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Obsessive compulsive disorders (OCD) are marked by distress, negative emotions, mental processes and behaviors that are reflected in physiological signals such as heart rate, electrodermal activity, and temperature. Continuous monitoring of physiological signals associated with OCD symptoms may make measures of OCD more objective and facilitate close monitoring of prodromal symptoms, treatment progress and risk of relapse. Thus, we explored the feasibility of capturing OCD events in the real world using an unobtrusive wrist worn biosensor and machine learning models. Nine children and adolescents (mean age = $12.3$, SD = $2.6$) with mild to severe OCD were recruited from child and adolescent mental health services. Participants were asked to wear the biosensor in the lab during conditions of rest and exposure to OCD symptom-triggering stimuli and for up to eight weeks in their everyday lives and register OCD events, i.e., every time their OCD symptoms caused distress. We explored the relationships among the amount of physiological data, registered OCD events, age, OCD symptom severity and symptom types. In the machine learning models, we considered detection of OCD events as a binary classification problem. A two-layer cross validation strategy with either random 10-folds, leave-one-person out, or leave-week(s)-out in both layers was used. We compared the performance of four models: logistic regression, random forest (RF), feedforward neural networks, and mixed-effect random forest (MERF). To explore the ability of the models to detect OCD events in new patients, we assessed the performance of participant-based generalized models. To explore the ability of models to detect OCD events in future, unseen data from the same patients, we compared the performance of temporal generalized models trained on multiple patients with personalized models trained on single patients. Eight of the nine participants collected biosensor signals totaling $2,045$ hours and registered $1,639$ OCD events. RF and MERF models outperformed the other models in terms of accuracy in all cross-validation strategies, reaching 70\% accuracy in random and temporal cross validation. Better performance was obtained when generalizing across time compared to across patients. Generalized temporal models trained on multiple patients were found to perform better than personalized models trained on single patients. Our pilot results suggest that it is possible to detect OCD episodes in the everyday lives of youths using physiological signals captured with a wearable biosensor. Large scale studies are needed to train and test models capable of detecting and predicting episodes.

Behavioral observation is an important tool for research and practice in clinical, developmental, and social psychology. Traditional,expert-based methods for behavioral observation from videos are limited by the amount of time and resources it requires. Artificialintelligence tools are available that can automatically and reliably code specific emotions and behaviors. However, the generatedoutput is not specifically aligned to applications in psychology. We present methods for automating behavioral coding using opensource software and provide an overview of available sources and instructions on how they can be applied to generate codes fromwidely used behavioral coding manuals. Using two examples, we describe methods for applying open source computer visionand hearing tools to code behavior in two settings: a parent-child interaction and a psychotherapeutic exposure session. We use amodular approach, defining specific behaviors with features extracted with computer vision and hearing tools that can be combinedinto higher order constructs. Modules can be combined in different ways to allow a flexible application to a variety of codingmanuals or observational tasks. In addition, we propose ways of testing the validity of the automated codes. Some modalities arebetter suited than others for specific tasks. For example, the performance of computer vision tools is excellent for detecting emotion,whereas speech signal processing is less sensitive to detecting specific emotions. However, speech is better suited for detectingvocalization than computer vision. Issues of privacy and bias are discussed as well as methods for mitigating these risks. Weidentified behaviors that can be computationally coded. Our proposed automated methods will enable researchers to code more oftheir video and audio data than is possible with human coding for meaningful behavioral information and investigate mechanisms atplay in social interactions. Some of these methods can be directly applied by psychologists whereas others necessitate collaborationwith computer scientists.

BACKGROUND Physiological signals such as heart rate and electrodermal activity can provide insight into an individual’s mental state, which is invaluable information for mental health care. Using recordings of physiological signals from wearable devices in-the-wild can facilitate objective monitoring of symptom severity and evaluation of treatment progress. OBJECTIVE We designed a study to test the feasibility of predicting obsessive-compulsive disorder (OCD) events from physiological signals recorded using wrist-worn devices in-the-wild. Here, we present an analysis plan for the study to document our a-priori hypotheses and increase the robustness of the findings of our planned study. METHODS Time-domain and frequency-domain features are extracted from the heart rate, skin conductivity, and skin temperature signals within sliding windows. The features are used to predict the distress event logged by participants during data collection. We will test the prediction models within participants across time and across multiple participants. Model selection and estimation using two-layer cross-validation is outlined for both scenarios. RESULTS Physiological signals from 18 participants (nine diagnosed with OCD and nine controls) between the ages of 8 and 17 years are collected using wrist-worn devices during waking hours for up to eight weeks. For the nine participants with an OCD diagnosis and the severity of the diagnosis, number of, and type of symptoms has been graded using the CY-BOCS. CONCLUSIONS A major strength of the planned study is the investigation of predictions of OCD events in-the-wild. A major challenge of the study is the inherent noise of in-the-wild data and the lack of contextual knowledge associated with the recorded signals. This pre-registered analysis plan may help reduce interpretation bias of the upcoming results. CLINICALTRIAL ClinicalTrials.gov: NCT05064527, registered October 1, 2021.

Background: Concerns have been raised that synthetic oxytocin, a widely used obstetric tool for labor induction and augmentation, may have deleterious effects on the neuropsychological development of children. Few studies have examined the relationship between oxytocin-stimulated labor and emotional disorders. Methods: We conducted a nationwide register-based cohort study including 677,629 singletons born in Denmark in the years 2000 to 2012 and followed through 2016 (median age = 10.6 years). Data on oxytocin-stimulation were obtained from the Danish Medical Birth Register. Cases of emotional disorders - anxiety, obsessive-compulsive disorder, mood or traumatic stress disorders or a redeemed prescription for a selective serotonin reuptake inhibitor - were identified using Danish patient and prescription registries. Results: Oxytocin was used to stimulate 31% of births, and oxytocin-stimulated labor was not associated with childhood emotional disorders (HR = 1.05, 95% CI 0.99, 1.11) after adjustment for maternal history of psychopathology, antidepressants during pregnancy, cohabitation status, highest educational attainment, smoking status during pregnancy, birth year, and indications for labor stimulation. The crude cox model was also small and close to unity (HR = 1.09, 95% CI 1.03, 1.15). Limitations: About 50% of our population had reached the age of 10 years, but the outcome included disorders with later average debut ages. Oxytocin dosage levels are not recorded in the registers. Conclusions: Our small effect size estimates suggest that perinatal synthetic oxytocin does not contribute to the development of emotional disorders. Current evidence does not warrant revision of guidelines for the use of oxytocin in obstetrics.

In a recent letter to the editor, a group of clinician-researchers posit that the conclusions in our published systematic review1 on cognitive-behavioral therapy (CBT) for pediatric obsessive-compulsive disorder (OCD) are based on inappropriate methodology. In this reply, we address the concerns expressed by Storch et al.2

BACKGROUND Despite the importance of oxytocinergic signalling for satiety regulation and energy balance, the impact of exposure to synthetic oxytocin during childbirth on obesity during childhood remains unknown. OBJECTIVES To examine the association between oxytocin exposure during labour and the risk of being overweight or obese during childhood. METHODS Synthetic oxytocin exposure data of mothers from the Danish Medical Birth Registry were linked with self-reported anthropometric data of their children from the Danish National Birth Cohort (5 months-11 years of age). Multinomial logistic regression and latent class growth analyses were performed to determine the association between oxytocin exposure and obesity during childhood. RESULTS With the exception of the normal weight-to-overweight group between ages 5 and 12 months, none of the other analyses revealed a significant association between synthetic oxytocin use and the risk of being overweight until the age of 11 years. Furthermore, latent class growth analysis did not reveal an association between oxytocin exposure at birth and the risk of being overweight or obese during childhood. CONCLUSIONS Our analysis of a large cohort of children who varied in their synthetic oxytocin exposure status at childbirth did not reveal an association between oxytocin exposure and the risk of childhood overweight/obesity.

Objective: To assess benefits and harms of cognitive-behavioral therapy (CBT) versus no intervention or versus other interventions for pediatric obsessive-compulsive disorder (OCD). Method: We searched for randomized clinical trials of CBT for pediatric OCD. Primary outcomes were OCD severity, serious adverse events, and level of functioning. Secondary outcomes were quality of life and adverse events. Remission from OCD was included as an exploratory outcome. We assessed risk of bias and evaluated the certainty of the evidence with the Grading of Recommendations Assessment, Development and Evaluation (GRADE). Results: Nine trials (N = 645) were included comparing CBT with no intervention and 3 trials (N = 146) comparing CBT with selective serotonin reuptake inhibitors (SSRIs). Compared with no intervention, CBT decreased OCD severity (mean difference [MD] = −8.51, 95% CI = −10.84 to −6.18, p < .00001, low certainty), improved level of functioning (patient-rated: standardized MD [SMD] = −0.90, 95% CI = −1.19 to −0.62, p < .00001, very low certainty; parent-rated: SMD = −0.68, 95% CI = −1.12 to −0.23, p = .003, very low certainty), had similar proportions of participants with adverse events (risk ratio = 1.06, 95% CI = 0.93−1.22, p = .39, GRADE: low certainty), and was associated with reduced risk of still having OCD (risk ratio = 0.50, 95% CI = 0.37−0.67, p < .00001, very low certainty). We had insufficient data to assess the effect of CBT versus no intervention on serious adverse events and quality of life. Compared with SSRIs, CBT led to similar decreases in OCD severity (MD = −0.75, 95% CI = −3.79 to 2.29, p = .63, GRADE: very low certainty), and was associated with similar risk of still having OCD (risk ratio = 0.85, 95% CI = 0.66−1.09, p = .20, very low certainty). We had insufficient data to assess the effect of CBT versus SSRIs on serious adverse events, level of functioning, quality of life, and adverse events. Conclusion: CBT may be more effective than no intervention and comparable to SSRIs for pediatric OCD, but we are very uncertain about the effect estimates.

Experts have raised concerns that oxytocin for labor induction and augmentation may have detrimental effects on the neurodevelopment of children. To investigate whether there is the reason for concern, we reviewed and evaluated the available evidence by searching databases with no language or date restrictions up to 9 September 2018. We included English-language studies reporting results on the association between perinatal oxytocin exposure and any cognitive impairment, psychiatric symptoms or disorders in childhood. We assessed the quality of studies using the Newcastle–Ottawa Quality Assessment Scales. Independent risk estimates were pooled using random-effects meta-analyses when at least two independent datasets provided data on the same symptom or disorder. Otherwise, we provided narrative summaries. Two studies examined cognitive impairment, one examined problem behavior, three examined attention-deficit/hyperactivity disorder (ADHD) and seven focused on autism spectrum disorders (ASD). We provided narrative summaries of the studies on cognitive impairment. For ADHD, the pooled risk estimate was 1.17; 95% confidence interval (CI) 0.77–1.78, based on a pooled sample size of 5 47 278 offspring. For ASD, the pooled risk estimate was 1.10; 95% CI 1.04–1.17, based on 8 87 470 offspring. Conclusions that perinatal oxytocin increases the risks of neurodevelopmental problems are premature. Observational studies of low to high quality comprise the evidence-base, and confounding, especially by the genetic or environmental vulnerability, remains an issue. Current evidence is insufficient to justify modifying obstetric guidelines for the use of oxytocin, which state that it should only be used when clinically indicated.

Background Although there is substantial evidence for the role of emotion regulation in the etiology and maintenance of anxiety disorders, knowledge about what contributes to emotion dysregulation is sparse. Attachment style is related to emotion regulation and anxiety symptoms, but these variables have rarely been examined together. Examining emotion dysregulation within the context of anxiety disorders through an attachment theory framework will lead to a better understanding of the etiology and maintenance of anxiety disorders. In the present study we combined theoretically and empirically derived knowledge to examine the mediating role of emotion regulation between attachment dimensions (avoidance and anxiety) and anxiety symptoms. Methods A total of 147 individuals were assessed with Beck Anxiety Inventory (BAI), Experiences in Close Relationships-Revised (ECR-R) and Difficulties in Emotion Regulation Scale (DERS), and statistical mediation analyses were conducted. Results Our results indicate that the significant association between anxiety and attachment anxiety was mediated by emotion dysregulation, whereas attachment avoidance was not significantly related to anxiety when covarying for attachment anxiety. The primary limitation of our study is that data is cross-sectional and so causation cannot be inferred. Secondly, all measures used in this study were derived from self-reported questionnaires, which may be more susceptible to bias. Conclusions Our results suggest that it is not insecure attachment in general that is important in anxiety disorders, but that attachment anxiety is specifically relevant. Thus, clinical interventions for anxiety disorders may improve by targeting attachment related difficulties.

Recent research suggests that adults and children with anxiety disorders have a particular set of metacognitive beliefs and strategies. Knowing whether parents’ metacognitions, beliefs and behaviors are associated with their children’s metacognitions is important for understanding how anxiety-related metacognitions and clinical anxiety develop. We hypothesized that there are positive relationships between mother and corresponding child anxiety-related metacognitions even after controlling for maternal depression, anxiety and stress symptoms. We also hypothesized that maternal beliefs about child anxiety and maternal controlling behavior would be positively related to child metacognitions and would account for any associations between mother and child metacognitions. The study employed a cross-sectional design in a community sample of 7–12 year old children and their mothers. Mothers and children completed questionnaires to assess anxiety-related metacognitions and an interaction task to assess mothers’ overinvolvement. Mothers also completed questionnaires regarding their beliefs about child anxiety and controlling rearing behavior. We examined correlations between variables before investigating which maternal variables made unique contributions to the variation in children’s metacognitions in a series of multiple regressions and mediation analyses. Mothers’ positive worry beliefs and cognitive confidence contributed a modest amount of unique variance in the corresponding beliefs in children. Mothers’ and children’s metacognitions were positively associated. The unique contributions of mothers’ anxiety-related metacognitions on children’s anxiety-related metacognitions found in our study indicate that a metacognitive-parental intervention for preventing and treating child anxiety is worth investigation. Our findings place anxious metacognitions in a developmental context.

We aimed to bring a developmental perspective to metacognitive theory. The metacognitive model (MCM) was originally developed for adults. However, an increasing number of studies demonstrate the MCM is relevant to child anxiety. Therefore, it is important to understand the origins of anxiety-specific metacognitions. Given the role experiences of controlling parenting play in maintaining and perhaps forming anxious cognitions or a cognitive vulnerability we focused on maternal behavioral and psychological control. Using a cross-sectional design, Danish school children (9–17 years old; N = 1062) rated their levels of anxiety and anxiety-specific metacognitions, and their mothers' controlling behavior. Child-perceived maternal psychological control was positively correlated with each anxiety specific metacognition (positive and negative worry beliefs, cognitive confidence, need to control, and cognitive self-consciousness). Child-perceived autonomy-granting was negatively correlated with all metacognitions except cognitive self-consciousness. Child perceived maternal psychological control was indirectly associated with anxiety via total metacognitions. Child-perceived autonomy-granting, but not psychological control, was directly related to anxiety. Given the differential findings for psychological control and autonomy-granting, we suggest that specific types of parenting behavior may be related to specific elements of (meta-) cognitive vulnerability. Our findings are theoretically important because they propose maternal psychological control is an environmental factor that may play a role in the development of a metacognitive vulnerability related to anxiety. A potential clinical implication of our findings is that metacognitive therapy for children should include a parental component.

INTRODUCTION: The objective was to examine the association between obstetric synthetic oxytocin use and hyperactivity/inattention problems in offspring.MATERIAL AND METHODS: We identified children born in 2000-2003, enrolled in the Danish National Birth Cohort, with data on the Strengths and Difficulties Questionnaire (SDQ) reported by parents at age seven (n = 33 896) and age 11 (n = 27 561) and the children themselves around age 11 (n = 27 251). Information on oxytocin administration was provided in the Medical Birth Register. We estimated mean differences and odds ratios for childhood hyperactivity/inattention problems according to oxytocin exposure.RESULTS: Synthetic oxytocin was administered in 26% of the deliveries. We did not find the use of synthetic oxytocin during birth to be associated with childhood hyperactivity/inattention problems, whether analyzed in linear or logistic regression models.CONCLUSIONS: Our findings do not support any effects of obstetric use of synthetic oxytocin on hyperactivity/inattention problems in children when measured with the SDQ subscale at 7 or 11 years of age.

The purpose of this study was to evaluate reductions in negative automatic thoughts and metacognitive beliefs as predictors of treatment gains in CBT for childhood anxiety disorders. A sample of 44 clinically anxious children between 7 and 12 years of age, who underwent CBT, completed questionnaires assessing negative thinking, metacognitive beliefs and processes, and anxiety symptoms before, after, and 6 months following treatment. Results indicated that negative thoughts and metacognitions decreased equally during the treatment period. Furthermore, metacognitions continued to decrease during the posttreatment period. Negative thinking and metacognitions were both significant predictors of reductions in child-reported anxiety from pre- to posttreatment. For long-term anxiety changes, only decreases in negative thoughts were related to anxiety reduction. Mediation analysis showed that metacognitions partially mediated the relation between negative thinking and anxiety. The study supports negative automatic thoughts and metacognitive beliefs and processes as putative mediators of CBT.

Background Infant socioemotional development is often held under informal surveillance, but a formal screening program is needed to ensure systematic identification of developmental risk. Even when screening programs exist, they are often ineffective because health care professionals do not adhere to screening guidelines, resulting in low screening prevalence rates. Objectives To examine feasibility and acceptability of implementing universal screening for infant socioemotional problems with the Alarm Distress Baby Scale in primary care. The following questions were addressed: Is it possible to obtain acceptable screening prevalence rates within a 1-year period? How do the primary care workers (in this case, health visitors) experience using the instrument? Are attitudes toward using the instrument related to screening prevalence rates? Design A longitudinal mixed-method study (surveys, data from the health visitors' digital filing system, and qualitative coding of answers to open-ended questions) was undertaken. Setting and participants Health visitors in three of five districts of the City of Copenhagen, Denmark ( N =79). Methods We describe and evaluate the implementation process from the date the health visitors started the training on how to use the Alarm Distress Baby Scale to one year after they began using the instrument in practice. To monitor screening prevalence rates and adherence to guidelines, we used three data extractions (6, 9, and 12 months post-implementation) from the electronic filing system. Surveys including both quantitative and open-ended questions (pre- and post-implementation) were used to examine experiences with and attitudes towards the instrument. Descriptive and inferential statistical and qualitative content analyses were used. Results Screening prevalence rates increased during the first year: Six months after implementation 47% ( n = 405) of the children had been screened; 12 months after implementation 79% ( n =789) of the children were screened (the same child was not counted more than once). Most (92%) of the health visitors reported that the instrument made a positive contribution to their work. The majority (81%) also reported that it posed a challenge in their daily work at least to some degree. The health visitors' attitudes (positive and negative) toward the Alarm Distress Baby Scale, measured 7 months post-implementation, significantly predicted screening prevalence rates 12 months post-implementation. Conclusions Adding the Alarm Distress Baby Scale to an established surveillance program is feasible and accepTable Screening prevalence rates may be related to the primary care worker's attitude toward the instrument, i.e. successful implementation relies on an instrument that adds value to the work of the screener.

The metacognitive model has increased our understanding of the development and maintenance of generalized anxiety disorders in adults. It states that the combination of positive and negative beliefs about worry creates and sustains anxiety. A recent review argues that the model can be applied to children, but empirical support is lacking. The aim of the 2 presented studies was to explore the applicability of the model in a childhood sample. The first study employed a Danish community sample of youth (n = 587) ages 7 to 17 and investigated the relationship between metacognitions, worry and anxiety. Two multiple regression analyses were performed using worry and metacognitive processes as outcome variables. The second study sampled Danish children ages 7 to 12, and compared the metacognitions of children with a GAD diagnosis (n = 22) to children with a non-GAD anxiety diagnosis (n = 19) and nonanxious children (n = 14). In Study 1, metacognitive processes accounted for an additional 14% of the variance in worry, beyond age, gender, and anxiety, and an extra 11% of the variance in anxiety beyond age, gender, and worry. The Negative Beliefs about Worry scale emerged as the strongest predictor of worry and a stronger predictor of anxiety than the other metacognitive processes and age. In Study 2, children with GAD have significantly higher levels of deleterious metacognitions than anxious children without GAD and nonanxious children. The results offer partial support for the downward extension of the metacognitive model of generalized anxiety disorders to children.

Theoretical models of anxiety have been developed in adult populations. The applicability of these models in child samples has been assessed using downward extensions of the questionnaires developed to assess the proposed theoretical mechanisms. This poses a challenge, as children are still in the process of developing the skills that are being assessed. Psychometrically sound assessment tools are therefore needed for this developing population, in order to ensure the early detection of mechanisms leading to anxiety disorders in children. This study examined if metacognitions, which play a key role in generalized anxiety disorder (GAD) in adults, can also be reliably assessed in childhood. The study investigated the psychometric properties of the 30-item Metacognitions Questionnaire for Children (MCQ-C30; Gerlach, Adam, Marschke, & Melfsen, 2008) in a national sample of 974 children and adolescents (538 girls) ages 9-17 years. Confirmatory factor analysis supported the 5-factor subscale structure and a 2nd-order total scale factor, which corresponds with previous versions of the scale. MCQ-C30 expectedly correlated significantly with anxiety symptoms and worry. Structural equation modeling revealed that both obsessive-compulsive disorder and generalized anxiety disorder symptoms regressed significantly onto the MCQ-C30. We fitted separate models for children and adolescents, and no noticeable differences are suggested between the models. Female gender was, expectedly, associated with increased levels of general metacognitions. This gender effect was mediated by level of anxiety. Overall, the MCQ-C30 exhibited acceptable psychometric properties in our community sample of children ages 9-17 years. Future studies should investigate the psychometric properties of the instrument in clinical samples and samples of younger children.