learning during exposure-based psychotherapy. Some have hypothesized that improved treatment response is a function of increased compliance and engagement in therapeutic homework tasks, a core component of behavioral treatment. The present study examined the relationship between DCS augmented cognitive-behavioral therapy (CBT) and homework compliance in a double-blind, placebo controlled trial with 30 youth with OCD. All children received 10 CBT sessions, the last seven of which included exposure and response prevention paired with DCS or placebo dosed 1 h before the session started. Results suggested that DCS augmented CBT did not predict improved homework compliance over the course of treatment, relative to the placebo augmented CBT group. However, when groups were collapsed, homework compliance was directly associated with treatment outcome. These findings suggest that while DCS may not increase homework compliance over time, more generally, homework compliance is an integral part of pediatric OCD treatment outcome.

Pharmacological and behavioral interventions have focused on reducing tic severity to alleviate tic-related impairment for youth with chronic tic disorders (CTDs), with no existing intervention focused on the adverse psychosocial consequences of tics. This study examined the preliminary efficacy of a modularized cognitive behavioral intervention ("Living with Tics", LWT) in reducing tic-related impairment and improving quality of life relative to a waitlist control of equal duration. Twenty-four youth (ages 7-17 years) with Tourette Disorder or Chronic Motor Tic Disorder and psychosocial impairment participated. A treatment-blind evaluator conducted all pre- and post-treatment clinician-rated measures. Youth were randomly assigned to receive the LWT intervention (n=12) or a 10-week waitlist (n=12). The LWT intervention consisted of up to 10 weekly sessions targeted at reducing tic-related impairment and developing skills to manage psychosocial consequences of tics. Youth in the LWT condition experienced significantly reduced clinician-rated tic-impairment, and improved child-rated quality of life. Ten youth (83%) in the LWT group were classified as treatment responders compared to four youth in the waitlist condition (33%). Treatment gains were maintained at one-month follow-up. Findings provide preliminary data that the LWT intervention reduces tic-related impairment and improves quality of life for youth with CTDs.

Perianal streptococcal dermatitis is an infection caused by group A streptococcus (GAS). Children with a pediatric autoimmune neuropsychiatric disorder associated with streptococcal infections (PANDAS) phenotype may have tics or obsessive compulsive symptoms secondary to a systemic immune activation by GAS infecting perianal areas. In this retrospective case series, the authors describe three children with symptoms consistent with PANDAS and a confirmed perianal streptococcal dermatitis as the likely infectious trigger. Concomitant perianal dermatitis and new-onset obsessive-compulsive symptoms and/or tics are strong indications for perianal culture and rapid antigen detection test in young children.

Intensive outpatient treatments for pediatric obsessive-compulsive disorder (OCD) have demonstrated efficacy for treating youth with OCD and may be especially useful for youth with severe symptomology and/or those who are partial- or non-responders to other forms of intervention. However, participation in these treatments can present challenges for youth and their families, and it is unclear if intensive treatments are more appropriate for certain individuals than others. Identification of potential predictors of treatment response and viability of intensive treatment at an individual level may aid families in their decision to participate in intensive cognitive-behavioral therapy (CBT). The present study aimed to examine the effects of three categories of predictors (demographics, OCD symptom characteristics, and comorbidity) on key target outcomes (post-treatment symptom severity, remission, and treatment response). Participants included 78 youth with a primary diagnosis of OCD who received 14 sessions of family based intensive CBT treatment over 3 weeks. Of the entire sample, 88.5% were classified as treatment responders, with 62.8% of the sample achieving clinical remission. Results identified three significant predictor variables (i.e., symptom severity, family accommodation, and gender) for post-treatment symptom severity and remission status within the context of the examined predictive models. No variables were identified as predictive of treatment response, and comorbidity was not identified as a predictor variable for any treatment outcome.

During the last few years, an increased interest in the possibility of immune mediated pathophysiology of obsessive compulsive disorder (OCD) and related disorders has been seen. In the late 1980s, the National Institute of Mental Health reported an increase of obsessive compulsive symptoms in patients with Sydenham chorea (SC). Subsequently, a precipitating streptococcal infection in children with sudden onset of OCD symptoms but no chorea led to the coining of PANDAS (pediatric autoimmune neuropsychiatric disorders associated with streptococcus). This association has furthered interest in studying immune parameters in non-PANDAS OCD as well. This article will review the neuropsychiatric findings in OCD and Tourette syndrome (TS) with emphasis placed on PANDAS, and its association with SC, and a review of the existing studies that have assessed immunologic measures in patients with OCD and TS.

Background: Previous research has suggested that a subgroup of children with obsessive compulsive disorder (OCD) have neuropsychiatric sequelae of streptococcal pharyngitis, similar to that seen in the neurological manifestation of rheumatic fever (RF). Monoclonal antibody D8/17 demonstrates increased binding to B cells in patients with RF and in patients with neuropsychiatric disorders using immunofluorescent microscopy. Objective: The aim of this study was to determine if an earlier immunofluorescent microscopy study of monoclonal antibody D8/17 in childhood-onset OCD and/or chronic tic disorder (CTD) could be replicated using the more objective method of flow cytometric analysis. Method: D8/17 binding to B cells was determined in patients with OCD and or CTD (N=32), and healthy controls (N=12) by flow cytometric analysis. Results: Subjects with OCD/CTD showed increased mean cell binding (26.0%) of monoclonal antibody compared with healthy controls (9.1%) (p

Sydenham's chorea (SC) is a major manifestation of rheumatic fever characterized by an array of neuropsychiatric symptoms that vary in severity, timing, and character. Some of the same symptoms are seen in Tourette's syndrome and childhood-onset obsessive-compulsive disorder. Genetic vulnerability appears to play a role in all three conditions. The term PANDAS (pediatric autoimmune neuropsychiatric disorder associated with streptococcus) has been introduced to describe a putative subset of obsessive-compulsive disorder and Tourette's syndrome that bears some resemblance to Sydenham's chorea. This article discusses whether PANDAS should be subsumed under Sydenham's chorea, thus expanding the diagnostic boundaries of Sydenham's chorea to include primarily neuropsychiatric presentations now classified as cases of obsessive-compulsive disorder or Tourette's syndrome. We conclude that PANDAS is a useful construct, but that it would be premature to view it as a subset of Sydenham's chorea-whether defined narrowly or broadly.

Early childhood trichotillomania (TTM) has often been considered to be benign. However, untreated early childhood TTM can have significant negative physical and psychological consequences. This report describes the behavioral treatment of a 29-month-old girl with TTM. Treatment consisted of 14 daily sessions of behavioral intervention, followed by 3 consecutive days of follow-up treatment conducted 7 weeks after the end of initial treatment. The hair pulling was addressed by using reinforcers for not pulling, provided at intervals of increasing length. At the end of initial treatment, the hair pulling improved significantly. At follow-up, although some of the initial treatment gains were reduced, the patient maintained significant improvement compared with baseline.