Dia 1 - VGCt

CBT for pediatric OCD:
The AACAP guideline reconsidered
Lidewij Wolters & Else de Haan
Research questions:
• Are OCD severity, initial improvement, PDD symptoms and comorbidity predictors of treatment effect?
• Should CBT be continued for children who are not sufficiently improved after 16 sessions CBT?
• The AACAP guideline reconsidered
AACAP Practice Parameter for the Assessment and Treatment of Children and Adolescents With OCD (2012)
Recommendation 6: For moderate to severe OCD medication is indicated in addition to CBT. Although CBT is the first line of
treatment in mild to moderate and, depending on the patient’s and doctor’s preference, even in severe cases of OCD, more
severe symptoms are an indication for medication, preferebly added to CBT. Scores higher than 23 on the CY-BOCS …,
provide a threshold for the consideration of drug intervention.
Methods
• All children (mild-severe OCD) were treated
with CBT monotherapy (16 sessions).
• After 16 sessions CBT the clinician decided
about further treatment: no further treatment,
continued CBT, CBT+SSRI; inpatient
treatment.
Participants
• 59 children & adolescents with OCD (25♂, 34♀)
• 8-18 years (M=12.8, SD=2.6)
• Primary diagnosis OCD
• CY-BOCS ≥ 16 (M=25; SD=4.1; range 16-35)
• 66% comorbidity
• IQ ≥ 80
• No medication / CBT during the past 6 months
R
T0 (n=23)
Waitlist
(8 weeks)
T1 (n=59)
CBT
(8 sessions)
T2 (n=53)
CBT
(8 sessions)
T3 (n=46)
4 months
Measures
• OCD severity (CY-BOCS)
• Comorbidity (ADIS-C/P)
• PDD (CSBQ)
Waitlist vs CBT:
no differences in age, gender, CY-BOCS,
comorbidity.
FU1 (n=43)
8 months
FU2 (n=44)
RESULTS
Predictors of treatment effect
Effect of CBT
Treatment completers
26
22
20
*
18
16
CY-BOCS
(n=46, 78%)
Waitlist
24
14
*
12
10
8
Improved
(Jacobson & Truax, 1991)
Deteriorated
4
2
0
pre
mid
post
fu1
85%
2%
76%
Non-clinical
CB < 16
Remission
CB ≤ 10
*
6
fu2
Initial improvement
OCD severity
Reliable Change
CY-BOCS
t
Post CBT
Is small initial improvement a
reason to stop CBT?
mild (CB 16-23)
32
severe (CB 27-35)
20
16
44%
continued
Study drop-out
16
8
4
4
mid
post
fu1
0
fu2
pre
mid
post
fu1
fu2
Lineair mixed model: main effect change T1-T2
interaction change*CBT
There are different responders: slowresponders and fast-responders
4 (7%)
11 (19%)
CY-BOCS
Is CBT less effective for OCD
with PDD symptoms?
low-average
32
high
28
Lineair mixed model: main effect PDD
CBT resulted in a favourable outcome for
all groups (CB<16). At the end (T5), no sign
differences between groups.
20
19 (32%)
6 (10%)
not continued
*
24
PDD symptoms
*
16
12
*
*
very high
24
CY-BOCS
19 (32%)
8
Inpatient treatment
20
Continued CBT
28
Continued CBT + SSRI
high change
8
Lineair mixed model main effect severity
CBT resulted in a fávourable outcome for
all groups (CB<16). At the end still different
outcome for severe vs mild-moderate OCD.
After the treatment protocol…
Continued CBT monotherapy
24
12
12
pre
No further treatment for OCD
low change
24
0
After the treatment protocol…
28
moderate (CB 24-26)
28
CY-BOCS
CBT
CY-BOCS
Effect CBT
Is CBT less effective for moderate
and severe OCD?
20
16
12
8
4
0
pre
mid
post
fu1
fu2
Number of comorbid disorders was
no predictor of treatment effect.
4
0
pre
mid
post
fu1
fu2
Conclusion
• OCD severity and PDD symptoms were predictors of the effect of CBT monotherapy.
• Slow response at the start of CBT, does not imply non-response at the end.
• Continuing CBT resulted in better treatment outcome.
The AACAP recommends combined treatment (CBT + medication) for children with a CY-BOCS > 23.
Our results do not support this recommendation of the AACAP:
• Continuing CBT led to further improvement, also for children with severe OCD and slow-responders.
• Continued CBT resulted in comparable treatment outcome for children with a CY-BOCS ≤ 23 vs a CY-BOCS 23–26.
• Not all children with severe OCD needed medication to improve; 71% with a CY-BOCS > 23 improved without medication.