Objective: Obsessive-Compulsive Disorder (OCD) defined at the diagnostic level encompasses divergent symptoms and is often associated with other psychiatric problems.The present study examines OCD versus co-morbid symptom patterns in OCD in children and adolescents in order to investigate the presence of diagnostic heterogeneity Subjects and methods: One-hundred and thirteen outpatients with primary OCD participated.The patients' and primary caretakers' responses on semi-structured interviews (child version of Schedule for Affective Disorders and Schizophrenia and the Children's Yale-Brown Obsessive Compulsive Scale) and parents' responses on the Child Behaviour Checklist were used in the study. Psychiatric diagnoses were related to CBCL syndrome scores and CBCL scores were compared with the Swedish normative data.Results: Co-morbid diagnoses were very common and only one out of five patients had only OCD. The most common group was the neuropsychiatric disorders (47%) where tic disorders were most common (27%), especially among boys (40.8%; p= .006, Fisher's exact test). Also anxiety disorders were common (39.8%) as were affective disorders (24.8%) neither with any gender differences. Diagnoses of disruptive disorders were less common (8.8%), almost exclusively of the oppositional kind (ODD) (8.8%). From the dimensional point of view using the CBCL, patients with OCD scored higher than Swedish youngster generally do, and some gender differences were seen in that girls scored higher on anxiety and depression while both girls and boys had high scores on thought problems, attention problems and especially aggressive behaviour. Comorbidities explained from 25-50% of the CBCL sub-syndrome scales, often with both main effects and through complex patterns of interaction with gender, OCD-severity and other co-morbid problems.OCD co-morbidity Conclusions: While co-morbid problems is an important facet of OCD, sub-syndromal levels of symptoms that can be assessed using a dimensional approach, is a large part of the total symptom burden in these youngsters. Our data indicate contributions of different pathways for girls and for boys for several comorbid problems together with OCD-severity.

This study was registered in Current Controlled Trials; Nordic Long-term Obsessive-compulsive disorder (OCD) Treatment Study (www.controlled-trials.com ISRCTN66385119).

Objective: Assess the prevalence of autistic traits (AST) in pediatric OCD and relate them to OCD co-morbidity and compare them with published normative data.Methods: Pediatric patients with Obsessive-Compulsive Disorder (n=109) according to the DSM IV were studied using parent ratings of the Autistic Symptom/Syndrome Questionnaire to assess AST symptoms as a continuous rather than categorical trait. The KSADS, a semistructured psychiatric interview, was used for the psychiatric diagnostic evaluation. Also, the Children's Yale-Brown Obsessive Compulsive Scale was used to assess OCD severity and other clinical features.Results: AST was common among our patients. Symptom scores were highest in cases with co-morbid Autistic Spectrum Disorders, but cases with other co-morbidities as tics/Tourette and attention/behavioral disorders also scored higher. All sub-groups, including OCD without these co-morbidities scored higher than the Swedish normative group. Using ANOVA, comorbid ASD and tics/Tourette (plus a term for gender by tic interaction indicating that girls with tics scored high, otherwise low) and pathological doubt contributed (R 2 = .41) to the AST-traits, while OCD severity and co-morbid anxiety-and depressive disorders did not.Conclusion: AST traits are prevalent in OCD and seem to be intricately associated with the co-morbidities as well as the OCD syndrome itself. The findings might have implication for our nosological understanding of OCD which currently is discussed.4

In the multivariate analysis, only age predicted better treatment outcome. Using univariate analysis, a variety of predictors of poorer treatment outcome after CBT was identified. The high impact of comorbid symptoms on outcome in pediatric OCD suggests that treatment should address comorbidity issues. The lack of a family predictor may be related to high family involvement in this study. Future research strategies should focus on optimizing intervention in the presence of these characteristics to achieve greater benefits for patients with OCD. Clinical trial registration information-Nordic Long-term Obsessive compulsive disorder (OCD) Treatment Study; www.controlled-trials.com; ISRCTN66385119.

In most countries, young people with obsessive-compulsive disorder have limited access to specialist cognitive behavioral therapy (CBT), a first-line treatment.OBJECTIVE To investigate whether internet-delivered CBT implemented in a stepped-care model is noninferior to in-person CBT for pediatric obsessive-compulsive disorder. DESIGN, SETTING AND PARTICIPANTSA randomized clinical noninferiority trial conducted at 2 specialist child and adolescent mental health clinics in Sweden. Participants included 152 individuals aged 8 to 17 years with obsessive-compulsive disorder. Enrollment began in October 2017 and ended in May 2019. Follow-up ended in April 2020. INTERVENTIONS Participants randomized to the stepped-care group (n = 74) received internet-delivered CBT for 16 weeks. Nonresponders at the 3-month follow-up were then offered a course of traditional face-to-face treatment. Participants randomized to the control group (n = 78) immediately received in-person CBT for 16 weeks. Nonresponders at the 3-month follow-up received additional face-to-face treatment. MAIN OUTCOMES AND MEASURESThe primary outcome was the masked assessor-rated Children's Yale-Brown Obsessive-Compulsive Scale (CY-BOCS) score at the 6-month follow-up. The scale includes 10 items rated from 0 (no symptoms) to 4 (extreme symptoms), yielding a total score range of 0 to 40, with higher scores indicating greater severity. Assessors were masked to treatment allocation at pretreatment, posttreatment, 3-month follow-up, and 6-month follow-up assessments. The predefined noninferiority margin was 4 points on the CY-BOCS. RESULTS Among the 152 randomized participants (mean age, 13.4 years; 94 [62%] females), 151 (99%) completed the trial. At the 3-month follow-up, 34 participants (46%) in the stepped-care group and 23 (30%) in the in-person CBT group were nonresponders. At the 6-month follow-up, the CY-BOCS score was 11.57 points in the stepped-care group vs 10.57 points in the face-to-face treatment group, corresponding to an estimated mean difference of 0.91 points ([1-sided 97.5% CI, −ϱ to 3.28]; P for noninferiority = .02). Increased anxiety (30%-36%) and depressive symptoms (20%-28%) were the most frequently reported adverse events in both groups. There were 2 unrelated serious adverse events (1 in each group).CONCLUSIONS AND RELEVANCE Among children and adolescents with obsessive-compulsive disorder, treatment with an internet-delivered CBT program followed by in-person CBT if necessary compared with in-person CBT alone resulted in a noninferior difference in symptoms at the 6-month follow-up. Further research is needed to understand the durability and generalizability of these findings.

Expert guidelines recommend cognitive-behavior therapy (CBT) as a first-line treatment in pediatric obsessive–compulsive disorder (OCD) and the addition of selective serotonin reuptake inhibitors when CBT is not effective. However, the recommendations for CBT non-responders are not supported by empirical data. Our objective was to investigate the effectiveness of sertraline (SRT) versus continued CBT in children and adolescents that did not respond to an initial course of CBT. Randomized controlled trial conducted in five sites in Denmark, Sweden and Norway, 54 children and adolescents, age 7–17 years, with DSM-IV primary OCD were randomized to SRT or continued CBT for 16 weeks. These participants had been classified as non-responders to CBT following 14 weekly sessions. Primary outcomes were the CY-BOCS total score and clinical response (CY-BOCS <16). The study was a part of the Nordic Long-Term OCD Treatment Study (NordLOTS). Intent-to-treat sample included 50 participants, mean age 14.0 (SD = 2.7) and 48 % (n = 24) males. Twenty-one of 28 participants (75 %) completed continued CBT and 15 of 22 participants (69.2 %) completed SRT. Planned pairwise comparison of the CY-BOCS total score did not reveal a significant difference between the treatments (p = .351), the response rate was 50.0 % in the CBT group and 45.4 % in the SRT group. The multivariate χ2 test suggested that there were no statistically significant differences between groups (p = .727). Within-group effect sizes were large and significant across both treatments. These large within-group effect sizes suggest that continued treatment for CBT non-responders is beneficial. However, there was no significant between-group differences in SRT or continued CBT at post-treatment.

BackgroundThis paper describes and discusses the methodology of the Nordic long-term OCD-treatment study (NordLOTS). The purpose of this effectiveness study was to study treatment outcome of CBT, to identify CBT non- or partial responders and to investigate whether an increased number of CBT-sessions or sertraline treatment gives the best outcome; to identify treatment refractory patients and to investigate the outcome of aripiprazole augmentation; to study the outcome over a three year period for each responder including the risk of relapse, and finally to study predictors, moderators and mediators of treatment response.MethodsStep 1 was an open and uncontrolled clinical trial with CBT, step 2 was a controlled, randomised non-blinded study of CBT non-responders from step 1. Patients were randomized to receive either sertraline plus CBT-support or continued and modified CBT. In step 3 patients who did not respond to either CBT or sertraline were treated with aripiprazole augmentation to sertraline.ConclusionsThis multicenter trial covering three Scandinavian countries is going to be the largest CBT-study for paediatric OCD to date. It is not funded by industry and tries in the short and long-term to answer the question whether further CBT or SSRI is better in CBT non-responders.

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