Elsevier

Psychiatry Research

Volume 199, Issue 2, 30 September 2012, Pages 115-123
Psychiatry Research

Comorbidity and treatment response in pediatric obsessive-compulsive disorder: A pilot study of group cognitive-behavioral treatment

https://doi.org/10.1016/j.psychres.2012.04.035Get rights and content

Abstract

This pilot study evaluated the effectiveness of group cognitive-behavioral treatment (CBT) on treatment outcomes for children and adolescents who presented with obsessive–compulsive disorder (OCD) and complex comorbid conditions, including depression, attention deficit/hyperactivity disorder and pervasive developmental disorders (PDD). Specifically, the impact of comorbidity on treatment response rates and remission rates was examined. Forty-three youth (aged 7–17) with OCD participated in group family-based CBT. Assessments were conducted at pre- and post-treatment and 6 months. Eighty-six percent of youth presented with a secondary psychiatric disorder, and 74% presented with a tertiary psychiatric condition. Contrary to the expected, comorbidity was not associated with poorer treatment outcomes at post-assessment. At longer term follow-up (6 months), however, treatment outcomes were poorer for youth with multiple comorbid conditions and for those with attention deficit/hyperactivity disorder. The finding that group CBT is largely effective for youth with comorbid conditions is of clinical and practical significance. Group delivery of CBT provides an efficient and cost-effective approach, and alleviates strain on services and service providers. Continued efforts are needed to improve long-term outcomes for youth with multiple comorbid conditions and attention deficit/hyperactivity disorder. Examining treatment response as a function of comorbidity with larger clinical samples is important to extend this research.

Introduction

Pediatric obsessive–compulsive disorder (OCD) is a debilitating neurobehavioral anxiety disorder affecting between 1% and 4% of children and youth (Douglass et al., 1995, Valleni-Basile et al., 1995, Shaffer et al., 1996, Zohar, 1999). During childhood, the condition is associated with impairment and dysfunction across multiple domains, including family relationships and household routines (Cooper, 1996, Barrett et al., 2001), school functioning (Toro et al., 1992, Piacentini et al., 2003) and peer relationships (Allsopp and Verduyn, 1990, Storch et al., 2006), leading to lifelong suffering if left untreated (Stewart et al., 2004). The high rate of comorbidity associated with pediatric OCD is one reason why this disorder is so debilitating and why it is so often described as a complex psychiatric disorder and often times difficult to treat (Geller et al., 2003, Masi et al., 2004, Sukhodolsky et al., 2005, Masi et al., 2006, Termine et al., 2006, Storch et al., 2008, Krebs and Heyman, 2010). In fact, comorbidity is the norm in this clinical sample, with up to 80% of children affected having at least one comorbid diagnosis (Swedo et al., 1989, Geller et al., 1996, Storch et al., 2008, Lewin et al., 2010), and as many as 50–60% of youth experiencing two or more other mental disorders during their lifetime (Rasmussen and Eisen, 1990).

Some of the most commonly co-occurring psychiatric conditions associated with pediatric OCD include other anxiety disorders (affecting 26–70% of children with OCD), depression (10–73% of children with OCD), tics and Tourette's Syndrome (17–59% of children with OCD), attention deficit/hyperactivity disorders (10–50% of children with OCD), disruptive behavioral disorders (10–57%), and pervasive developmental disorders (PDD) (e.g., Flament et al., 1990; Thomsen, 1994; Geller et al., 1996, Geller et al., 2001a, Geller et al., 2001b, Ivarsson et al., 2008). In addition to these more frequently co-occurring conditions, youth with OCD may also present with comorbid eating disorders, body dysmorphia and trichotillomania (King et al., 1995, Geller et al., 2001a, Phillips et al., 2005). Studies have suggested that certain comorbid psychiatric disorders associated with OCD (e.g., disruptive behavioral disorders, depression, attention deficit disorder) not only impact upon the severity of a child's OCD but also have a negative effect on children's psychosocial functioning and response to treatment (see Storch et al., 2008, Storch et al., 2010). Understanding the unique correlates of specific comorbid conditions and the impact of such on OCD treatment outcomes is important in both the assessment of OCD and the prescription of individualized treatments.

Cognitive-behavioral treatment (CBT), including exposure and response prevention (ERP), has been designated as probably efficacious for pediatric OCD based on a recent systematic review of the psychosocial treatment literature (see Barrett et al., 2008). Combined with the recommendations included in the OCD Expert Consensus guidelines (March et al., 1997a, March et al., 1997b) and other recent meta-analyses (e.g., O'Kearney et al., 2010), the general consensus in the literature and among experts in the field is that CBT combined with ERP, either alone or in combination with a serotonin reuptake inhibiting (SRI) medication is both an effective and acceptable treatment for children and youth with OCD (see Barrett et al., 2004a, Barrett et al., 2004b, Barrett et al., 2008, Abramowitz et al., 2005, O'Kearney et al., 2010).

Despite the fact that CBT produces impressive treatment effect sizes (i.e., between-group effect sizes of 0.99–2.84; Barrett et al., 2008) and that the majority of children and adolescents with OCD experience clinically significant reduction in OCD symptoms following CBT, the outcomes in terms of actual remission rates provide less than optimal results. Across published studies and across sites within studies (e.g., POTS, 2004), remission rates vary. However, based on results from the largest multi-site RCT to date (Pediatric OCD Treatment Study (POTS), 2004), as many as 60% of children receiving CBT alone, 50% receiving combined CBT and serotonergic medication, and almost 80% receiving serotonergic medication failed to fully remit following treatment. These findings suggest that one in two treatment-seeking children and youth will continue to suffer clinically significant OCD even after combined CBT and SRI treatment. There is therefore a pressing need to understand the predictors and moderators of treatment response in pediatric OCD, in order to determine which children will respond optimally to current generation treatments, and to identify ways to augment or refine these treatments for those who do not. Based on a recent review of predictors and moderators of treatment response (Farrell et al., in press) a consensus is emerging in regards to specific comorbid conditions that might attenuate treatment response for children with OCD.

To date, severity of OCD at pre-treatment, family dysfunction (Ginsburg et al., 2008, Garcia et al., 2010) and family accommodation (Garcia et al., 2010) have all been shown to be associated with poorer response to CBT. Conversely, in medication alone studies, comorbid tics have been associated with poorer outcome (Ginsburg et al., 2008), whilst across treatment modalities, externalizing disorders have been found to be associated with poorer response (Garcia et al., 2010). Gender, age and duration of illness do not appear to differentially predict treatment outcome (Ginsburg et al., 2008, Garcia et al., 2010).

In a recent study, Storch and colleagues (2008) specifically examined the impact of comorbidity on response to CBT in a sample of 96 youth with a primary diagnosis of OCD. In this study, it was found that having one or more comorbid conditions was associated with a poorer response to CBT outcome, and that the number of comorbid conditions was negatively related to outcome. Moreover, and consistent with both Garcia et al. (2010) and Ginsburg et al. (2008), Storch and colleagues found that the presence of comorbid externalizing disorders (i.e., attention deficit/hyperactivity disorder, oppositional defiant disorder (ODD), and conduct disorder) was associated with a poorer treatment response, and that both externalizing disorders and depressive disorders were associated with lower treatment remission rates. The authors of this study did not find evidence to suggest that comorbid anxiety disorders or comorbid tic disorders were associated with a poorer response to CBT, even though these co-occurring disorders were seen in a number of the youth.

Few studies have examined the important issue of moderators of treatment response in pediatric OCD. March and colleagues (2007) reported on the impact of comorbid tic disorder on outcomes in the POTS trial (2004), examining treatment response for the 15% of the POTS sample (n=17 of 112) who had a comorbid tic disorder. In patients without tic disorders, outcomes were consistent with the entire intent-to-treat sample (POTS, 2004) with combined treatment (CBT+sertraline) being superior to CBT alone, which was superior to sertraline alone, which was superior to the placebo condition (POTS, 2004). However, for the sample with comorbid tic disorders, sertraline alone did not differ significantly from the placebo condition, whilst combined treatment (CBT+sertraline) remained superior to CBT, and CBT remained superior to PBO. This finding, consistent with Ginsburg et al. (2008), provides a strong evidence that children with comorbid OCD and tic disorders respond differentially to medication alone versus cognitive-behavioral treatments. Based on this finding, March and colleagues (2007) recommend that children with OCD and comorbid tic disorder should begin treatment with CBT alone or a combined treatment of CBT and SRI, given that medication alone does not provide benefit over a placebo pill.

The issue of treatment response as a function of comorbidity in pediatric OCD warrants further consideration in terms of: (a) an examination across a broader array of comorbid diagnoses, and (b) an examination of treatment response to group-based CBT—which to date has not been systematically examined. Whilst our understanding about specific comorbidties is advancing, we still know very little about the impact of other commonly co-occurring psychiatric conditions PDD, including autism spectrum disorders (ASD), given that these disorders are frequently excluded from randomised controlled treatment trials and to date have not been systematically examined as potential predictors of treatment response. In particular, CBT might be more difficult to deliver with children who have comorbid PDD and/or ASD, due to poor emotional understanding and cognitive rigidity characteristic of these disorders (Krebs and Heyman, 2010). Furthermore, whilst group-based CBT has been established as possibly efficacious and provides an alternative to individual CBT for children and youth with OCD (see Barrett et al., 2008) we do not yet know what impact comorbidity may have on group treatment outcomes. Group CBT is a favorable modality of therapy, with evidence so far providing comparable outcomes to individual CBT in a randomised controlled trial at post-treatment and at 18 months follow-up (Barrett et al., 2004a, Barrett et al., 2004b, Barrett et al., 2005). In fact, group CBT offers an efficient and economical alternative, which improves both access to treatment and reduces treatment costs and therapist time. Moreover, group therapy arguably provides additional benefits for children and families beyond the technical aspects of CBT, by providing peer normalization and peer support in a positive group setting. However, to date little is known about the impact of comorbidity on CBT outcomes for children treated in groups. Given that certain comorbid disorders would likely have a negative impact on the group therapy process—for e.g., disruptive behavioral disorders or ASD, it is important to establish the impact of such on group CBT outcomes for pediatric OCD.

The present study aims to: (1) evaluate the effectiveness of group CBT in an open pilot trial design, to specifically examine the impact of comorbidity on outcome, using a highly comorbid sample of children with OCD up to 6 months following treatment; and (2) to examine the effect of specific comorbidity's on treatment response and treatment remission in a children and youth with OCD (aged 7–17 years). Based on studies involving signal detection analysis to identify optimal cut-offs on the Yale-Brown Obsessive–Compulsive Scale (Y-BOCS; Goodman et al., 1989; Child Y-BOCS; Scahill et al., 1997) for predicting treatment response and clinical remission (Tolin et al., 2005, Storch et al., 2010), this study uses criteria of at least 25% reduction in CY-BOCS scores for determining treatment response, and a reduction of 50% on the CY-BOCS combined with a post-treatment CY-BOCS score of <14 for determining treatment remission (Storch et al., 2010).

Given that comorbidity with other anxiety disorders has not previously been identified as a significant predictor of response to treatment, nor have tics or Tourette's in the case of CBT, this study aims to examine other arguably more complex comorbidity—that is, comorbid conditions that have previously been indicated to possibly attenuate treatment response or to date have not yet been adequately studied, including (a) depression (DEP), (b) attention deficit/hyperactivity disorders (ADHD) and (c) PDD, including ASD. This paper examines the impact of comorbidity on group treatment response and remission at post-treatment and at 6 months follow-up following a standardised group cognitive-behavioral treatment. Based on previous research (e.g., Storch et al., 2008, Storch et al., 2010), it was hypothesized (a) based on pre-treatment comparisons, the presence of comorbid conditions (i.e., DEP, ADHD, PDD) would be associated with significantly worse OCD and higher functional impairment at baseline relative to children without these comorbid conditions (i.e., no comorbid DEP, ADHD, or PDD); (b) group treatment would be effective for the overall sample; however, (c) specific comorbidity (i.e., DEP, ADHD, PDD) would be associated with poorer treatment response and treatment remission following group-based CBT, relative to children without comorbidity.

Section snippets

Participants

Participants were 43 children and adolescents (aged 7–17 years), with a mean age of 11.09 years (S.D.=2.52), comprised of 30 males and 13 females, who were consecutively referred for treatment of OCD to Griffith University and who completed the assessment and participated in treatment. There were a further four participants who were referred to the program, who were eligible for participation, but who withdrew prior to completion of assessment or prior to treatment commencing and were therefore

Results

All statistical analyses were conducted using SPSS version 19.0. Initial data analyses compared baseline demographics and clinical characteristics across two groups—those children with a comorbid diagnosis of interest (i.e., DEP, ADHD, PDD: n=20) and those children without any of the three comorbid conditions of interest (n=23). Independent samples t-tests (t) were computed for continuous variables and chi-square (χ2) analyses were computed for categorical data. Treatment outcome was examined

Discussion

This pilot study evaluated the effectiveness of group CBT on outcomes for children and youth with OCD who presented with complex comorbidity, including depression (DEP), attention deficit/hyperactivity disorder (ADHD) and PDD, including ASD). Specifically, this study examined the correlates of complex comorbidity at baseline (including severity, and impairment), as well as group treatment outcomes at post-treatment and 6-month follow-up, by way of remission rates and treatment response as a

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