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Exposure therapy is a highly effective, evidence-based treatment technique for children and adolescents with anxiety disorders. Regardless, therapists in the community are reported to use exposure relatively rarely compared with other approaches. The goal of the present study was to identify how practicing clinicians treat youth with anxiety disorders across the United States and what factors contribute to their use of exposure therapy. Recruited from public directories, 257 private practice therapists who treat anxious youth were surveyed. Non-exposure cognitive-behavioral techniques like cognitive restructuring and relaxation techniques were used significantly more frequently than exposure. Providers with more training in exposure therapy and fewer negative beliefs about this approach reported using exposure significantly more in the treatment of youth with social anxiety, obsessive-compulsive, and panic disorders. Self-identification as an anxiety disorder specialist significantly predicted exposure use for youth with posttraumatic stress disorder. Most therapists in private practice have minimal training in exposure therapy, perceive a lack of training options, and believe there would be a benefit to acquiring more training. The implications of these findings are discussed, including how to optimally design training opportunities in exposure therapy.

This article provides an update on the evidence base for the treatment of pediatric obsessive-compulsive disorder (OCD). Recent meta-analyses have found that cognitive-behavioral therapy (CBT) is the most efficacious monotherapy for pediatric OCD, and that serotonin reuptake inhibitors demonstrate a moderate treatment effect. There is little evidence to indicate when CBT should be combined with pharmacology, despite it being recommended for all severe cases. Although access to high-quality CBT is often limited, there is promising evidence supporting the use of intensive CBT and therapist-guided e-therapy. There is insufficient information about the efficacy and safety of second-line pharmacological interventions in pediatric populations even though they are widely used. Although existing treatments can be highly efficacious for pediatric OCD, there is a clear need to increase access to evidence-based treatments, improve response and remission rates in available treatments, and evaluate second-line interventions for treatment nonresponders. [ Psychiatr Ann. 2017;47(11):537–541.]

This study investigated the prevalence of common barriers to the use of exposure therapy (ET) in the treatment of youth with anxiety disorders, specifically examining both logistical limitations and negative beliefs about ET. Results from 230 practicing clinicians who treat youth with anxiety disorders found that the top three barriers were session length (56%), lack of training (48%), and concern about parent reaction (47%). Endorsement of barriers to ET was associated with less ET utilization and less optimal implementation of ET. Results suggest that several barriers, especially logistical limitations, must be addressed in order to improve the dissemination of ET.

Contains fulltext : 174490.pdf (Publisher’s version ) (Open Access) Importance: Whether and under which conditions D-cycloserine (DCS) augments the effects of exposure-based cognitive behavior therapy for anxiety, obsessive-compulsive, and posttraumatic stress disorders is unclear. Objective: To clarify whether DCS is superior to placebo in augmenting the effects of cognitive behavior therapy for anxiety, obsessive-compulsive, and posttraumatic stress disorders and to evaluate whether antidepressants interact with DCS and the effect of potential moderating variables. Data Sources: PubMed, EMBASE, and PsycINFO were searched from inception to February 10, 2016. Reference lists of previous reviews and meta-analyses and reports of randomized clinical trials were also checked. Study Selection: Studies were eligible for inclusion if they were (1) double-blind randomized clinical trials of DCS as an augmentation strategy for exposure-based cognitive behavior therapy and (2) conducted in humans diagnosed as having specific phobia, social anxiety disorder, panic disorder with or without agoraphobia, obsessive-compulsive disorder, or posttraumatic stress disorder. Data Extraction and Synthesis: Raw data were obtained from the authors and quality controlled. Data were ranked to ensure a consistent metric across studies (score range, 0-100). We used a 3-level multilevel model nesting repeated measures of outcomes within participants, who were nested within studies. Results: Individual participant data were obtained for 21 of 22 eligible trials, representing 1047 of 1073 eligible participants. When controlling for antidepressant use, participants receiving DCS showed greater improvement from pretreatment to posttreatment (mean difference, -3.62; 95% CI, -0.81 to -6.43; P = .01; d = -0.25) but not from pretreatment to midtreatment (mean difference, -1.66; 95% CI, -4.92 to 1.60; P = .32; d = -0.14) or from pretreatment to follow-up (mean difference, -2.98, 95% CI, -5.99 to 0.03; P = .05; d = -0.19). Additional analyses showed that participants assigned to DCS were associated with lower symptom severity than those assigned to placebo at posttreatment and at follow-up. Antidepressants did not moderate the effects of DCS. None of the prespecified patient-level or study-level moderators was associated with outcomes. Conclusions and Relevance: D-cycloserine is associated with a small augmentation effect on exposure-based therapy. This effect is not moderated by the concurrent use of antidepressants. Further research is needed to identify patient and/or therapy characteristics associated with DCS response. 10 p.

Although obsessive–compulsive disorder (OCD) has often been characterized as an internalizing disorder, some children with OCD exhibit externalizing behaviors that are specific to their OCD. This study sought to demonstrate that parents perceive both internalizing and externalizing behaviors in childhood OCD by examining the factor structure of the Child Obsessive–Compulsive Externalizing/Internalizing Scale (COCEIS), a parent-report questionnaire intended to measure these constructs. This study also investigated clinical correlates of internalizing and externalizing factors in the COCEIS. A factor analysis of questionnaire responses from 122 parents of youth with OCD revealed both externalizing and internalizing factors in the COCEIS. Externalizing behaviors in childhood OCD were associated with other, co-occurring externalizing behavior problems, while both factors were positively correlated with OCD severity and co-occurring internalizing symptoms. They were positively associated with each other at a trend level, and neither showed a significant relationship with insight. Sixty-two percent of parents endorsed “often” or “always” to at least one externalizing item, though modal responses to items suggested that each individual feature captured by the COCEIS may be relatively uncommon. Mean responses were significantly greater for internalizing items. This study provides evidence for distinct but related externalizing and internalizing behaviors specific to childhood OCD. Treatment for children with OCD presenting with more externalizing behaviors may require a greater emphasis on behavioral parent training and motivational enhancement.

Contains fulltext : 209315.pdf (Publisher’s version ) (Closed access) The apparent efficacy of d-cycloserine (DCS) for enhancing exposure treatment for anxiety disorders appears to have declined over the past 14 years. We examined whether variations in how DCS has been administered can account for this "declining effect". We also investigated the association between DCS administration characteristics and treatment outcome to find optimal dosing parameters. We conducted a secondary analysis of individual participant data obtained from 1047 participants in 21 studies testing the efficacy of DCS-augmented exposure treatments. Different outcome measures in different studies were harmonized to a 0-100 scale. Intent-to-treat analyses showed that, in participants randomized to DCS augmentation (n = 523), fewer DCS doses, later timing of DCS dose, and lower baseline severity appear to account for this decline effect. More DCS doses were related to better outcomes, but this advantage leveled-off at nine doses. Administering DCS more than 60 minutes before exposures was also related to better outcomes. These predictors were not significant in the placebo arm (n = 521). Results suggested that optimal DCS administration could increase pre-to-follow-up DCS effect size by 50%. In conclusion, the apparent declining effectiveness of DCS over time may be accounted for by how it has been administered. Optimal DCS administration may substantially improve outcomes. Registration: The analysis plan for this manuscript was registered on Open Science Framework (https://osf.io/c39p8/). 8 p.

Little has been written as to how clinicians in specialty treatment clinics go about training unlicensed trainees to work with patients with OCD. The University of Florida's OCD (UF OCD) treatment and training program was founded over 20 years ago by Drs. Wayne Goodman and Gary Geffken and has reported treatment response rates above the national average. The success of the program is largely due to a continued emphasis on trainee development through a progressive cascading model of mentorship. Using this competency based model, the UF OCD program focuses on skill acquisition and competency based evaluation through mentoring, collaboration, and co-therapy with clinicians and other trainees. Trainee satisfaction with this model was assessed using qualitative and questionnaire based feedback from trainees whom had completed at least one semester within the training program. Most trainees felt competent in implementing exposure therapy and were satisfied following their training within the program, reporting particular benefit from the co-therapy approach. Recommendations for implementation of this model in graduate training clinics are discussed.

Activation Syndrome (AS) is a side-effect of antidepressants consisting of irritability, mania, self-harm, akathisia, and disinhibition. The current study was conducted to analyze how AS may hinder treatment outcome for multimodal treatment for children and adolescents with Obsessive-Compulsive Disorder.Fifty-six children or adolescents were recruited at two treatment sites in a double-blind randomized-controlled trial where participants received Cognitive-Behavioral Therapy and were randomized to slow titration of sertraline, regular titration of sertraline or placebo.Using a recently developed measure of AS, results suggested that higher average levels of irritability, akathisia, and disinhibition significantly interfered with treatment response and explained 18% of the variance in obsessive-compulsive symptoms during treatment. Interestingly, only session-to-session increases in irritability resulted in a session-to-session increase in obsessive-compulsive symptoms. The observed results were unchanged with the addition of SSRI dosage as a covariate.Results provide empirical support for the proposed hypothesis that AS may hinder multimodal treatment outcome for pediatric OCD. These findings suggest that dosage changes due to AS do not explain why those with higher AS had worse multimodal outcome. Other possible mechanisms explaining this observed disruption are proposed, including how AS may interfere with Cognitive-Behavioral Therapy.

The cognitive-behavioral model of obsessive-compulsive disorder, along with several contemporary theories, suggests that self-esteem is likely an important component of OCD psychopathology and treatment. Little research, however, has explored the association between self-esteem and OCD. The study of self-esteem is itself a complex pursuit. A comprehensive investigation of self-esteem requires consideration of state and trait aspects of this construct and a longitudinal perspective, particularly when self-esteem is studied during the course of psychological treatment. In this study, adults participating in psychological treatment for OCD provided repeated self-reports of self-esteem throughout the course of therapy. The aims of this study were to evaluate the relationship between self-esteem and severity of OCD and depressive symptoms; to examine whether temporal variability (i.e., fluctuation) in self-esteem was associated with symptom reduction; and to measure changes in self-esteem over time. Our results indicated the following: average self-esteem across treatment, variability in self-esteem, and depressive symptomatology were significantly correlated with post-treatment OCD severity; self-esteem did not affect the rate of OCD symptom change over treatment but did significantly affect the rate of depressive symptom change; self-esteem increased significantly before and after sessions, on average, and over the course of treatment. Implications and further directions are discussed.

Violating expectancies during exposure therapy is proposed to promote inhibitory learning and improved treatment outcomes. Because people tend to overestimate how distressing emotionally challenging situations will be, violating expectations of distress may be an intuitive way to promote treatment outcome during exposure-based cognitive-behavioral therapy (CBT). This study evaluated overpredictions of distress during exposure tasks in 33 youth with obsessive-compulsive disorder (OCD; ages 8-17) participating in CBT. Youth with more variable prediction accuracy and a higher proportion of overpredictions experienced more rapid symptom reduction, b = −0.29, p = .002. Underpredictions were less common toward the end of therapy as youth experienced less severe OCD, b = 0.12, p= .001. Findings suggest that although youth often accurately predict the intensity of exposure, overpredictions are common as well. The frequency of these overpredictions promoted treatment outcome, supporting expectancy violations as one indicator of inhibitory learning during exposure therapy.

The present study developed parallel clinician- and parent-rated measures of family accommodation (Pediatric Accommodation Scale, PAS; Pediatric Accommodation Scale-Parent Report; PAS-PR) for youth with a primary anxiety disorder. Both measures assess frequency and impact of family accommodation on youth and families. Studying youth ages 5-17 (N=105 caregiver-youth dyads), results provide evidence for the psychometric properties of the PAS, including internal consistency, inter-rater reliability, and convergent and discriminant validity. The PAS-PR exhibited good internal consistency and convergent validity with the PAS. Nearly all parents (>95%) endorsed some accommodation and accommodation frequency was associated with parent-rated impairment (home and school), and with youth-rated impairment (school only). Greater impact of accommodation on parents was associated with parent self-reported depressive symptoms. Findings support the common occurrence of family accommodation in youth with anxiety disorders, as well as for the use of the PAS and PAS-PR to measure family accommodation in this population.

Attention-deficit/hyperactivity disorder (ADHD) has been found to be highly comorbid in children and adolescents with obsessive-compulsive disorder (OCD). Some have proposed, however, that obsessive anxiety may cause inattention and executive dysfunction, leading to inappropriate ADHD diagnoses in those with OCD. If this were the case, these symptoms would be expected to decrease following successful OCD treatment. The present study tested this hypothesis and evaluated whether ADHD symptoms at baseline predicted OCD treatment response. Obsessive-compulsive and ADHD symptoms were assessed in 50 youth enrolled in a randomized controlled trial investigating selective serotonin reuptake inhibitor and cognitive behavioral treatment. Repeated-measures analysis of variance (RMANOVA) revealed that ADHD symptoms at baseline do not significantly predict treatment outcome. A multivariate RMANOVA found that OCD treatment response moderated change in inattention; participants who showed greater reduction in OCD severity experienced greater reduction in ADHD-inattentive symptoms, while those with less substantial reduction in obsessions and compulsions showed less change. These findings suggest that children and adolescents with OCD and inattention may experience meaningful improvements in attention problems following OCD treatment. Thus, in many youth with OCD, inattention may be inherently tied to obsessions and compulsions. Clinicians may consider addressing OCD in treatment before targeting inattentive-type ADHD.

The care of youth with type 1 diabetes mellitus (T1DM) has become increasingly complex given the importance of good glycemic control in decreasing the rates of diabetes-related complications. Today, youth with TIDM are more frequently prescribed intensive insulin regimens (i.e. multiple daily injections or insulin pump therapy) which require a great deal of planning, organization, and problem-solving to execute correctly. However, there has been a paucity of research on psychological and family factors that may impact pediatric patients’ diabetes management when using intensive regimens. Seventy-two youth with T1DM on intensive insulin regimens and their caregivers participated in the study, which entailed completing self-report questionnaires, an adherence interview, a parent-report measure of executive functioning, and measurement of glycemic control. Results suggested that although adherence mediated the relation between child executive functioning and glycemic control in youth reporting relatively bet...

Family accommodation is a salient phenomenon within pediatric obsessive–compulsive disorder (OCD), with a large number of families engaging in behaviors and modifying family routines in response to the youth’s OCD symptoms. Family accommodation is commonly considered as a unidimensional construct, resulting in limited research on the phenomenological aspects of family accommodation and how different facets (i.e., participation, modification, and distress/consequences) may impact pediatric OCD. As such, the present study sought to examine the extent to which family accommodation, as a whole and within subtypes, was related to OCD symptom severity and symptom dimensions, youth clinical characteristics (i.e., internalizing/externalizing symptoms, depressive symptoms), and family factors (i.e., cohesion and conflict). Family accommodation was related to OCD symptom severity and the contamination symptom dimension, youth depressive symptoms (but not the participation domain), and youth internalizing/externalizing symptoms. Youth externalizing symptoms mediated the relationship between OCD symptom severity and family accommodation. After controlling for OCD symptom severity, youth externalizing symptoms predicted family accommodation in general, as well as the distress/consequences domain. Family cohesion predicted participation in OCD symptoms, above and beyond OCD symptom severity. Detailed results and implications of the findings are discussed.

Objective: To examine the extent to which effortful control (EC) and sensation seeking (SS) tendencies explain the association between the severity of ADHD symptoms and risky behaviors. Method: Participants included 555 college students (66% females) who completed self-report measures assessing their ADHD symptoms, EC abilities, SS tendencies, and risky health (e.g., substance use) and driving/financial behaviors (e.g., misuse of credit cards). Results: Severity of college students’ ADHD symptoms, EC abilities, and SS tendencies were related to all risky behaviors. Multiple mediational analyses further indicated that students’ SS tendencies significantly mediated the association between ADHD symptoms and the risky health factor but not the risky driving/financial factor. EC, however, significantly mediated the association between ADHD symptoms and both the risky health and driving/financial factors. Conclusion: The current study provides initial data showing potentially different mechanisms that explain the link between college students’ severity of ADHD symptoms and risky behaviors.

The intersection of obsessive-compulsive disorder (OCD) and executive functioning (EF) in children and adolescents is an emerging topic in the current literature. Spurred by the consistent association between increased EF deficits and higher adult obsessive-compulsive severity, a few initial studies have replicated this relationship in pediatric OCD samples and also have found preliminary evidence that EF deficits are associated with worse response to first-line psychotherapeutic or psychopharmacological treatments for pediatric OCD. This study aimed to extend the literature by providing the first comprehensive investigation of how multiple EF domains, measured repeatedly over the course of treatment, impact pediatric obsessive-compulsive severity and response to multimodal treatment. Multi-level modeling results found that deficits in shifting, inhibition, emotional control, planning/organizing, monitoring and initiating all predicted higher average obsessive compulsive severity across treatment. Interestingly, out of the eight domains of EF investigated, only emotional control moderated treatment outcome such that those with worse emotional control experienced less of a reduction in obsessive-compulsive severity during treatment. The findings generally align with previous theories for the link between EF and OCD and indicate that emotional control has important implications in the treatment of pediatric OCD. In fact, emotional control may provide one explanation for why factors such as disgust sensitivity, oppositional behavior, and third-wave behavioral treatment techniques have all been linked to pediatric OCD treatment outcome. Future research should investigate augmentation strategies that target emotional control in children and adolescents.

Despite extensive use of the Children's Yale Brown Obsessive Compulsive Scale (CYBOCS; Scahill et al., 1997), the lack of normative data impedes interpretation of individual CYBOCS scores. Consequently, psychometrics on CYBOCS severity scores from 815 treatment-seeking youth with obsessive-compulsive disorder (OCD) are presented, across age and sex, so that normative comparisons of obsessive, compulsive, and combined obsessive-compulsive severity could be calculated. Our findings suggest no evidence for marked age or sex differences. Further, obsessive-compulsive symptom severity scores (measured via the CYBOCS) appear consistent with global OCD syndrome severity (measured via the Clinician Global Impression-Severity scale [CGI-S; Guy, 1976]; r = .58). This study contributes the 1st empirically based guidelines for interpreting obsessive-compulsive symptom severity scores. After a diagnosis of OCD is determined, the CYBOCS can be used to determine severity of illness (however, categories of severity proposed by this article should not be used in the screening of OCD symptoms). Findings can facilitate clinicians' and investigators' ability to draw comparisons across obsessive-compulsive severity scores.

Online forums for chronic health conditions emerged as early as 30 yr ago and interest in their study has blossomed. Type 1 diabetes (T1D) forums have grown exponentially since 2005. Therefore, a comprehensive evaluation of these forums is needed. This study assesses the demographics and motivations of parents who use type 1 diabetes forums and the potential impact that forum membership (FM) has on parenting stress and hypoglycemic fear. One hundred and two parents were recruited through online T1D forums and asked to complete qualitative and quantitative measures of their experience with the T1D forums. Results of this study suggest that parents who use T1D forums mirror those who participate in clinic-based research protocols and are primarily motivated to participate in forums to increase their diabetes knowledge and gain social support. Indeed, parents who use T1D forums report high levels of trust, social support, and perceived knowledge gained. However, FM was positively related to increased self-reported parenting stress frequency and hypoglycemic fear behaviors. Taken together, the relationships formed within these communities may have a significant impact on the experience of these caregivers. The need for future research and potential implications for physicians, including parent debriefing, are discussed.

We evaluated the construct validity of the Child Yale-Brofwn Obsessive-Compulsive Scale (CYBOCS) in a large clinical sample (N=730) using confirmatory factor analysis. Results found inadequate fit for a priori models, though a model accounting for overlapping item content displayed good fit. Parallel obsessions/compulsions items may provide largely redundant information on the CYBOCS. Findings suggest modifying the CYBOCS to reduce burden on researchers, patients, and clinicians, and to more accurately measure pediatric obsessive-compulsive disorder (OCD).

Although obsessive compulsive disorder (OCD) and common co-occurring conditions share deficits in self-regulatory abilities, there has been minimal examination of impaired self-regulation (dysregulation) in youth with OCD. This study examined the association of dysregulation with symptom severity, impairment, and treatment outcome in pediatric OCD. Clinicians assessed obsessive-compulsive severity, family accommodation and global severity in 144 youth with OCD. Youth completed self-report severity ratings of anxiety and depressive symptoms. Parents completed the Child Behavior Checklist (CBCL), and both children and parents completed parallel ratings of obsessive-compulsive impairment. Ninety-seven youth received cognitive behavioral therapy (CBT) and were re-assessed after treatment. Dysregulation was assessed using the CBCL-Dysregulation Profile. Before treatment, dysregulated youth exhibited greater obsessive-compulsive symptom severity, depressive mood, family accommodation, and impairment than non-dysregulated youth. The magnitude of dysregulation directly predicted child-rated impairment, parent-rated impairment, and family accommodation, beyond obsessive-compulsive severity. The magnitude of pretreatment dysregulation predicted treatment discontinuation but not treatment response. Obsessive-compulsive symptom severity and dysregulation level significantly decreased after CBT. Dysregulated youth with OCD presented as more clinically severe than their non-dysregulated counterparts, and may require more individualized interventions to reduce dysregulated behavior to prevent CBT attrition. For treatment completers, CBT was associated with a decrease in dysregulation level.

This study examined relations among diabetes-specific family factors, adherence to medical regimen, quality of life (QOL), and glycemic control in youth and adolescents with type 1 diabetes. During an endocrinologist visit, patient and parent–caregiver dyads (n = 70) completed family factors and QOL measures and participated in a structured interview to assess medical regimen compliance, and the patient's glycemic control was assessed by a medical professional. Combined measures accounted for 42% of the variance in glycemic control. QOL partially mediated adherence and glycemic control. Ethnic minority status was associated with poorer glycemic control.

The present study examined the prospective relationship between obsessive-compulsive and depressive symptoms during a multimodal treatment study involving youth with obsessive-compulsive disorder (OCD). Participants included fifty-six youth, aged 7-17 years (M = 12.16 years) who were enrolled in a two-site randomized controlled pharmacological and cognitive behavioral therapy treatment trial. Obsessive-compulsive severity was measured using the Children's Yale-Brown Obsessive-Compulsive Scale, and depressive symptoms were rated using the Children's Depression Rating Scale-Revised. Multi-level modeling analyses indicated that, on average over the course of treatment, variable and less severe obsessive-compulsive symptoms significantly predicted a decrease in depressive symptoms. Additionally, week-to-week fluctuations in OCD severity did not significantly predict weekly changes in depressive symptom severity. Level of baseline depressive symptom severity did not moderate these relationships. Findings suggest that when treating youth with OCD with co-occurring depression, therapists should begin by treating obsessive-compulsive symptoms, as when these are targeted effectively, depressive symptoms diminish as well.

This study examined the association of various clinical features of obsessive-compulsive disorder (OCD) with quality of life (QoL) in 102 adults with a principal diagnosis of OCD. Participants were assessed by trained clinicians using the Anxiety Disorders Interview Schedule 4th edition, the Yale-Brown Obsessive-Compulsive Scale, and an unstructured clinical interview. Subjects completed the MOS-36 Item Short Form Health Survey, and Beck Depression Inventory-II. Obsessive-compulsive symptom severity was negatively correlated with emotional health, social functioning and general health QoL. Depressive symptoms mediated the relationship between obsessive-compulsive symptom severity and emotional health, social functioning and general health QoL. Additionally, interference of obsessive-compulsive symptoms mediated the relationship between obsessive-compulsive symptom severity and emotional health, social functioning and general health QoL. Resistance against obsessive-compulsive symptoms mediated the relationship between obsessive-compulsive symptom severity and social functioning QoL. Diminished QoL is present in persons with OCD and is essential in understanding the complete clinical picture of OCD.

This study examined differences in clinical presentation and functional impairment in youth with obsessive-compulsive disorder (OCD) with or without comorbid depressive disorders and sought to determine the predictors of youth-reported depressive symptoms. One-hundred and sixty youth were reliably diagnosed with OCD and comorbid disorders using the Anxiety Disorders Interview Schedule for DSM-IV: Parent version (Silverman and Albano, 1996) and confirmed by an experienced clinician. Sixteen percent (n = 25) had a comorbid diagnosis of a current depressive disorder (DD). Significantly more females than males had a DD. Those with a DD showed increased OCD symptom severity, OCD-related functional impairment, and family accommodation relative to those without a comorbid DD. Depressive symptoms were significantly positively correlated with years of age, degree of OCD symptom severity, measures of OCD-related functional impairment, and non-OCD anxiety symptoms. Hierarchical regression analyses showed that age, gender, functional impairment, and non-OCD anxiety were significant predictors of depressive symptoms, even when OCD symptom severity was controlled. Notably, functional impairment was a partial mediator of the relationship between OCD symptom severity and depression levels, suggesting depression levels are the product of both degree of symptoms and amount of day-to-day impairment. Results are discussed in terms of implications for assessment and treatment.

To explore the link between pediatric obesity and attention deficit/hyperactivity disorder (ADHD) by examining whether executive functioning (EF) and medication status are associated with body mass index (BMI) and weight status in children with ADHD.Participants for this study included 80 children (mean age=10 years, 9 months) with a DSM-IV diagnosis of ADHD, confirmed by a comprehensive clinical diagnostic assessment. Children's EF was measured using three neuropsychological tests, and severity of ADHD symptoms and medication status were obtained from parent report. Children's height and weight were also measured during the visit using a wall-mounted stadiometer and a balance beam scale.Children with ADHD who performed poorly on the neuropsychological battery had greater BMI z-scores, and were more likely to be classified as overweight/obese compared with children with ADHD who performed better on the neuropsychological battery. In addition, children with ADHD who were taking a stimulant medication had significantly lower BMI z-scores compared with children with ADHD who were not taking medication or who were taking a non-stimulant medication.EF is more impaired among children with ADHD and co-occurring weight problems, highlighting the importance of self-regulation as a link between pediatric obesity and ADHD.

The goal of the current study was to determine within a clinical sample what differentiates children with ADHD who experience social functioning difficulties from those who appear to have healthy social functioning. Participants for this study included 62 children (mean age = 11.3 years) with a DSM-IV diagnosis of ADHD confirmed by a comprehensive clinical diagnostic assessment. Multiple indicators of children's social functioning were collected via parent report including: social skills, social adaptability, peer difficulties, and social quality of life. Parent reports of children's externalizing, internalizing, and atypical behaviors were also collected. Results indicated that both externalizing symptoms and atypical behaviors predicted children with ADHD's social functioning, even after controlling for ADHD symptoms severity. No association was found between internalizing symptoms and social functioning. The current study provides initial data suggesting that atypical behaviors found in children with ADHD are as powerful as comorbid externalizing symptoms in predicting social functioning difficulties. Due to the shared variance from relying solely on parent report, it will be critical for future research to replicate our findings using multi-informant data such as peer and teacher reports which provide unique information on children's social functioning.

Graziano PA, Geffken GR, Williams LB, Lewin AB, Duke DC, Storch EA, Silverstein JH. Gender differences in the relationship between parental report of self-regulation skills and adolescents' management of type 1 diabetes. Objective: To examine the extent to which self-regulation skills of adolescents with type 1 diabetes (T1D), including executive functioning and emotion regulation, relate to treatment adherence and glycemic control. Method: Participants were 109 adolescents aged 12–18 yr with TID and their primary caregiver who attended an outpatient appointment at a pediatric endocrinology clinic. Parents and adolescents completed a measure of treatment adherence. Parents completed a self-regulation measure while a glycemic control measure [i.e., hemoglobin A1c (HbA1c)] was collected. Results: For boys, executive functioning and emotion regulation deficits were significantly associated with worse treatment adherence and glycemic control. Further analyses indicated that emotion regulation was the primary self-regulation measure related to treatment adherence and glycemic control. No significant associations were found for girls. Conclusion: For adolescent boys, the ability to cope with various stressors and emotions may be as important as higher-order thinking skills for maximizing treatment adherence and diabetes control. Clinical implications and potential mechanisms by which emotion regulation skills relate to adolescent boys' diabetes treatment management are discussed.

Background Research on the neural circuitry underlying fear extinction has led to the examination of D-cycloserine (DCS), a partial agonist at the N- methyl-D-aspartate receptor in the amygdala, as a method to enhance exposure therapy outcome. Preliminary results have supported the use of DCS to augment exposure therapy in adult anxiety disorders; however, no data have been reported in any childhood anxiety disorder. Thus, we sought to preliminarily examine whether weight-adjusted DCS doses (25 or 50 mg) enhanced the overall efficacy of cognitive-behavioral therapy (CBT) for pediatric obsessive-compulsive disorder (OCD). Method Participants were 30 youth (aged 8–17) with a primary diagnosis of OCD. The study design was a randomized, double-blinded, placebo-controlled augmentation trial examining CBT + DCS versus CBT + Placebo (15 youth per group). All patients received seven exposure and response prevention sessions paired with DCS or placebo taken 1 hour before sessions. Results Although not significantly different, compared with the CBT + Placebo group, youth in the CBT + DCS arm showed small-to-moderate treatment effects ( d = .31–.47 on primary outcomes). No adverse events were recorded. Conclusions These results complement findings in adult OCD and non-OCD anxiety disorders and provide initial support for a more extensive study of DCS augmentation of CBT among youth with OCD.

The goal of the current case study was to illustrate an evidence-based assessment and the cognitive-behavioral treatment of an 11-year-old male with emetophobia. A multimodal assessment of the child’s anxiety symptoms was conducted, including a semistructured diagnostic interview (Anxiety Disorders Interview Schedule: Child and Parent Versions), parent report (Behavior Assessment System for Children—Second Edition.), and child self-report (Revised Children’s Manifest Anxiety Scale and Child Depression Inventory). Emetophobia symptoms were assessed via parent and child report of the Emetophobia Questionnaire. Treatment included graduated exposure, cognitive restructuring, and parent training. Improvement was seen within 22 sessions and maintained at a 6 months follow-up. In addition to a reduction in symptoms of emetophobia, discontinuation of medication, and no longer meeting Diagnostic and Statistical Manual of Mental Disorders (4th ed.; DSM-IV) criteria for specific phobia, treatment gains also included a reduction in internalizing and somatization symptoms as well as an increase in the patient’s adaptive skills. This case study illustrates the use of CBT along with parent training as an efficacious treatment for children with emetophobia. It also demonstrates how to incorporate simple, everyday technology (i.e., Internet) to simulate exposures that are otherwise difficult to duplicate in the therapy session.

The objective of this research is to determine the direct impact of family variables on initial status of a glycosylated hemoglobin A1c test (HbA1c) and HbA1c rate of change, and to determine the indirect effects of family variables on HbA1c through adherence. Study participants were 224 children and their parents who completed baseline measures of diabetes-specific family functioning and separate parent- and child-structured adherence interviews. HbA1c assays were performed at baseline, Year 1, and Year 2. Latent growth curve modeling indicated that, together, disagreement about responsibility for diabetes regimen, critical parenting, parental guidance, and parental warmth predicted initial status of HbA1c through adherence. Individually, critical parenting indirectly predicted initial status of HbA1c. Family variables did not directly predict initial status or rate of change in HbA1c, and did not indirectly predict rate of change in HbA1c over 2 years. Risk for high HbA1c remains elevated over time for ...

This study examines the impact of several of the most common comorbid psychiatric disorders (i.e., generalized anxiety disorder (GAD); major depressive disorder (MDD); social phobia, and panic disorder) on cognitive-behavioral therapy (CBT) response in adults with obsessive–compulsive disorder (OCD). One hundred and forty-three adults with OCD (range = 18–79 years) received 14 sessions of weekly or intensive CBT. Assessments were conducted before and after treatment. Primary outcomes included scores on the Yale-Brown Obsessive–Compulsive Scale (Y-BOCS), response rates, and remission status. Sixty-nine percent of participants met criteria for at least one comorbid diagnosis. Although baseline OCD severity was slightly higher among individuals with OCD + MDD and OCD + GAD (in comparison to those with OCD-only), neither the presence nor the number of pre-treatment comorbid disorders predicated symptom severity, treatment response, remission, or clinically significant change rates at post-treatment. These data suggest that CBT for OCD is robust to the presence of certain common Axis-I comorbidities.

The present study aimed to assess the phenomenology and treatment sensitivity of insight, avoidance, indecisiveness, overvalued responsibility, pervasive slowness, and pathological doubting among youth with Obsessive-compulsive disorder (OCD) using the ancillary items on the Children's Yale-Brown Obsessive Compulsive Scale (CY-BOCS). These factors are believed to be relevant to the clinical presentation of youth with OCD but remain understudied. Eighty-nine youth with OCD were administered the CY-BOCS, including six subsidiary items aimed at the constructs of interest in this research. Participants also completed measures of OCD symptom clusters, depressive and anxious symptoms, externalizing/internalizing behavioral problems, and functional impairment. Associations between OCD symptom clusters and insight, avoidance, indecisiveness, overvalued responsibility, pervasive slowness, and pathological doubting are presented. Low insight, significant avoidance, indecisiveness, pervasive slowness and excessive sense of responsibility were all related to elevations in functional impairment. Clinical improvement in OCD severity was related to reductions in avoidance, doubting, and sense of responsibility. The six ancillary items of the CY-BOCS appear to be a practical and valid assessment of several constructs that are prognostically linked to cognitive-behavioral therapy outcomes in youth with OCD. Implications for clinicians are discussed.

This review provides a broad and thorough synthesis of the Trichotillomania (TTM) literature as a resource for health professionals seeking the most current and complete information available. For the treatment provider, up to date information can help inform assessment, treatment, or referral decisions. For the student, this review provides a general overview and broad background information necessary to better understand hair-pulling and associated problems. For the researcher, information can help inform study planning. Prevalence, gender distributions, comorbidities, subtypes, and phenomenological characteristics are presented. Etiological theories are reviewed, and assessment and treatment options are offered. The validity of current DSM requirements is discussed and psychological and psychiatric treatment options are presented and evaluated for their strength of recommendation. Challenges to research and treatment are presented and directions for future research are suggested.

This study reports an open-trial of family-based cognitive-behavioral therapy (CBT) in children and adolescents with obsessive-compulsive disorder (OCD). Thirty primarily Caucasian youth with OCD (range = 7-19 years; 15 girls) who were partial responders or nonresponders to two or more medication trials that were delivered either serially or concomitantly received 14 sessions of intensive family-based CBT. Eighty percent of participants were considered improved at posttreatment and at 3-month follow-up, and symptom severity was reduced by 54% at both posttreatment and follow-up. Seventeen (56.6%) and 16 (53.3%) participants were classified as being in remission at posttreatment and follow-up, respectively. Significant reductions in OCD-related impairment, depressive symptoms, behavioral problems, and family accommodation were noted. No significant difference in youth-reported anxiety was found.

The objective of this research was to develop and validate the Diabetes Family Adherence Measure (D–FAM), a comprehensive and up-to-date tool designed for the assessment of adherence-related parenting behaviors for youth with type 1 diabetes (T1D). Further, this article outlines an empirical approach for scale design. First, experts reviewed a battery of potential items to create a preliminary version of the D–FAM. Subsequently, 165 youth with T1D and their families completed an initial administration. A parsimonious measure resulted, consisting of 19 items with 4 additional validity items. Factor analysis identified supportive, coercive, control, and monitoring subscales. D–FAM factors were generally associated with both adherence and health status (HbA1c [glycosolated hemoglobin]), as well as with extant scales of family functioning. Strong internal consistency, test–retest reliability, and construct-convergent reliability were obtained. This initial evaluation of the D–FAM suggests utility for efficien...

Background: Poor management of type 1 diabetes mellitus (T1DM) may result in serious medical complications. Psychological intervention may improve adherence to medical regimens; however, access to trained professionals is limited, particularly in rural communities. Telehealth interventions may address this by allowing families to access services at home; however, little is known about the efficacy of such services. Method: This study presents results from a pilot trial of a randomized waitlist controlled trial of Telehealth Behavioral Therapy (TBT) for youths with T1DM. Primary outcome measures were adherence to the diabetes regimen, glycemic control, and level of family discord. Thirty-two youths (23 female) with T1DM (aged 9 to 17 years) and one parent or caregiver participated. Telehealth Behavioral Therapy sessions were conducted thrice weekly for 12 weeks by phone and lasted an average of 15 min each. Results: Results indicated that youths in treatment decreased their hemoglobin A1c by 0.74 compared to 0.09 in the waitlist, though this was not statistically significant. Youths in treatment reported increased unsupportive and decreased caring parental behaviors. Conclusion: Telehealth Behavioral Therapy improves access to knowledgeable providers and results in a clinically significant improvement in glycemic control. Despite some youths experiencing an increase in unsupportive parental behaviors, TBT is a promising method of service delivery that warrants further investigation.

Assessment and treatment of trichotillomania (TTM) has evolved substantially over the past decade. However, standardized assessment and empirically supported treatment for TTM is still in early stages of development. We proposed that information important to the ongoing evolution of assessment and treatment could be obtained through the study of hairpulling across its range of severity. Hairpulling phenomenology was assessed in a large community sample across its range of presentation. Although the estimated prevalence rate of .6% for TTM is congruent with past studies, the 1.2% prevalence estimated for clinically significant hairpulling suggests that the current diagnostic criteria are overly restrictive. Overall, hairpulling occurred at a rate of 6.5%, while age of onset was 15.92 years. Symptoms of depression, anxiety, and history of teasing were positively associated with hairpulling, while self-esteem was negatively related to hairpulling. Cognitions most commonly associated with hairpulling were “feels coarse” (53.3%), “doesn’t feel right” (30.0%), “is curly” (26.7%), and “doesn’t look right” (23.3%). Environments most commonly associated with hairpulling included “while reading” (38.9%), “while watching television” (37.0%), and “in class” (35.25). Applications of findings to assessment and intervention formulation are suggested, and limitations and future directions are discussed.

Type 1 diabetes, one of the most common diseases of childhood, requires adherence to a complicated regimen which is often times difficult to manage resulting in stress for children, siblings, and caregivers. Many children with diabetes are nonadherent, likely due to the difficulty and complexity of the tasks required, and, thus, are at greater risk for diabetes related complications. For health care educators, it is important to understand the various psychosocial issues that affect adherence and adjustment to diabetes. This article will discuss these issues, including coping with a new diagnosis, school factors, regimen adherence and family variable and parenting strategies. Recommendations for health care educators are also discussed.

This study examined the phenomenology of hairpulling in a large nonclinical college student sample. Given that hairpulling is conceptualized as occurring on a continuum of severity, we expected to inform the assessment and treatment of Trichotillomania (TTM) by examining hairpulling behavior across its range of presentation. Hairpulling occurred at a rate of 9.7%, while average age of onset was 13.57 years. Self-reported hairpulling styles were identified with 31.3% endorsing focused hairpulling, while 68.7% endorsed an automatic hairpulling style. The most commonly endorsed ritual was “examine the root (37.3%) while the scalp was the most frequently endorsed hairpulling site (49%). Eyelashes were more frequently endorsed as a pulling site by focused (43.8) compared to automatic (5.7%) hairpullers. The hairpulling environments most often endorsed were “while reading” and “while studying” (75%). Affective states were found to change across the pulling cycle in support of hairpulling serving in an emotion regulation capacity. Focused hairpullers endorsed significantly higher trait anxiety than automatic hairpullers. Depression scores (BDI) were elevated for hairpullers compared to non-hairpullers. Implications for assessment and treatment were discussed and directions for future research were provided.

Objective This study provides normative data, divided by age and gender, for the Diabetes Self-Management Profile (DSMP), an empirically supported structured interview that assesses adherence with the type 1 diabetes treatment regimen. Despite wide use, normative data on the DSMP have yet to be reported. Methods The sample included 444 parents and 275 youth with type 1 diabetes. The DSMP was administered by a trained clinician. Results For both child and parent ratings of adherence, means and standard deviations for the overall sample and subdivision by gender and three age groups are presented for normative comparisons. Subscale data (e.g., glucose monitoring, diet, exercise) are similarly presented. Lower adherence scores were reported among older adolescents relative to preadolescents. Conclusions The literature has lacked normative data on pediatric diabetes adherence. These data present means and standard deviations for parent and child ratings of regimen adherence from a relatively large sample of youth with diabetes that can be utilized for normative comparisons for clinical and research purposes.

This study reports the prevalence and symptom correlates of sleep related problems (SRPs) in a sample of young people with Tourettes Syndrome (TS) or Chronic Tic Disorder. Fifty-six young people (and one of their parents) with a tic disorder were administered the Yale Global Tic Severity Scale. Children completed the Pediatric Quality of Life Inventory and Multidimensional Anxiety Scale for Children. Parents completed the Pediatric Quality of Life Inventory – Parent Proxy and Child Behavior Checklist. Overall, SRPs were widely endorsed, with 80.4% experiencing at least one SRP and 19.7% experiencing four or more. SRPs were negatively associated with quality of life and positively associated with internalising and externalising behaviours. Children with comorbid anxiety disorders had more SRPs than those without. We conclude by recommending that SRPs be assessed in young people with tics (particularly when comorbid anxiety is present), and highlight the role of psychotherapeutic and pharmacological intervention in reducing SRPs. • Sleep related problems (SRPs) are relatively common in young people with tic disorders and suggest the need for SRPs to be included in the comprehensive assessment and management of young people with tics • SRPs were positively linked to both anxiety and internalising and externalising behaviours and negatively related to child- and parent-rated quality of life • Should SRPs be present and clinically meaningful, treatment per evidence-based guidelines may be warranted

Management of type 1 diabetes (T1D) involves balancing several components including diet, exercise, and medication. Peer involvement in management tasks is an important, but understudied, issue in T1D. This study presents results of a preliminary examination of perceptions of disease management in youth with T1D and their peers. Data were collected using a mixed methods (qualitative and quantitative data) approach during medical education time at a camp for youth with T1D and their peers. Results suggest that both youth with T1D and their peers believe that peers need more information about medical consequences of having diabetes. Further, youth with T1D and their peers would like coaching on how peers may help the child with T1D manage their illness better. Results provide preliminary ideas for intervention (i.e., including peers, assessing social support) in the medical setting as well as ideas for future research (i.e., examining relationships among perceptions and gender, time since diagnosis).

Cognitive-behavioral therapy (CBT) with exposure and response prevention has documented efficacy in adults with body dysmorphic disorder (BDD) but has yet to be systematically studied in youth. With this in mind, the authors report on the case of “Amanda,” a 16-year-old female with significantly impairing BDD symptoms. Following 17 sessions of intensive family-based CBT, Amanda exhibited marked improvement in her BDD symptoms as illustrated by a decrease in her score on the Body Dysmorphic Disorder Modification of the Yale-Brown Obsessive Compulsive Scale from 27 at baseline to 10 at posttreatment. Therapeutic gains were maintained at a 3-month follow-up. This case study provides preliminary support for the use of intensive family-based CBT for adolescent BDD.

Psychiatric comorbidity is common in pediatric patients with obsessive-compulsive disorder (OCD) and may negatively affect treatment outcome. In particular, comorbid disruptive behavior disorders have been associated with attenuated treatment response in youth undergoing cognitive-behavioral therapy (CBT) for OCD. This article presents the case of a 10-year-old female with a primary diagnosis of OCD and secondary diagnosis of oppositional defiant disorder who was successfully treated with parent management training (PMT) prior to initiation of CBT. PMT was effective in reducing oppositional behaviors and resulted in improved adherence to the treatment protocol. The current report provides preliminary evidence for the effectiveness of PMT in youth with OCD and comorbid disruptive behavior. Clinical recommendations are provided to foster improved outcomes in this population.

Management of type 1 diabetes (T1D) involves a complex regimen. Adherence may improve glycemic control and health outcomes. Accurately assessing adherence is critical. A parent and child self-report measure of regimen adherence was developed: Assessment of Diabetes Adherence, Parent and Child (ADA–P/–C). One hundred sixty-five youth with T1D and parents completed the Diabetes Self-Management Profile (DSMP), psychosocial measures, and the ADA–P/–C. Results revealed good psychometric properties. Parent and child agreement was adequate. Although not intended to replace the DSMP, the ADA–P/–C may be used for multiple adherence measurements, as part of a larger assessment battery, and when a trained clinician is not available.

Pediatric obsessive-compulsive disorder (OCD) is a chronic, disabling condition that affects both patients and their families. Despite the identification of efficacious treatments (e.g., cognitive-behavioral therapy and selective serotonin reuptake inhibitor medications), not all patients respond fully. The purpose of the present study was to examine whether the amount of family accommodation provided to pediatric patients with OCD is associated with treatment outcome, and whether decreases in accommodation are associated with improved outcome. The sample consisted of 49 youths (6-18 years of age), who participated in 14 sessions of family-based cognitive-behavioral therapy for OCD, and their parents. Participants completed measures at pretreatment and posttreatment. Results indicate that family accommodation was prevalent among families of pediatric patients with OCD and that such accommodation was associated with symptom severity at pretreatment. In addition, decreases in family accommodation during treatment predicted treatment outcome, even when controlling for pretreatment OCD severity-impairment. Results suggest that the level of accommodation provided by the family may indicate an important obstacle to, or predictor of, treatment outcome in pediatric OCD. Directions for future research are discussed.

Despite the frequent use of the Yale-Brown Obsessive-Compulsive Scale-Symptom Checklist (Y-BOCS-SC; Goodman et al., 1989a) and the Obsessive-Compulsive Inventory-Revised (OCI-R; Foa et al., 2002), there are limited data on the psychometric properties of the two instruments. In the present research, clinician ratings on the Y-BOCS-SC for 112 patients with obsessive-compulsive disorder (OCD) were compared to their self-report ratings on the OCI-R. In addition, Y-BOCS-SC and OCI-R scores were compared to measures of OCD symptom severity and self-report measures of anxiety (State-Trait Anxiety Inventory-Trait Subscale [STAI-T]; Spielberger, Gorusch, & Lushene, 1970) and depression (Beck Depression Inventory-II [BDI-II]; Beck, Steer, & Brown, 1996). The six symptom scales of the OCI-R had good internal consistency reliabilities (alphas). For the Y-BOCS-SC, three of five scales had good reliabilities (alphas >.80), but alphas for symmetry/ordering and sexual/religious symptom scales were inadequate. Total scores for the two instruments were strongly correlated with their corresponding "checking" scales, but no individual symptoms scales were identified as indices of overall OCD symptom presence. Scales assessing washing/contamination, symmetry/ordering, and hoarding from the two OCD instruments correlated well, but lower correlations for the other scales suggested differences in symptom coverage by the two instruments. Most symptom scales from the Y-BOCS-SC and OCI-R had low correlations with the BDI-II and STAI-T, but the OCI-R obsessing scale was well correlated (r=.54) with the STAI-T. These findings reveal some of the strengths and weaknesses of these two OCD instruments, and the results provide guidance for selecting scales that are suitable for measuring OCD symptoms.

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.