The intersection of obsessive-compulsive disorder (OCD) and executive functioning (EF) in children and adolescents is an emerging topic in the current literature. Spurred by the consistent association between increased EF deficits and higher adult obsessive-compulsive severity, a few initial studies have replicated this relationship in pediatric OCD samples and also have found preliminary evidence that EF deficits are associated with worse response to first-line psychotherapeutic or psychopharmacological treatments for pediatric OCD. This study aimed to extend the literature by providing the first comprehensive investigation of how multiple EF domains, measured repeatedly over the course of treatment, impact pediatric obsessive-compulsive severity and response to multimodal treatment. Multi-level modeling results found that deficits in shifting, inhibition, emotional control, planning/organizing, monitoring and initiating all predicted higher average obsessive compulsive severity across treatment. Interestingly, out of the eight domains of EF investigated, only emotional control moderated treatment outcome such that those with worse emotional control experienced less of a reduction in obsessive-compulsive severity during treatment. The findings generally align with previous theories for the link between EF and OCD and indicate that emotional control has important implications in the treatment of pediatric OCD. In fact, emotional control may provide one explanation for why factors such as disgust sensitivity, oppositional behavior, and third-wave behavioral treatment techniques have all been linked to pediatric OCD treatment outcome. Future research should investigate augmentation strategies that target emotional control in children and adolescents.
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In previous work from our lab, we reported that an increase in average obsessive-compulsive severity predicted an increase in average depressive symptom severity during treatment (Meyer et al. 2013). In controlling for depressive symptoms in this study with the same sample as our previous study, we have found that an increase in average depressive symptoms predicted an increase in average OCD symptom severity during treatment, with a small effect size. Thus, there appears to be evidence for a bidirectional model of how depressive symptoms and obsessive-compulsive symptoms interact prospectively, however this bidirectional model would need to be tested in future research with a larger sample size and is beyond the scope of this paper.
Abramovitch, A., Mittelman, A., Henin, A., & Geller, D. (2012). Neuroimaging and neuropsychological findings in pediatric obsessive-compulsive disorder: a review and developmental considerations. Neuropsychiatry, 2(4), 313–329.
Adrian, M., Zeman, J., & Veits, G. (2011). Methodological implications of the affect revolution: a 35-year review of emotion regulation assessment in children. Journal of Experimental Child Psychology, 110(2), 171–197.
Anderson, P. (2002). Assessment and development of executive function (EF) during childhood. Child Neuropsychology, 8(2), 71–82.
Anderson, V. A., Anderson, P., Northam, E., Jacobs, R., & Mikiewicz, O. (2002). Relationships between cognitive andbehavioral measures of executive function in children with brain disease. Child Neuropsychology, 8, 231–240.
Andrés, S., Boget, T., Lázaro, L., Penadés, R., Morer, A., Salamero, M., et al. (2007). Neuropsychological performance in children and adolescents with obsessive-compulsive disorder and influence of clinical variables. Biological Psychiatry, 61(8), 946–951.
Andrés, S., Lázaro, L., Salamero, M., Boget, T., Penadés, R., & Castro-Fornieles, J. (2008). Changes in cognitive dysfunction in children and adolescents with obsessive-compulsive disorder after treatment. Journal of Psychiatric Research, 42(6), 507–514.
Bannon, S., Gonsalvez, C. J., Croft, R. J., & Boyce, P. M. (2006). Executive functions in obsessive–compulsive disorder: state or trait deficits? Australian and New Zealand Journal of Psychiatry, 40, 1031–1038.
Blandon, A. Y., Calkins, S. D., Grimm, K. J., Keane, S. P., & O’Brien, M. (2010). Testing a developmental cascade model of emotional and social competence and early peer acceptance. Development and Psychopathology, 22(04), 737–748.
Borkowski, J. G. (1996). Metacognition: theory or chapter heading? Learning and Individual Differences, 8(4), 391–402.
Bussing, R., Fernandez, M., Harwood, M., Hou, W., Garvan, C. W., Eyberg, S. M., et al. (2008). Parent and teacher SNAP-IV ratings of attention deficit hyperactivity disorder symptoms psychometric properties and normative ratings from a school district sample. Assessment, 15(3), 317–328.
Bussing, R., Murphy, T. K., Storch, E. A., McNamara, J. P., Reid, A. M., Garvan, C. W., et al. (2012). Psychometric properties of the Treatment-Emergent Activation and Suicidality Assessment Profile (TEASAP) in youth with OCD. Psychiatry Research, 205(3), 253–61.
Chamberlain, S. R., Blackwell, A. D., Fineberg, N. A., Robbins, T. W., & Sahakian, B. J. (2005). The neuropsychology of obsessive compulsive disorder: the importance of failures in cognitive and behavioral inhibition as candidate endophenotypic markers. Neuroscience and Biobehavioral Reviews, 29, 399–419.
Cohen, J. A., Berliner, L., & Mannarino, A. (2010). Trauma focused CBT for children with co-occurring trauma and behavior problems. Child Abuse & Neglect, 34(4), 215–224.
De Luca, C. R., Wood, S. J., Anderson, V., Buchanan, J., Profitt, T. M., Mahony, K., et al. (2003). Normative data from the Cantab. I: development of executive function over the lifespan. Journal of Clinical and Experimental Neuropsychology, 25(2), 242–254.
Douglass, H. M., Moffitt, T. E., Dar, R., McGee, R., & Silva, P. (1995). Obsessive-compulsive disorder in a birth cohort of 18-year-olds: prevalence and predictors. Journal of the American Academy of Child and Adolescent Psychiatry, 34, 1424–1431.
Eysenck, M. W., & Calvo, M. G. (1992). Anxiety and performance: the processing efficiency theory. Cognition & Emotion, 6(6), 409–434.
Fairfax, H. (2008). The use of mindfulness in obsessive compulsive disorder: suggestions for its application and integration in existing treatment. Clinical Psychology & Psychotherapy, 15(1), 53–59.
Flament, M. F., Rapoport, J. L., Berg, C. J., Sceery, W., Kilts, C., Mellstrom, B., et al. (1985). Clomipramine treatment of childhood obsessive-compulsive disorder. A double-blind controlled study. Archives of General Psychiatry, 42(10), 977–983.
Flessner, C. A., Allgair, A., Garcia, A., Freeman, J., Sapyta, J., Franklin, M. E., et al. (2010). The impact of neuropsychological functioning on treatment outcome in pediatric obsessive–compulsive disorder. Depression and Anxiety, 27(4), 365–371.
Foa, E. B., & Kozak, M. J. (1986). Emotional processing of fear: exposure to corrective information. Psychological bulletin, 99(1), 20–35.
Ginsburg, G. S., Kingery, J. N., Drake, K. L., & Grados, M. A. (2008). Predictors of treatment response in pediatric obsessive-compulsive disorder. Journal of the American Academy of Child and Adolescent Psychiatry, 47(8), 868–878.
Gioia, G. A., Isquith, P. A., Guy, S. C., & Kenworthy, L. (2000). Test review behavior rating inventory of executive functioning. Child Neuropsychology, 6(3), 235–238.
Gioia, G. A., Kenworthy, L., & Isquith, P. K. (2010). Executive function in the real world: BRIEF lessons from Mark Ylvisaker. The Journal of Head Trauma Rehabilitation, 25(6), 433–439.
Greisberg, S., & McKay, D. (2003). Neuropsychology of obsessive-compulsive disorder: a review and treatment implications. Clinical Psychology Review, 23(1), 95–117.
Hayes, A. M., & Feldman, G. (2004). Clarifying the construct of mindfulness in the context of emotion regulation and the process of change in therapy. Clinical Psychology: Science and Practice, 11(3), 255–262.
Kahn, J. H., & Schneider, W. J. (2013). It’s the destination and It’s the journey: using multilevel modeling to assess patterns of change in psychotherapy. Journal of Clinical Psychology, 69(6), 543–70.
Kaufman, J., Birmaher, B., Brent, D., Rao, U., Flynn, C., Moreci, P., et al. (1997). Schedule for affective disorders and schizophrenia for school-age children-present and lifetime version (K-SADS-PL): initial reliability and validity data. Journal of the American Academy of Child and Adolescent Psychiatry, 36, 980–988.
Kreft, I., & De Leeuw, J. (1998). Introducing multilevel modeling. London: Sage Publications.
Lázaro, L., Bargalló, N., Castro-Fornieles, J., Falcón, C., Andrés, S., Calvo, R., et al. (2009). Brain changes in children and adolescents with obsessive–compulsive disorder before and after treatment: a voxel-based morphometric MRI study. Psychiatry Research: Neuroimaging, 172(2), 140–146.
Leonard, H. L., Swedo, S. E., Rapoport, J. L., Koby, E. V., Lenane, M. C., Cheslow, D. L., et al. (1989). Treatment of obsessive-compulsive disorder with clomipramine and desipramine in children and adolescents. A double-blind crossover comparison. Archives of General Psychiatry, 46, 1088–1092.
MacDermott, S. T., Gullone, E., Allen, J. S., King, N. J., & Tonge, B. (2010). The emotion regulation index for children and adolescents (ERICA): a psychometric investigation. Journal of Psychopathology and Behavioral Assessment, 32(3), 301–314.
MacKinnon, D. P., Fairchild, A. J., & Fritz, M. S. (2007). Mediation analysis. Annual review of psychology, 58, 593–614.
March, J. S., Frances, A., Carpenter, D., & Kahn, D. (1997). The expert consensus guideline series: treatment of OCD. Journal of Clinical Psychiatry, 58, 27.
Mayes, T. L., Bernstein, I. H., Haley, C. L., Kennard, B. D., & Emslie, G. J. (2010). Psychometric properties of the children’s depression rating scale–revised in adolescents. Journal of Child and Adolescent Psychopharmacology, 20(6), 513–516.
McAuley, T., Chen, S., Goos, L., Schachar, R., & Crosbie, J. (2010). Is the BRIEF more strongly associated with measures of impairment or executive function? Journal of the International Neuropsychological Society, 16(3), 495–505.
McCandless, S., & O’Laughlin, L. (2007). The clinical utility of the Behavior Rating Inventory of Executive Function (BRIEF) in the diagnosis of ADHD. Journal of Attention Disorders, 10(4), 381–389.
McGuire, J. F., Small, B. J., Lewin, A. B., Murphy, T. K., De Nadai, A. S., Phares, V., et al. (2013). Dysregulation in pediatric obsessive compulsive disorder. Psychiatry Research, 209(3), 589–95.
Meyer, J., McNamara, J. P. H., Reid, A. M., Storch, E.A., Geffken, G. R., Mason, D. M., et al. (2013). Prospective relationship between obsessive-compulsive and depressive symptoms during multimodal treatment in pediatric obsessive-compulsive disorder. Child Psychiatry and Human Development.
Miyake, A., Friedman, N. P., Emerson, M. J., Witzki, A. H., Howerter, A., & Wager, T. D. (2000). The unity and diversity of executive functions and their contributions to complex “frontal lobe” tasks: a latent variable analysis. Cognitive Psychology, 41(1), 49–100.
Murray, C. J., & López, A. D. (1996). The global burden of disease: a comprehensive assessment of mortality and disability from diseases, injuries, and risk factors in 1990 and projected to 2020. Published by the Harvard School of Public Health on behalf of the World Health Organization and the World Bank.
Nakao, T., Nakagawa, A., Nakatani, E., Nabeyama, M., Sanematsu, H., Yoshiura, T., et al. (2009). Working memory dysfunction in obsessive—compulsive disorder: a neuropsychological and functional MRI study. Journal of Psychiatric Research, 43(8), 784–791.
Nielen, M. M. A., & Den Boer, J. A. (2003). Neuropsychological performance of OCD patients before and after treatment with fluoxetine: evidence for persistent cognitive deficits. Psychological Medicine, 33(5), 917–925.
Olatunji, B. O., Tart, C. D., Ciesielski, B. G., McGrath, P. B., & Smits, J. A. (2011). Specificity of disgust vulnerability in the distinction and treatment of OCD. Journal of Psychiatric Research, 45(9), 1236–1242.
Olley, A., Malhi, G., & Sachdev, P. (2007). Memory and executive functioning in obsessive–compulsive disorder: a selective review. Journal of Affective Disorders, 104, 15–23.
Ornstein, T. J., Arnold, P., Manassis, K., Mendlowitz, S., & Schachar, R. (2010). Neuropsychological performance in childhood OCD: a preliminary study. Depression and Anxiety, 27(4), 372–380.
Pediatric OCD Treatment Study (POTS) Team. (2004). Cognitive-behavior therapy, sertraline, and their combination for children and adolescents with obsessive-compulsive disorder: the Pediatric OCD Treatment Study (POTS) randomized controlled trial. Journal of the American Medical Association, 292(16), 1969–1976.
Poznanski, E. O., & Mokros, H. B. (1996). Children’s Depression Rating Scale-Revised (CDRS-R) manual. Los Angeles, CA: Western Psychological Services.
Purcell, R., Maruff, P., Kyrios, M., & Pantelis, C. (1998). Cognitive deficits in obsessive-compulsive disorder on tests of frontal-striatal function. Biological Psychiatry, 43(5), 348–357.
Rao, N. P., Reddy, Y. C., Kumar, K. J., Kandavel, T., & Chandrashekar, C. R. (2008). Are neuropsychological deficits trait markers in OCD? Progress in Neuro-Psychopharmacology and Biological Psychiatry, 32(6), 1574–1579.
Rosenberg, D. R., Benazon, N. R., Gilbert, A., Sullivan, A., & Moore, G. J. (2000). Thalamic volume in pediatric obsessive–compulsive disorder patients before and after cognitive behavioral therapy. Biological Psychiatry, 48(4), 294–300.
Scahill, L., Riddle, M. A., McSwiggin-Hardin, M., Ort, S. I., King, R. A., Goodman, W. K., et al. (1997). Children’s Yale-Brown obsessive compulsive scale: reliability and validity. Journal of the American Academy of Child and Adolescent Psychiatry, 36(6), 844–852.
Semrud-Clikeman, M., Walkowiak, J., Wilkinson, A., & Butcher, B. (2010). Executive functioning in children with Asperger syndrome, ADHD-combined type, ADHD-predominately inattentive type, and controls. Journal of Autism and Developmental Disorders, 40(8), 1017–1027.
Singer, J. D., & Willett, J. B. (2003). Applied longitudinal data analysis: modeling change and event occurrence. Oxford: Oxford University Press.
Storch, E. A., Murphy, T. K., Geffken, G. R., Soto, O., Sajid, M., Allen, P., et al. (2004). Psychometric evaluation of the Children’s Yale–brown obsessive-compulsive scale. Psychiatry Research, 129(1), 91–98.
Storch, E. A., Merlo, L. J., Larson, M. J., Geffken, G. R., Lehmkuhl, H. D., Jacob, M. L., et al. (2008). Impact of comorbidity on cognitive-behavioral therapy response in pediatric obsessive-compulsive disorder. Journal of the American Academy of Child and Adolescent Psychiatry, 47(5), 583–592.
Swanson, J. M., Kraemer, H. C., Hinshaw, S. P., Arnold, L. E., Conners, C. K., Abikoff, H. B., et al. (2001). Clinical relevance of the primary findings of the MTA: success rates based on severity of ADHD and ODD symptoms at the end of treatment. Journal of the American Academy of Child and Adolescent Psychiatry, 40, 168–179.
Valleni-Basile, L. A., Garrison, C. Z., Jackson, K. L., Waller, J. L., McKeown, R. E., Addy, C. L., et al. (1994). Frequency of obsessive-compulsive disorder in a community sample of young adolescents. Journal of the American Academy of Child and Adolescent Psychiatry, 33(6), 782–791.
Voderholzer, U., Schwartz, C., Freyer, T., Zurowski, B., Thiel, N., Herbst, N., et al. (2013). Cognitive functioning in medication-free obsessive-compulsive patients treated with cognitive-behavioural therapy. Journal of Obsessive-Compulsive and Related Disorders., 2(3), 241–248.
Watkins, L. H., Sahakian, B. J., Robertson, M. M., Veale, D. M., Rogers, R. D., Pickard, K. M., et al. (2005). Executive function in Tourette's syndrome and obsessivecompulsive disorder. Psychological medicine, 35(4), 571–582.
Zandt, F., Prior, M., & Kyrios, M. (2009). Similarities and differences between children and adolescents with autism spectrum disorder and those with obsessive compulsive disorder executive functioning and repetitive behaviour. Autism, 13(1), 43–57.
Zhou, Q., Chen, S. H., & Main, A. (2012). Commonalities and differences in the research on children’s effortful control and executive function: a call for an integrated model of self‐regulation. Child Development Perspectives, 6(2), 112–121.
Zohar, A. H. (1999). The epidemiology of obsessive-compulsive disorder in children and adolescents. Child and Adolescent Psychiatric Clinics of North America.
This research was supported by grant 5UO1 MH078594 from the National Institute of Mental Health. The authors thank the study coordinators, all staff members who contributed to data collection, the families for their participation, and Drs. Ayesha Lall, Jane Mutch and Omar Rahman for their contribution to the study interventions.
Conflict of Interest
Dr. Regina Bussing has received research support from Pfizer Inc. and Otsuka Pharmaceuticals. She also has served as a consultant for Pfizer Inc. and Shire Pharmaceuticals and has received travel support and honorarium to present original research findings at meetings in Germany. Dr. Tanya Murphy reports research support from the AstraZeneca Neuroscience iMED, Otsuka Pharmaceuticals, Shire Pharmaceuticals, National Institute of Health/National Institute of Mental Health, Center for Disease Control, International Obsessive-Compulsive Disorder Foundation, Ortho-McNeil Janssen Pharmaceuticals, Pfizer Inc., and Massachusetts General Hospital. She also reports travel support from the Tourette Syndrome Association. Finally, Dr. Eric Storch reports research support from the National Institute of Health, Center for Disease Control, Agency for Healthcare Research and Quality, International Obsessive-Compulsive Disorder Foundation, and Ortho-McNeil Janssen Pharmaceuticals. All other authors of this paper have no conflicts of interest to report.
This study was approved by the university Internal Review Board and all study procedures, including informed consent, were conducted in adherence to this review board and the standards of the National Institute of Mental Health.
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McNamara, J.P.H., Reid, A.M., Balkhi, A.M. et al. Self-Regulation and Other Executive Functions Relationship to Pediatric OCD Severity and Treatment Outcome. J Psychopathol Behav Assess 36, 432–442 (2014). https://doi.org/10.1007/s10862-014-9408-3
- Obsessive-compulsive disorder
- Cognitive behavioral therapy
- Serotonin reuptake inhibitors
- Treatment outcome