Elsevier

Journal of Affective Disorders

Volume 266, 1 April 2020, Pages 585-594
Journal of Affective Disorders

Research paper
Clinical expression and treatment response among children with comorbid obsessive compulsive disorder and attention-deficit/hyperactivity disorder

https://doi.org/10.1016/j.jad.2020.01.144Get rights and content

Highlights

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    Children and adolescents with comorbid OCD and ADHD experience fewer sexual obsessions, higher rates of comorbidity (separation anxiety, ASD, tic disorder, ODD), poorer executive functioning, as well as significantly higher impairment in home/family functioning relative to youth with OCD, but without ADHD.

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    Families of children and adolescents with comorbid OCD and ADHD report engaging in significantly more accommodating behaviours and report more maladaptive parenting rearing practices characterised by higher anxious rearing and rejection.

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    Finally, children and adolescents with comorbid OCD and ADHD are less likely to be responders or remitters immediately following CBT, relative to youth without ADHD.

Abstract

Background

Paediatric obsessive-compulsive disorder (OCD) is highly comorbid with other psychological disorders, including attention deficit/hyperactivity disorder (ADHD). Preliminary evidence suggests that youth with comorbid OCD and ADHD may experience greater impairments than children with other comorbidities; however, there is limited research examining the clinical expression and treatment response of these youth.

Methods

Youth (7 to 17 years) with a primary diagnosis of OCD and comorbid ADHD (n = 40) were compared a sample of age and gender matched youth with OCD and other comorbidity (without ADHD, n = 40). The study investigated symptoms, severity, functioning, comorbidity, family accommodation, in addition to parental psychopathology and rearing styles. Treatment response was investigated at post-treatment and six-month follow-up.

Results

Youth with comorbid OCD and ADHD had fewer sexual obsessions, higher rates of comorbidity, poorer executive functioning and higher family impairment. Families of comorbid youth engaged in significantly more accommodation and reported more negative rearing. Finally, comorbid youth were significantly less likely to be responders or remitters at post-treatment.

Limitations and Conclusions

Limitations include the cross-sectional design, relatively small clinical sample, and lack of an experimental control group of youth with ADHD without OCD. Current approaches to treatment may be improved for youth with comorbid OCD and ADHD by addressing cooccurring anxiety, behavioural difficulties, and maladaptive family accommodation and rearing. Moreover, given pronounced deficits in executive function, these youth may require a stronger initial dose of CBT to achieve an adequate response.

Section snippets

Clinical characteristics

Children with ADHD experience significant dysfunction and impairments across multiple domains of life including social, school, and family functioning (Barkley, 2002; DuPaul et al., 2001; Mariani and Barkley, 1997). Given that both OCD and ADHD are individually associated with impairment in functioning, it is not surprising that children with both diagnoses experience significant psychosocial adversity. Children with comorbid OCD and externalising disorders (including ADHD symptomatology),

Family functioning

In childhood, OCD is often associated with profound impairments to family life due to high rates of family accommodation to OCD symptoms, which has been found to be associated with hieghtened parental distress and burden (Lee et al., 2015). Moreover, studies highlight that greater parental distress predicts greater OCD severity and higher functional impairment (Storch et al., 2009), and poorer family functioning (i.e., blame, conflict, low cohesion) predicts poorer response to treatment (Peris

Executive function

Functional imaging studies in adult OCD support theory that the cortico-striato-thalamo-cortical (CSTC) is involved in the pathogenesis and expression of OCD (Saxena and Rauch, 2000), which is proposed to explain the observed associations between OCD and deficits in executive functions (Bannon et al., 2002; Chamberlain et al., 2007; Kuelz et al., 2004). However, findings across the neuropsychological literature in OCD are inconsistent and heterogeneous (Abramovitch et al., 2013; Kuelz et al.,

Treatment response

CBT, including exposure with response prevention (ERP), either alone or in combination with SRI medication, is considered the gold-standard treatment for paediatric OCD (O'Kearney, 2007). However, despite best efforts, a large number of children and adolescents do not achieve complete remission following CBT. Comorbidity has consistently been found to be associated with poorer response to OCD treatment (Stewart et al., 2004; Storch et al., 2008), with several studies demonstrating that comorbid

The present study

The aim of the present study was to examine the clinical expression (i.e., symptoms, comorbidity) and correlates (i.e., family variables, executive functioning) of comorbid OCD and ADHD in a sample of treatment-seeking children and adolescents with a primary diagnosis of OCD and comorbid ADHD (OCD+ADHD group), compared to an age- and gender-matched sample of youth with OCD and other comorbidity, but without ADHD (OCD without ADHD). Based on the literature reviewed, it was hypothesised that (1)

Participants

The participants for the current study included 40 children and adolescents aged 7 to 17 years (M = 12.18, SD = 2.85) with a primary diagnosis of OCD and comorbid ADHD, as well as an age- and gender-matched sample of 40 children and adolescents with OCD without ADHD (M = 12.13, SD = 2.85). Sixty-nine percent of the overall sample were male. The sample was drawn from consecutive referrals into cognitive-behavioural treatment studies being offered at Griffith University, Queensland, Australia.

Discussion

In the current study, we investigated the unique clinical expression and CBT treatment response of youth with comorbid OCD and ADHD relative to children with a diagnosis of OCD but not ADHD. Results of the current study suggest that the comorbid OCD and ADHD is relatively common, affecting between 14 and 20% of treatment seeking youth in the current study. Youth with both disorders may represent a specific subtype of OCD, characterised by high comorbidity and significant OCD-related impairments

Funding

The current research was supported by funding from the Foundation for Children, Financial Markets grant scheme, as well as a National Health and Medical Research Council (NHMRC) project grant (Farrell APP1058025).

Author contributions

LJF designed the study, oversaw data collection, analysis and revising the paper. Author CL and EB assisted with data collection, literature searchers, data analysis and drafting / editing the first drafts of the manuscript. Authors AW and MZG contributed to the final drafting and revising the manuscript and contributed to the methodology and deigns. All authors contributed to and have approved the final manuscript. All authors warrant that the article is the authors' original work, hasn't

Declaration of Competing Interest

None.

Acknowledgements

The current research was supported by funding from the Foundation for Children, Financial Markets grant scheme, as well as a National Health and Medical Research Council (NHMRC) project grant (Farrell APP1058025).

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