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There are no reports of a child taking a selective serotonin reuptake inhibitor and an atypical anti-psychotic being successfully tapered from these medications after completion of cognitive-behavioral therapy (CBT) for obsessive-compulsive disorder. With this in mind, we report the case of an 8.5-year–old male who was taking risperidone 0.5 mg bid, sertraline 100 mg, and atomoxetine 25 mg at presentation. After a successful course of CBT, we describe how medications were systematically withdrawn. Implications of this case on practice parameters (e.g., CBT may be an effective augmenting agent for those non-responsive to initial pharmacological treatments) are highlighted. Depression and Anxiety, 2009. © 2008 Wiley-Liss, Inc.

We report the case of adolescent male with obsessive-compulsive disorder (OCD) who had an incomplete response to combined cognitive-behavioral therapy (CBT) and sertraline before successful augmentation of CBT with aripiprazole. Standardized assessments indicated significant reductions in OCD symptomatology associated with both initial treatment and aripiprazole augmentation. This case suggests that aripiprazole may have utility as an augmenting agent of CBT in adolescents with OCD and underscores the need for conducting controlled studies to test this hypothesis.

Exposure-based cognitive-behavioral therapy and serotonin reuptake inhibitor medications are efficacious treatment options for the management of pediatric obsessive-compulsive disorder. Despite established efficacy, many youths receiving either therapy remain symptomatic after acute treatment. Regardless of the rationale for persistent symptoms, a clear need emerges for treatment options that restore functioning efficiently to symptomatic youths. One innovative approach builds upon the identified role of NMDA receptors in the fear extinction process. Instead of breaking existing connections during fear extinction, new associations develop that eventually predominate over prior associations. Recent investigations have explored augmenting exposure-based cognitive-behavioral therapy with the NMDA partial agonist d-cycloserine, with preliminary results demonstrating expedited treatment gains and moderately larger effects above exposure and response prevention therapy alone. A large randomized clinical trial is underway to evaluate the efficacy and efficiency of this therapeutic combination in pediatric obsessive–compulsive disorder. Results from this trial may translate into improved management practices.

Serotonin reuptake inhibitor medications and cognitive-behavioral therapy (CBT) are both effective treatments for pediatric obsessive-compulsive disorder (OCD). Despite recommendations that youth with OCD be treated with CBT alone or together with serotonin reuptake inhibitor medication, many youth are treated with medication alone or with non-CBT psychotherapy initially. Although effective, symptom remission with medication alone is rare (e.g., only 21.4% of youth achieved remission with sertraline in the Pediatric OCD Treatment Study, 2004) and residual symptoms often remain (e.g., 58% of subjects in the March et al. [1998] sertraline trial were not considered treatment responders). This paper reviews the literature on the efficacy of CBT for pediatric OCD, particularly as it relates to the treatment of youth with prior inadequate response to medication. It also describes an intensive, family-based CBT program for children and adolescents with OCD and support for its efficacy among those with prior partial- or nonresponse to medication. Finally, we present a case study of an adolescent girl with OCD who participated in the intensive treatment program after having limited benefit from medication and non-CBT psychotherapy and experienced a favorable response.

Few studies have examined neuropsychological functioning among youth with obsessive compulsive disorder (OCD), with inconclusive results. Although methodological differences may contribute to inconsistent findings, clinical factors may also account for differential performance. Symptom dimensions are associated with specific patterns of genetic transmission, comorbidity, and treatment outcome, and may also be uniquely associated with neuropsychological performance. This study examined differences in cognitive sequelae and neurocognitive impairment across symptom dimensions among youth with OCD.Participants included 93 treatment-seeking youth diagnosed with OCD. A trained clinician administered the Children's Yale-Brown Obsessive Compulsive Scale (CY-BOCS) to parents and children together. Afterward, youth completed a battery of neuropsychological tests that assessed nonverbal memory and fluency, verbal memory, verbal fluency, verbal learning, processing speed, and inhibition/switching.Across five symptom dimensions, youth exhibiting Hoarding symptoms (χ(2) = 5.21, P = .02) and Symmetry/Ordering symptoms had a greater occurrence of cognitive sequelae (χ(2) = 4.86, P = .03). Additionally, youth with Symmetry/Ordering symptoms had a greater magnitude of cognitive impairment (Mann-Whitney U = 442.50, Z = -2.49, P.02), with specific deficits identified on nonverbal fluency (P.01), processing speed (P.01), and inhibition and switching (P.02).Neuropsychological deficits identified in youth with Hoarding and Symmetry/Ordering symptoms may suggest that these symptoms have characteristics specific to neurocognitive impairment. Alternatively, symptoms associated with these dimensions may impede youth's performance during testing. Findings advise neuropsychological testing for youth with symptoms on either of these dimensions when concerns about neuropsychological and/or academic impairment are present.

Background To examine the efficacy of sequential sertraline and cognitive-behavioral therapy (CBT) treatment relative to CBT with pill placebo over 18 weeks in children and adolescents with obsessive–compulsive disorder (OCD). Methods Forty-seven children and adolescents with OCD (Range = 7–17 years) were randomized to 18-weeks of treatment in one of three arms: 1) sertraline at standard dosing + CBT (RegSert + CBT); 2) sertraline titrated slowly but achieving at least 8 weeks on the maximally tolerated daily dose + CBT (SloSert + CBT); or 3) pill placebo + CBT (PBO + CBT). Assessments were conducted at screening, baseline, weeks 1–9, 13, and 17, and post-treatment. Raters and clinicians were blinded to sertraline (but not CBT) randomization status. Primary outcomes included the Children's Yale-Brown Obsessive–Compulsive Scale, and response and remission status. Secondary outcomes included the Child Obsessive Compulsive Impact Scale–Parent/Child, Children's Depression Rating Scale-Revised, Multidimensional Anxiety Scale for Children, and Clinical-Global Impressions-Severity. Results All groups exhibited large within-group effects across outcomes. There was no group by time interaction across all outcomes suggesting that group changes over time were comparable. Conclusions Among youth with OCD, there was no evidence that sequentially provided sertraline with CBT differed from those receiving placebo with CBT. ClinicalTrials.gov Identifier NCT00382291 .

In children presenting with obsessive compulsive disorder (OCD) and/or tics, especially those with a temporal association with streptococcal pharyngitis (eg, Pediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcus), there is speculation about whether tonsillectomy/adenoidectomy might improve the child's neuropsychiatric course. Our objective was to examine whether removal of the tonsils and/or adenoids impacted streptococcal antibody titers, the timing of onset of OCD and/or tics and the clinical severity of these symptoms.Study participants (N = 112; average age = 9.2 ± 2.4; 44 women) were recruited as part of a prospective investigation of neuropsychiatric phenomena with temporal association to streptococcal pharyngitis and examined by family history, diagnostic interview, physical examination, medical record review, psychological testing and streptococcal antibodies and divided into surgical or nonsurgical groups. The surgical group consisted of children having previously had a tonsillectomy and/or adenoidectomy (n = 32). The remaining children were categorized as nonsurgical group (n = 76). Measures of OCD and tic severity, streptococcal antibody titers and Pediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcus classification were compared between both groups.There were no significant differences as determined by streptococcal antibody titers, Pediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcus classification and OCD or tic severity between the surgical and nonsurgical groups. Most participants had surgery before the onset of neuropsychiatric symptoms and surgery did not affect symptomology.Streptococcal antibodies and neuropsychiatric symptom severity did not differ on the basis of surgical status. From these data, we cannot infer that tonsillectomy and adenoidectomy are likely to impact positively the course of OCD/tics or streptococcal antibody concentrations.

The psychometric properties of the Children’s Yale-Brown Obsessive Compulsive Scale (CY-BOCS) were investigated in 46 treatment-seeking youth, 7–15 years of age, who were diagnosed with an autism spectrum disorder (ASD) and exhibited obsessive–compulsive symptoms. The CY-BOCS Total score exhibited good internal consistency, with differing internal consistencies observed on the Obsession Severity scale (α = 0.86) and Compulsion Severity scale (α = 0.59). Good to excellent inter-rater reliability was observed for the CY-BOCS Total score and both Severity scales. Convergent and divergent validity of the CY-BOCS Total score and both Severity scales were satisfactory. Insight into obsessive–compulsive symptoms was moderately associated with the CY-BOCS Total score. The CY-BOCS demonstrated treatment sensitivity, demonstrating significant changes in obsessive–compulsive symptoms within a subsample of youth receiving cognitive-behavioral treatment. Overall, the CY-BOCS demonstrated adequate psychometric properties and utility in assessing obsessive–compulsive symptoms in youth with ASD and clinically significant obsessive–compulsive symptoms.

This pilot study explored the preliminary efficacy, parent acceptability and economic cost of delivering Step One within Stepped Care Trauma-Focused Cognitive Behavioral Therapy (SC-TF-CBT). Nine young children ages 3–6 years and their parents participated in SC-TF-CBT. Eighty-three percent (5/6) of the children who completed Step One treatment and 55.6 % (5/9) of the intent-to-treat sample responded to Step One. One case relapsed at post-assessment. Treatment gains were maintained at 3-month follow-up. Generally, parents found Step One to be acceptable and were satisfied with treatment. At 3-month follow-up, the cost per unit improvement for posttraumatic stress symptoms and severity ranged from $27.65 to $131.33 for the responders and from $36.12 to $208.11 for the intent-to-treat sample. Further research on stepped care for young children is warranted to examine if this approach is more efficient, accessible and cost-effective than traditional therapy.

In some instances, neuropsychiatric symptoms, such as obsessive–compulsive symptoms and tics, can have a sudden and dramatic onset following an infection in a condition known as Pediatric Autoimmune Neuropsychiatric Disorder Associated with Streptococcus (PANDAS). This chapter discusses the PANDAS phenotype, immune triggers, diagnosis, and treatment of the condition, as exemplified through a case study.

This study assessed the impact of a prior-authorization process on the use of antipsychotic medications by children under six years old in Florida's fee-for-service Medicaid program.Child psychiatrists reviewed requests for antipsychotic treatment (N=1,424) using forms and criteria created by a panel of Florida-based experts. Data on the characteristics of the children and clinicians involved were organized into 11 consecutive quarters beginning in July 2008. Multivariate generalized estimating equations were used to examine the association between each study variable and changes in the odds of submission of a new request over time.Prior-authorization requests declined from 124 in the first quarter to 81 in the last quarter. Compared with applications from child psychiatrists, the odds of applications being submitted by adult psychiatrists, neurologists, and pediatricians increased over time.Although applications declined, the diminished role of child psychiatry specialists raises questions about the impact of the program on the quality of care provided.

Importance Cognitive behavior therapy (CBT) among youth with obsessive-compulsive disorder (OCD) is effective, but many patients remain symptomatic after intervention.d-cycloserine, a partial agonist at theN-methyl-d-aspartate receptor in the amygdala, has been associated with enhanced CBT outcome for OCD among adults but requires evaluation among youth. Objectives To examine the relative efficacy of weight-adjustedd-cycloserine (25 or 50 mg) vs placebo augmentation of CBT for youth with OCD and to assess if concomitant antidepressant medication moderated effects. Design, Setting, and Participants In a placebo-controlled randomized clinical trial, 142 youths (age range, 7-17 years) enrolled between June 1, 2011, and January 30, 2015, at 2 academic health science centers (University of South Florida and Massachusetts General Hospital) with a primary diagnosis of OCD were randomized in a double-blind fashion tod-cycloserine plus CBT or placebo plus CBT. Intent-to-treat analysis was performed. Interventions Patients were randomly assigned in a 1:1 ratio to either 10 sessions ofd-cycloserine plus CBT or placebo plus CBT.d-cycloserine (25 or 50 mg) or placebo was taken 1 hour before sessions 4 through 10. Main Outcomes and Measures Children’s Yale-Brown Obsessive Compulsive Scale at randomization, biweekly, midtreatment, and posttreatment. Secondary outcomes included the Clinical Global Impressions–Severity or Clinical Global Impressions–Improvement, remission status, Children’s Depression Rating Scale, Multidimensional Anxiety Scale for Children, and Children’s Obsessive-Compulsive Impact Scale–Parent Version. Results The study cohort comprised 142 participants. Their mean (SD) age was 12.7 (2.9) years, and 53.5% (76 of 142) were female. A mixed-effects model using all available data indicated significant declines in the Children’s Yale-Brown Obsessive Compulsive Scale total score and Clinical Global Impressions–Severity. No significant interaction between treatment group and changes in the Children’s Yale-Brown Obsessive Compulsive Scale and Clinical Global Impressions–Severity indicated that thed-cycloserine plus CBT group and the placebo plus CBT group declined at similar rates per assessment point on the Children’s Yale-Brown Obsessive Compulsive Scale total score (estimate, −2.31, 95% CI, −2.79 to −1.83 and estimate, −2.03, 95% CI, −2.47 to −1.58, respectively) and Clinical Global Impressions–Severity (estimate, −0.29, 95% CI, −0.35 to −0.22 and estimate, −0.23, 95% CI, −0.29 to −0.17, respectively). No group differences in secondary outcomes were present. Antidepressant medication use at baseline did not moderate changes for either group. Conclusions and Relevance d-cycloserine augmentation of CBT did not confer additional benefit relative to placebo among youth with OCD. Other augmentation approaches should be examined to enhance outcome. Trial Registration clinicaltrials.gov Identifier:NCT00864123

Corrigendum to “Side-effects of SSRIs disrupt multimodal treatment for pediatric OCD in a randomized-controlled trial” [J. Psychiatr. Res. 71 (2015) 140e147] Adam M. Reid a, b, c, , Joseph P.H. McNamara a, , Tanya K. Murphy e, f, , Andrew G. Guzick a, , Eric A. Storch e, f, g, h, , Gary R. Geffken a, b, , Regina Bussing a a Department of Psychiatry, University of Florida, PO Box 100256, 1149 Newell Dr., L4-100, Gainesville, FL 32611, USA b Department of Clinical and Health Psychology, University of Florida, 1225 Center Drive, Room 3151, Gainesville, FL 32611, USA c Harvard Medical School, Department of Psychiatry, 401 Park Drive, 2 West Room 305, Boston, MA 02215, USA d Department of Psychology, University of Florida, 2014 Turlington Hall, Gainesville, FL 32611, P.O Box 117300, USA e Department of Psychiatry and Behavioral Neurosciences, University of South Florida, 3515 E. Fletcher Ave, Tampa, FL 33613, USA f Department of Pediatrics, University of South Florida, 880 6th Street South, Box 7523, St. Petersburg, FL 33701, USA g All Children's Hospital, John Hopkins Medicine, 600 N Wolfe St # 157, Baltimore, MD 21287, USA h Department of Health Policy and Management, University of South Florida, 13201 Bruce B. Downs Blvd., MDC56, Tampa, FL 33612, USA i Rodgers Behavioral Health-Tampa Bay, 2002 N Lois Ave, Tampa, FL 33607, USA j Department of Pediatrics, University of Florida, 1600 SW Archer Road, Gainesville, FL 32607, USA

This chapter reviews the literature on obsessive compulsive spectrum disorders (i.e., obsessive compulsive disorder, body dysmorphic disorder, trichotillomania, Tourette syndrome, and varied body-focused repetitive behaviors) in children and adolescents. For each disorder, data on phenomenology, associated clinical characteristics, etiology, and treatment are reviewed. The chapter concludes with a discussion of future research and clinical directions, such as novel augmentation strategies, diagnostic classification of obsessive compulsive spectrum disorders, and methods of maximizing treatment outcome.

Antimicrobial compounds and psychotropic medications often share overlapping mechanisms of actions and pharmacological effects. The immune system appears to be an important site of interaction as several antimicrobials display neurological and, at times, direct psychotropic effects, while psychotropics have shown significant immunomodulatory properties. The isoniazid class of antibiotics for example has been shown to possess monoamine oxidase activity, while selective serotonin reuptake inhibitors have shown significant effects on leukocyte populations. As the importance of the immune system's role in CNS homeostasis and disease continues to move to the forefront of neuropsychiatric research, these shared pharmacological effects may provide an important insight, elucidating the complexities in neuroimmune pathophysiology and guiding the development of potential treatments.

This study evaluated the psychometric properties of the treatment-emergent activation and suicidality assessment profile (TEASAP) in a clinical sample of 56 youth ages 7 to 17 with obsessive compulsive disorder (OCD) who participated in a double-blind randomized controlled trial. The 38-item TEASAP demonstrated good internal consistency for its total score (α = 0.93) and adequate to good performance for its five subscale scores (α = 0.65 to 0.92). One week test-retest stability (N = 18) was adequate (Intraclass correlation coefficient [ICC] = 0.68 to 0.80) except for Self-Injury (ICC = 0.46). Construct validity was supported by total and subscale TEASAP score relationships with related constructs, including irritability, hyperactivity, externalizing behaviors, manic symptoms, and suicidal ideation, and the absence of relationships with unrelated constructs. Predictive validity was established for the Disinhibition subscale through significant associations with subsequent activation events. Furthermore, TEASAP sensitivity to change in activation scores over time was supported by longitudinal associations of TEASAP scores with clinician ratings of activation over the course of treatment. Findings indicate that the TEASAP has acceptable psychometric properties in a clinical sample of youth with OCD and merits further study in larger samples for additional refinement of its measurement approaches.

Body-focused repetitive behavior (BFRB) is an umbrella term for debilitating, repetitive behaviors that target one or more body regions. Despite regularly occurring in youth, there has been limited investigation of BFRBs in pediatric populations. One reason for this may be that there are few reliable and valid assessments available to evaluate the presence, severity and impairment of BFRBs in youth. Given the shift toward evidence-based assessment in mental health, the development and utilization of evidence-based measures of BFRBs warrants increasing attention. This paper examines the available evidence-base for assessments in youth across three BFRB-related disorders: compulsive skin picking, chronic tic disorders and trichotillomania. Based upon present empirical support in samples of youth, recommendations are made for an evidence-based assessment of each condition.

The psychometric properties of the Pediatric Anxiety Rating Scale (PARS), a clinician-administered measure for assessing severity of anxiety symptoms, were examined in 72 children and adolescents diagnosed with an autism spectrum disorder (ASD). The internal consistency of the PARS was 0.59, suggesting that the items were related but not repetitive. The PARS showed high 26-day test-retest (ICC = 0.83) and inter-rater reliability (ICC = 0.86). The PARS was strongly correlated with clinician-ratings of overall anxiety severity and parent-report anxiety measures, supporting convergent validity. Results for divergent validity were mixed. Although the PARS was not associated with the sum of the Social and Communication items on the Autism Diagnostic Observation System, it was moderately correlated with parent-reported inattention, aggression and externalizing behavior. Overall, these results suggest that the psychometric properties of the PARS are adequate for assessing anxiety symptoms in youth with ASD, although additional clarification of divergent validity is needed.

Obsessive-compulsive disorder (OCD) is an anxiety disorder that affects between 1% to 2% of individuals and causes considerable impairment and disability. Although > 50% of individuals experience symptom onset in childhood, symptoms can continue to develop throughout adulthood. Accurate and timely assessment of clinical presentation is critical to limit impairment and improve prognosis. Presently, there are 2 empirically supported treatments available for OCD in children and adults, namely cognitive-behavioral therapy and pharmacotherapy with serotonin reuptake inhibitors. This article provides an introduction to the phenomenology, etiology, and clinical course of OCD. Assessment practices used to evaluate symptom severity are described, and evidence-based treatment options are reviewed, with appropriate distinctions drawn between children and adults. Finally, recommendations for assessment and treatment practices for OCD are explicated.

Background: Genetic linkages with psychiatric disorders have been documented. In our clinical practice, we noticed a high propensity for blood disorders in female patients with certain neuropsychiatric phenomenon, specifically Tourette Syndrome (TS) or Trichotillomania (TTM). With this clinical observation, we hoped to better understand a possible genetic correlation, namely the role of chromosome 11 which encodes for both the B globulin gene and human dopamine receptor D4 (DRD4) gene. Method: This is a retrospective case series of six children found to have a blood disorder and neuropsychiatric diagnosis in our clinic. We used family interview, lab results, and the patient’s medical chart for data collection Results: Our case series reveals six children with a repetitive neuropsychiatric disorder and a blood disorder. Conclusions: Currently, there are no definitive susceptibility genes that have been identified to date for TS or TTM. We postulate that blood disorders found on chromosome 11 may play a role as a susceptibility factor, particularly in females, for repetitive neuropsychiatric disorders.

Sydenham chorea (SC), a major manifestation of rheumatic fever (RF), is thought to occur when antibodies directed against group A streptococcus (GAS) cross-react with epitopes on neurons of the basal ganglia. In earlier work with SC, Swedo and colleagues identified children who, in addition to chorea, presented with obsessive-compulsive behavior. A precipitous onset of childhood obsessive-compulsive disorder (OCD) after streptococcal pharyngitis was subsequently described that shared many similarities to SC but did not have chorea or clinical signs of RF such as arthritis and carditis. Swedo and colleagues termed this subtype of childhood-onset OCD, pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections (PANDAS). Both pathogen- and host-related factors appear to influence the risk of acquiring RF, with only 2% to 3% of untreated individuals infected by GAS developing RF. Susceptibility to RF is influenced by age, GAS serotypes, family history, and environmental conditions. Children between the ages of 5 and 14 years show the highest rate of this complication. The observation that RF is more prevalent among relatives of the probands than unrelated controls supports the hypothesis that susceptibility to RF is, in part, genetically determined. Environmental influences, such as crowded living conditions, may contribute to the risk of developing RF. Pathogen-mediated factors play a role as well, with specific GAS serotypes conferring increased susceptibility to RF, although genome-based analyses of GAS should lead to identification of more specific virulence factors. In the absence of carditis and arthritis, the diagnosis of SC is frequently a diagnosis of exclusion. Elevated streptococcal titers at the time of presentation suggest but do not prove a causative role. Similarly, the association of streptococcal illness with children presenting with PANDAS may occur coincidentally. Advances in identification of reliable clinical and/or biological markers of these disorders could further our understanding of pathophysiology and lead to increased specificity in diagnosis and treatment. Progress toward identifying a molecular marker for RF began in the 1970s, when Patarroyo and colleagues isolated an antibody from the serum of a multiparous woman with several children who had developed RF. This alloantisera 883 reacted with B cells from 71% of patients with RF and 16% of controls. Later, Zabriskie and colleagues produced two monoclonal antibodies by immunizing mice with B cells from known 883positive and 883-negative RF patients, which, when used in

A growing body of evidence from research on autism spectrum disorder (ASD) confirms a substantial sensory motor component to ASD. Yet, policy and practice lag behind in recognizing the potential contributions of physical therapists in research, practice, and education related to ASD. The objective of this commentary is to inform and encourage reflection and formal dialogue among pediatric physical therapists regarding the assumption of vital roles in research, education, and clinical practice in ASD.Selected studies representative of the type of work being carried out with respect to motor aspects of ASD is presented with selected older literature for those unfamiliar with the range of information available.Findings from research provide ample substantiation for physical therapists to join interdisciplinary efforts as researchers, scholars, educators, policy analysts, and advocates in ASD. Physical therapists have the potential and ability to play a much greater role in ASD.

Objective Rage attacks have been documented in youth with varied psychiatric disorders, but few data have been reported on the clinical characteristics and correlates of rage attacks among children with obsessive-compulsive disorder (OCD). Method Participants were 86 children (ages 6–16 years) with a primary diagnosis of OCD. Patients and their primary caregiver were administered clinician-rated measures of obsessive-compulsive severity and rage severity. Children completed the Center for Epidemiologic Studies Depression Scale and the Child Sheehan Disability Scale-Child, whereas parents completed the Rage Attacks Questionnaire, Aberrant Behavior Checklist—Irritability Scale, Children's Affective Lability Scale, and Child Sheehan Disability Scale-Parent. Results Rage was common among youth with OCD and was associated with varied clinical characteristics. Rage severity accounted for functional impairment beyond the influence of obsessive-compulsive symptom severity; however, these relations were explained by the impact of family accommodation. Conclusions These data suggest that rage attacks are relatively common, have a negative impact on illness presentation, and contribute to functional impairment above and beyond obsessive-compulsive symptom severity. Rage may contribute to family accommodation of symptoms, which may further affect obsessive-compulsive symptom severity and impairment.

Family accommodation of symptoms is counter to the primary goals of cognitive-behavioral therapy for pediatric obsessive-compulsive disorder (OCD) and can pose an obstacle to positive treatment outcomes. Although increased attention has been given to family accommodation in pediatric OCD, relatively little is known about associated child and parent characteristics, and their mediating/moderating effects. This study examined a structural equation model of parent and child variables related to parent reports of family accommodation. Sixty-one children with OCD (ages 6–17 years, 39% female) and their parents were recruited from a university-based clinic. They were administered clinician- and parent-rated measures of child OCD symptom severity, OCD-specific impairment, internalizing problems, and externalizing problems as well as parent anxiety, depression, empathy, consideration of future consequences, and accommodation. Results generally supported the hypothesized model. Family accommodation mediated the relationship between OCD symptom severity and parent-rated functional impairment; child internalizing problems mediated the relationship between parent anxiety and family accommodation; and parent empathy and consideration of future consequences interacted to predict family accommodation. Child externalizing problems were significantly associated with family accommodation but neither of these two variables was associated with parent depression. Findings suggest that reductions in family accommodation might be maximized by routinely screening for comorbid psychopathology in children with OCD and their parents, and using prescriptive or modular approaches to intervention. Directions for future research are discussed.

Tic disorders impact quality of life, but when they are co-occurring with attention-deficit/hyperactivity disorder, the combined impact takes a toll on psychosocial functioning and adds another layer of complexity to treatment approaches. A review of the current literature supports evidence of a unique relationship between comorbid attention-deficit/hyperactivity disorder and tic disorders, emphasizing the intricate phenotype and impairment associated with these co-occurring conditions. The complexity of these symptoms requires careful diagnosis and appropriate treatment as determined by the level of impairment and can include pharmacotherapy, behavioral interventions, or a combination of therapies. To achieve the greatest benefits in improving quality of life and eliminating further comorbidity, an ideal treatment plan would include a comprehensive evaluation as well as a hierarchical treatment approach involving education of the child, family, and teachers; careful medication management; and cognitive and behavioral training.

There are little data concerning clinical characteristics of women with Tourette disorder and chronic tic disorders in the extant literature and what is available mostly focuses on treatment-seeking individuals. The present research was conducted to provide a phenomenological characterization of tic disorders among 185 adult women with tic disorders. In addition to providing a descriptive overview of specific tic symptoms, tic severity, self-reported history of other psychiatric conditions, and impairment/lifestyle impact due to tics, this study compares 185 women and 275 men between 18 and 79 years old with tic disorders (who completed an identical battery of measures) based on demographic, social/economic status indicators, psychiatric variables (comorbidity, family psychiatric history, symptom presentation), adaptive functioning/quality of life, and impairment variables among a nonclinical adult sample. Finally, this research examines the relationship between tic severity and impairment indicators among women with tics. Sixty-eight percent of women in our sample reported severe motor tics and 40% reported severe phonic tics. Our exploratory data suggest that a sizeable number of adult women with persistent tics are suffering from psychiatric comorbidity and psychosocial consequences such as underachievement and social distress. Tic severity in women may be associated with lifestyle interference as well as with symptoms of depression and anxiety, and such symptoms may be more common among women with tics than in men with tics.

This study reports a waitlist controlled randomized trial of family-based cognitive-behavioral therapy delivered via web-camera (W-CBT) in children and adolescents with obsessive-compulsive disorder (OCD). Thirty-one primarily Caucasian youth with OCD (range=7-16years; 19 male) were randomly assigned to W-CBT or a Waitlist control. Assessments were conducted immediately before and after treatment, and at 3-month follow-up (for W-CBT arm only). Primary outcomes included the Children's Yale-Brown Obsessive Compulsive Scale (CY-BOCS), clinical global improvement rates, and remission status. When controlling for baseline group differences, W-CBT was superior to the Waitlist control on all primary outcome measures with large effect sizes (Cohen's d≥1.36). Thirteen of 16 youth (81%) in the W-CBT arm were treatment responders, versus only 2/15 (13%) youth in the Waitlist arm. Similarly, 9/16 (56%) individuals in the W-CBT group met remission criteria, versus 2/15 (13%) individuals in the Waitlist control. Gains were generally maintained in a naturalistic 3-month follow-up for those randomized to W-CBT. This preliminary study suggests that W-CBT may be helpful in reducing obsessive-compulsive symptoms in youth with OCD. Given considerable access issues, such findings hold considerable promise for treatment dissemination.

Dr. Laurence Selling made one of the earliest reported cases of this potential correlation between the onset of tics and infectious disease in 1929 when he described three cases of tics associated with sinusitis (Selling, 1929). Subsequently, psychoanalytic theories prevailed in etiologic theories of Tourette Syndrome (TS) (Kushner & Kiessling, 1996). Just before the “medicalization” of (TS) in 1965, Langlois and Force described a 6-year-old child with TS and Sydenham chorea (SC) symptoms following several infectious illnesses that were successfully treated with antibiotics and neuroleptics (Langlois & Force, 1965). They argued that Tourette was wrong to say TS was incurable and separate from SC, but that TS should be viewed as sequel to acute chorea. After a lag of approximately 20 years, the argument reappeared that, in at least some cases, tics and obsessive compulsive disorder (OCD) are related to infectious processes. In the late 1980s, researchers noted that patients with SC often developed OCD symptoms, and further inquiry found that patients with SC often had tics as well. Additional investigation found that some patients with Group A Streptococcus (GAS) infections, but without the neurological findings of SC, also presented with OCD symptoms (Allen, Leonard, & Swedo, 1995; Swedo & Leonard, 1994). Similarly, around this same time, Louise Kiessling and colleagues reported on the association of tics during GAS outbreaks as seen in a developmental pediatric practice (Kiessling, Marcotte, & Culpepper, 1993). The first case report (Allen et al., 1995) detailed four children who presented with sudden onset or worsening of OCD and/or tics following an infection (2 viral, 2 GAS). Subsequently in 1998, based on these observations and reports, a group from the National Institute of Mental Health further characterized (in a 50 patient case series) an entity they called “pediatric autoimmune neuropsychiatric disorders associated with streptococcus” (PANDAS). Careful reading of these case series suggests that GAS is the inciting trigger, but future exacerbations are activated not only by GAS infection but GAS exposure and viral illness as well.

Clinical symptoms of precocious pubertal development were observed in two girls with mild mental retardation during treatment of aggressive behavior with clonidine. Both 7-year-old children developed early physical signs of puberty, whose progression ceased when clonidine was discontinued. Prior to treatment with clonidine, both patients had received several different psychoactive medications without any signs of onset of puberty. Biochemical confirmation of the diagnosis and evaluation of concomitant medical conditions were unobtainable due to individual circumstances. Based on the appearance of clinical symptoms of precocious puberty, it is hypothesized that clonidine may have stimulated the production or release of anterior pituitary hormones. If physical signs of precocious puberty appear during treatment with clonidine, clinicians might consider the possibility of a link to the medication as well as to pursue possible medical causes of precocious puberty.

Chronic tic disorders (CTD) are characterized by motor and/or vocal tics. Existing data on the impact of tics in adulthood is limited by small, treatment-seeking samples or by data aggregated across adults and children. The current study explored the functional impact of tics in adults using a nationwide sample of 672 participants with a self-reported CTD. The impact of tics on physical, social, occupational/academic, and psychological functioning was assessed. Results suggested mild to moderate functional impairment and positive correlations between impairment and tic severity. Notable portions of the sample reported social or public avoidance and experiences of discrimination resulting from tics. Compared to previously reported population norms, participants had more psychological difficulties, greater disability, and lower quality of life. The current study suggests that CTDs can adversely impact functioning in adults and highlights the need for clinical interventions and systemic efforts to address tic-related impairments.

This study explored the impact of disruptive behavior disorder (DBD) comorbidity on a number of theoretically relevant outcomes among 192 children and adolescents with obsessive-compulsive disorder (OCD). Youth were divided into three groups: OCD Only, OCD + DBD comorbidity and OCD + Other comorbidity. Relative to those without a comorbid condition and those with any non-DBD comorbidity, comorbid DBD was associated with greater family accommodation and less symptom resistance. Youth with comorbid DBD exhibited greater OCD symptom severity, OCD-related impairment, anxiety, and internalizing problems than those with no comorbidity. Those with comorbid DBD were over 3.6 times as likely to be taking an atypical antipsychotic medication relative to children without comorbidity. The present results suggest that comorbid DBD contributes to more severe illness presentation above and beyond an OCD diagnosis alone, and may be associated with differing pharmacotherapy prescribing practices.

The current study examined relationships between tic severity and both functional impairment and perceived quality of life (QOL) in adults with a chronic tic disorder. The authors explored whether these relationships were moderated by anxiety and depressive symptoms. Five-hundred adults with Tourette's Disorder, Chronic Motor Tic Disorder, or Chronic Vocal Tic Disorder participated in a comprehensive self-report internet-based survey. Anxiety and depressive symptoms moderated the relationship between tic severity and functional impairment such that stronger relationships were documented in participants with elevated depressive or anxious symptoms. Limitations and implications for research and clinical practice are discussed.

The Yale-Brown Obsessive-Compulsive Scale (Y-BOCS; Goodman, Price, Rasmussen, Mazure, Delgado, et al., 1989) is acknowledged as the gold standard measure of obsessive-compulsive disorder (OCD) symptom severity. A number of areas where the Y-BOCS may benefit from revision have emerged in past psychometric studies of the Severity Scale and Symptom Checklist. Therefore, we created the Yale-Brown Obsessive-Compulsive Scale-Second Edition (Y-BOCS-II) by revising the Severity Scale item content and scoring framework, integrating avoidance into the scoring of Severity Scale items, and modifying the Symptom Checklist content and format. One hundred thirty treatment-seeking adults with OCD completed a battery of measures assessing OCD symptom severity and typology and depressive and anxious symptomology. Interrater and test-retest reliability were assessed on a subsample of participants. The Y-BOCS-II showed strong internal consistency for the Symptom Checklist (Kuder-Richardson-20 = .91) and Severity Scale (alpha = .89). Test-retest and interrater reliabilities were both high (intraclass correlations > .85). Confirmatory factor analyses did not show adequate fit with previous models of the Y-BOCS. Exploratory factor analysis revealed a two-factor solution generally consistent with the Obsession and Compulsion Severity subscales. Construct validity was supported by strong correlations with clinician-rated measures of OCD symptom severity and moderate correlations with measures of worry and depressive symptoms. Taken together, the Y-BOCS-II has excellent psychometric properties in assessing the presence and severity of obsessive-compulsive symptoms. Although the Y-BOCS remains a reliable and valid measure, the Y-BOCS-II may provide an alternative method of assessing symptom presence and severity.

LAY SUMMARY: This case report illustrates lack of clinical efficacy of deep brain stimulation (DBS) for control of tics in a case of mild Tourette syndrome (TS) with severe comorbid obsessive-compulsive disorder (OCD). The brain target for stimulation was the anterior limb internal capsule (ALIC).To investigate the effect of anterior limb of internal capsule/nucleus accumbens (ALIC-NA) DBS on mild motor and vocal tics in a Tourette syndrome (TS) patient with severe OCD.The optimum target to address symptoms of TS with DBS remains unknown. Earlier lesional therapy utilized thalamic targets and also the ALIC for select cases which had been diagnosed with other psychiatric disorders. Evidence regarding the efficacy of DBS for the symptoms of TS may aid in better defining a brain target's suitability for use. We report efficacy data on ALIC-NA DBS in a patient with severe OCD and mild TS.A 33-year-old man underwent bilateral ALIC-NA DBS. One month following implantation, a post-operative CT scan was obtained to verify lead locations. Yale Global Tic Severity Scales (YGTSS) and modified Rush Videotape Rating scales (MRVRS) were obtained throughout the first 6 months, as well as careful clinical examinations by a specialized neurology and psychiatry team. The patient has been followed for 30 months.YGTSS scores worsened by 17% during the first 6 months. MRVRS scores also worsened over 30 total months of follow-up. There was a lack of clinically significant tic reduction although subjectively the patient felt tics improved mildly.DBS in the ALIC-NA failed to effectively address mild vocal and motor tics in a patient with TS and severe comorbid OCD.

Although effective in treating a range of childhood psychiatric conditions, selective serotonin reuptake inhibitors (SSRI) have been implicated in the induction of an “activation syndrome” (characterized by symptoms of irritability, restlessness, emotional labiality, etc.) that may represent an intermediary state change that fosters suicidality. SSRI-induced activation syndrome is well-accepted by many clinicians and thought to be relatively common, particularly in children and teens. However, gaps exist in empirical data on phenomenology and tools for early detection. With this in mind, we report on a recently funded National Institutes of Health grant to develop a measure of behavioral activation to be completed in a clinical setting. We discuss the development of this measure—the Treatment-Emergent Activation and Suicidality Assessment Profile (TE-ASAP)—as well as psychometric results from a sample of youth with internalizing disorders who were at varying stages of SSRI treatment. Overall, psychometric data were quite promising, with the TE-ASAP demonstrating excellent reliability (i.e., internal consistency, inter-rater, short-term test–retest stability) and strong validity properties. Through further evaluation of the TE-ASAP in the context of a controlled multimodal trial in youth with obsessive–compulsive disorder, we hope to augment understanding of activation syndrome and, in turn, mitigate risks through early detection of this potentially lifethreatening adverse effect.

The Yale Global Tic Severity Scale (YGTSS) is the most widely used scale to quantify tics. It is a rating that is based on a clinician-rated, semistructured interview that begins with a systematic inquiry of tic symptoms in the preceding week. Current motor and phonic tics are then rated separately according to number, frequency, intensity, complexity, and interference. The YGTSS has been psychometrically studied and it has many positive qualities, although it is not perfect. Several translations of the YGTSS and studies of their psychometric properties have been published, including versions in Spanish and Polish.

Lack of motivation may negatively impact cognitive behavioral therapy (CBT) response for pediatric patients with obsessive-compulsive disorder (OCD). Motivational interviewing is a method for interacting with patients in order to decrease their ambivalence and support their self-efficacy in their efforts at behavior change. The authors present a preliminary randomized trial (N = 16) to evaluate the effectiveness of adding motivational interviewing (MI) as an adjunct to CBT. Patients aged 6 to 17 years who were participating in intensive family-based CBT for OCD were randomized to receive either CBT plus MI or CBT plus extra psychoeducation (PE) sessions. After four sessions, the mean Children's Yale-Brown Obsessive Compulsive Scale (CY-BOCS) score for the CBT plus MI group was significantly lower than for the CBT plus psychoeducation group, t(14) = 2.51, p < .03, Cohen's d = 1.34. In addition, the degree of reduction in CY-BOCS scores was significantly greater, t(14) = 2.14, p = .05, Cohen's d = 1.02, for the CBT plus MI group (mean Delta = 16.75, SD = 9.66) than for the CBT plus psychoeducation group (mean Delta = 8.13, SD = 6.01). This effect decreased over time, and scores at posttreatment were not significantly different. However, participants in the MI group completed treatment on average three sessions earlier than those in the psychoeducation group, providing support for the utility of MI in facilitating rapid improvement and minimizing the burden of treatment for families.

Pediatric obsessive-compulsive disorder (OCD) is a chronic neuropsychiatric condition associated with broad impairments in functioning. This paper outlines current etiological theories of OCD, providing a review of neuroanatomical, neurochemical, neuroimmunological, and cognitive–behavioral explanations. Subsequently, first-line treatment modalities are discussed (serotonin reuptake inhibitors [SRIs] and cognitive–behavioral therapy [CBT] with exposure and response prevention [E/RP]) in the context of recent pharmacological, CBT, and combined trials.

Obsessive–compulsive disorder (OCD) is a chronic and debilitating condition that is relatively common in both children and adults, and it is associated with a wide range of functional impairments. Mental health researchers and practitioners have placed considerable attention on OCD over the past two decades, with the goal of advancing treatment and understanding its etiology. Until recently, it was unknown to what extent this disorder was associated with functional impairment. However, recent research shows that the condition has significant social and occupational liabilities. This article discusses etiology, common symptom presentations (including comorbid and ancillary symptoms), basic OCD subtypes, neuropsychological functioning, and the relation these have with functional disability in OCD. Recommendations for future research are also considered.

The presence of obsessive-compulsive disorder (OCD) has been linked to decreased quality of life (QoL) among adults, yet little is known about the impact of OCD on QoL in pediatric patients. Sixty-two youth with OCD and their parent(s) were administered the Children's Yale-Brown Obsessive Compulsive Scale following a clinical interview. Children completed the Pediatric Quality of Life Inventory and parents completed the Pediatric Quality of Life Parent Proxy Inventory and Child Behavior Checklist. QoL scores for OCD patients were significantly lower than for healthy controls, but similar to QoL in a general psychiatric sample on the majority of domains. Parent-child agreement on QoL was moderate to strong across age groups. Results indicate that, in youth with OCD, QoL is reduced relative to healthy controls, related to OCD symptom severity per parent-report, and are strongly predicted by the presence of comorbid externalizing and internalizing symptoms.

Obsessive-compulsive disorder (OCD) is a very common disease that affects approximately 2–3 % of the general population across the lifespan [APA (Diagnostic and statistical manual of mental disorders. APA, 1994)]. OCD has been listed as one of the ten most disabling illnesses by the World Health Organization [Murray and Lopez (Science 274(5288): 740–743, 1996)], while the National Comorbidity Survey Replication identified it as the anxiety disorder with the highest proportion of serious cases (50.6 %) [Kessler et al. (Arch Gen Psychiatry 62(6): 617–627, 2005)]. Many individuals with OCD receive markedly delayed diagnosis and treatment for this illness [Jenike (N Engl J Med 350(3): 259–265, 2004)]. Although it has a waxing and waning course, it frequently increases in severity due to ritual reinforcement when left untreated. Hence, improved understanding of OCD by clinicians is imperative to reduce the gap between symptom onset and eventual diagnosis and to promote early implementation of strategies for long-term symptomatic relief. This chapter will provide a general description of clinical features, assessment strategies, and treatment of OCD.