Recent Developments in Childhood Obsessive Compulsive Disorder

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Mar 5, 2010 - Obsessive compulsive disorder (OCD) is a complex and heterogeneous condition, with wide variations in symptom presentation, associated ...

Child Youth Care Forum (2010) 39:69–71 DOI 10.1007/s10566-010-9099-1 INTRODUCTION

Introduction to the Special Issue: Recent Developments in Childhood Obsessive Compulsive Disorder Eric A. Storch • Dean McKay

Published online: 5 March 2010 Ó Springer Science+Business Media, LLC 2010

Obsessive compulsive disorder (OCD) is a complex and heterogeneous condition, with wide variations in symptom presentation, associated clinical characteristics, and response to treatment (Keeley et al. 2008; McKay et al. 2004). Further, OCD has been associated with serious functional impairment due to the multiple behavioral and emotional domains affected by its manifestation (Markarian et al. 2010). As the field has come to recognize the complexity of the disorder, the movement to understand central features and common ancillary symptoms has been the source of increased research scrutiny. This has been true in the case of adults and children with the condition. This special issue is devoted to examination of several important lines of research for childhood OCD. To start, assessment of symptoms and severity has been investigated, with most measures simply downward extensions of existing adult measures. However, to add to the complexity of OCD, the domains of symptoms evident in children may not necessarily correspond to adult manifestations (i.e., McKay et al. 2006). And, the current state of available assessment measures may be limited to the degree that all relevant symptom domains are adequately assessed (Grabill et al. 2008). Accordingly, Lewin and Piacentini (this issue) begin the issue with a critical evaluation of the existing measures for assessing OCD and related constructs with recommendations for tying treatment to the specific domains assessed, and understanding methods of assessing treatment response and remission. Treatment has likewise progressed to address complex syndromal features of OCD. For example, recent conceptualizations have examined difficulties routinely encountered in cognitive-behavioral therapy (CBT; Marques et al. 2010; McKay et al. 2009, 2010; Storch et al. 2008). It has also been shown that treatment delivery has improved dramatically, and recent benchmarking research demonstrates that empirically supported approaches can be successfully implemented in community settings for childhood OCD (Farrell et al. in press). While this last point is encouraging, the findings of Farrell et al. (in press) showed E. A. Storch (&) Departments of Pediatrics and Psychiatry, University of South Florida, 800 6th Street South, 4th Floor North, Box 7523, St. Petersburg, FL 33701, USA e-mail: estor[email protected] D. McKay Fordham University, New York, NY, USA



Child Youth Care Forum (2010) 39:69–71

that only 63% of children responded positively. Therefore, a large percentage of children may fail to respond or only respond partially. Accordingly, two papers in this special issue report on methodological procedures for novel methods of treatment delivery. First, Ivarsson et al. (in press) report on a modified stepped care approach in the long term treatment and maintenance of gains for OCD in youth. This study is notable in its scope in that it will provide estimates of the proportion of children who will respond to: CBT monotherapy; antidepressant augmentation of CBT; and finally, atypical antipsychotic augmentation of CBT and antidepressant non-response. Such a study would be difficult to conduct in the United States given the high prevalence of youth who receive initial treatment with antidepressant medications despite this being inconsistent with practice parameters suggesting CBT alone or with SSRI therapy. Next, in light of the recent surge in research on specific pharmacologic agents intended to enhance the results of CBT (so called cognitive enhancers), Storch et al. (in press) present on the methods and rationale for the use of d-cycloserine in conjunction with CBT. D-cycloserine has been hypothesized to target the n-methyl-D-aspartate neural pathways, which has in turn been implicated in memory formation for changes in fear learning. Recent research has suggested that this medication may increase the speed of fear reduction when used in conjunction with CBT (Norberg et al. 2008), and its application in children is an appropriate next step in the research. In light of side effects associated with some classes of psychiatric medications, this approach may offer a safe alternative to augmenting exposure-based CBT. Finally, while assessment of primary symptoms has been the subject of research scrutiny, less attention has been paid to the evaluation of serious adverse effects which may be related to antidepressant medication use. Indeed, there has been recent controversy about the role of SSRI medications in the induction of suicidality among youth, which poses an issue for parents of children with OCD (and other problems that these medications are used to treat) regarding the relative benefits and risks profile. Accordingly, Reid et al. (this issue) highlight the importance of systematic methods for assessing behavioral activation symptoms in the context of a large pediatric OCD trial. As well, Reid et al. report on the development and initial psychometric properties of the Treatment-Emergent Activation and Suicidality Assessment Profile (TE-ASAP), a measure for assessing such symptoms. This has been a grossly under-examined area of investigation, and clinicians are routinely left with unclear practice guidelines for how to effectively evaluate risk in youth being treated with SSRIs. The advent of the TE-ASAP should help address this issue by providing a psychometrically sound manner of documenting behavioral activation symptoms. In sum, these articles provide a sample of the range of innovative research currently being conducted by international researchers, as well as insight into the multitude of complexities in childhood OCD research and the many areas that warrant investigation. It is our hope that these articles raise awareness in the reader about the impairing nature of childhood OCD; options for its effective treatment; and areas where critical research is being conducted. And, with this in mind, that the articles contained within this series promote scholarship in the realm of childhood OCD and related disorders with the ultimate goal of promoting affected children’s well-being.

References Farrell, L. J., Schlup, B., & Boschen, M. J. (in press). Cognitive behavioral treatment of childhood obsessive compulsive disorder in community based clinical practice: Clinical significance and benchmarking against efficacy. Behaviour Research and Therapy.


Child Youth Care Forum (2010) 39:69–71


Grabill, K., Merlo, L., Duke, D., Harford, K. L., Keeley, M. L., Gefken, G. R., et al. (2008). Assessment of obsessive-compulsive disorder: A review. Journal of Anxiety Disorders, 22, 1–17. Ivarsson, T., Thomson, P. H., Dahl, K., Valderhaug, R., Weidle, B., Nissen, J. B., et al. (in press). The rationale and some features of the Nordic long term OCD treatment study (NortLOTS) in childhood and adolescence. Child and Youth Care Forum. Keeley, M. L., Storch, E. A., Merlo, L. J., & Geffken, G. R. (2008). Clinical predictors of response to cognitive-behavioral therapy for obsessive-compulsive disorder. Clinical Psychology Review, 28, 118–130. Lewin, A. B., & Piacentini, J. (in press). Evidence-based assessment of child obsessive compulsive disorder (OCD): Recommendations for clinical practice and treatment research. Child and Youth Care Forum. Markarian, Y., Larson, M. J., Aldea, M. A., Baldwin, S. A., Good, D., Berkeljon, A., et al. (2010). Multiple pathways to functional impairment in obsessive-compulsive disorder. Clinical Psychology Review, 30, 78–88. Marques, L., Chosak, A., Phan, D.-M., Fama, J., Franklin, S., & Wilhelm, S. (2010). Avoiding treatment failures in obsessive compulsive disorder. In M. W. Otto & S. Hofmann (Eds.), Avoiding treatment failures in the anxiety disorders (pp. 125–145). New York: Springer Science ? Business. McKay, D., Abramowitz, J., Calamari, J., Kyrios, M., Radomsky, A., Sookman, D., et al. (2004). A critical evaluation of obsessive-compulsive disorder subtypes: Symptoms versus mechanisms. Clinical Psychology Review, 24, 283–313. McKay, D., Piacentini, J., Greisberg, S., Graae, F., Jaffer, M., & Miller, J. (2006). The structure of childhood obsessions and compulsions: Dimensions in an outpatient sample. Behaviour Research and Therapy, 44, 137–146. McKay, D., Storch, E. A., Nelson, B., Morales, M., & Moretz, M. W. (2009). Obsessive-compulsive disorder in children and adolescents: Treating difficult cases. In D. McKay & E. A. Storch (Eds.), Cognitive-behavior therapy for children and adolescents: Treating difficult cases (pp. 81–114). New York: Springer. McKay, D., Taylor, S., & Abramowitz, J. S. (2010). Obsessive-compulsive disorder. In D. McKay, J. S. Abramowitz, & S. Taylor (Eds.), Cognitive-behavioral therapy for refractory cases: Turning failure into success (pp. 89–109). Washington, DC: American Psychological Association Press. Norberg, M. M., Krystle, J. H., & Tolin, D. F. (2008). A meta-analysis of d-cycloserine and the facilitation of fear extinction and exposure therapy. Biological Psychiatry, 63, 1118–1126. Reid, J. M., Storch, E. A., Murphy, T. K., Bodzin, D., Morgan, J., Lehmkuhl, H., et al. (in press). Development and psychometric evaluation of the treatment-emergent activation and suicidality assessment profile. Child and Youth Care Forum. Storch, E. A., McKay, D., Reid, J. M., Geller, D., Goodman, W. K., & Murphy, T. K. (in press). D-cycloserine augmentation of cognitive-behavioral therapy in pediatric obsessive-compulsive disorder: Rationale, design, and methods. Child and Youth Care Forum. Storch, E. A., Merlo, L. J., Larson, M., Geffken, G. R., Lehmkuhl, H. D., Jacob, M. L., Murphy, T. K., & Goodman, W. K. (2008). The impact of comorbidity on cognitive-behavioral therapy response in pediatric obsessive compulsive disorder. Journal of the American Academy of Child and Adolescent Psychiatry, 47, 583–592.


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