Self-Regulation and Other Executive Functions Relationship to Pediatric OCD Severity and Treatment Outcome

Abstract

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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Fig. 1

Notes

  1. 1.

    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.

References

  1. 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.

    Article  Google Scholar 

  2. 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.

    PubMed  Article  Google Scholar 

  3. Anderson, P. (2002). Assessment and development of executive function (EF) during childhood. Child Neuropsychology, 8(2), 71–82.

    PubMed  Article  Google Scholar 

  4. 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.

    PubMed  Article  Google Scholar 

  5. 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.

    PubMed  Article  Google Scholar 

  6. 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.

    PubMed  Article  Google Scholar 

  7. 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.

    PubMed  Google Scholar 

  8. 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.

    PubMed Central  PubMed  Article  Google Scholar 

  9. Borkowski, J. G. (1996). Metacognition: theory or chapter heading? Learning and Individual Differences, 8(4), 391–402.

    Article  Google Scholar 

  10. 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.

    PubMed Central  PubMed  Article  Google Scholar 

  11. 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.

    PubMed Central  PubMed  Article  Google Scholar 

  12. 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.

    PubMed  Article  Google Scholar 

  13. 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.

    Article  Google Scholar 

  14. 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.

    PubMed  Article  Google Scholar 

  15. 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.

    PubMed  Article  Google Scholar 

  16. Eysenck, M. W., & Calvo, M. G. (1992). Anxiety and performance: the processing efficiency theory. Cognition & Emotion, 6(6), 409–434.

    Article  Google Scholar 

  17. 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.

    Article  Google Scholar 

  18. 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.

    PubMed  Article  Google Scholar 

  19. 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.

    PubMed  Article  Google Scholar 

  20. Foa, E. B., & Kozak, M. J. (1986). Emotional processing of fear: exposure to corrective information. Psychological bulletin, 99(1), 20–35.

    Google Scholar 

  21. 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.

    PubMed  Article  Google Scholar 

  22. 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.

    PubMed  Article  Google Scholar 

  23. 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.

    PubMed  Article  Google Scholar 

  24. Greisberg, S., & McKay, D. (2003). Neuropsychology of obsessive-compulsive disorder: a review and treatment implications. Clinical Psychology Review, 23(1), 95–117.

    PubMed  Article  Google Scholar 

  25. 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.

    Google Scholar 

  26. 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.

    PubMed  Article  Google Scholar 

  27. 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.

    PubMed  Article  Google Scholar 

  28. Kreft, I., & De Leeuw, J. (1998). Introducing multilevel modeling. London: Sage Publications.

    Google Scholar 

  29. 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.

    PubMed  Article  Google Scholar 

  30. 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.

    PubMed  Article  Google Scholar 

  31. 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.

    Article  Google Scholar 

  32. MacKinnon, D. P., Fairchild, A. J., & Fritz, M. S. (2007). Mediation analysis. Annual review of psychology, 58, 593–614.

  33. March, J. S., Frances, A., Carpenter, D., & Kahn, D. (1997). The expert consensus guideline series: treatment of OCD. Journal of Clinical Psychiatry, 58, 27.

    Google Scholar 

  34. 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.

    PubMed Central  PubMed  Article  Google Scholar 

  35. 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.

    PubMed  Article  Google Scholar 

  36. 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.

    PubMed  Article  Google Scholar 

  37. 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.

    PubMed  Article  Google Scholar 

  38. 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.

  39. 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.

    PubMed  Article  Google Scholar 

  40. 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.

  41. 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.

    PubMed  Article  Google Scholar 

  42. 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.

    PubMed  Article  Google Scholar 

  43. 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.

    PubMed Central  PubMed  Article  Google Scholar 

  44. 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.

    PubMed  Article  Google Scholar 

  45. 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.

    PubMed  Article  Google Scholar 

  46. 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.

    Article  Google Scholar 

  47. Poznanski, E. O., & Mokros, H. B. (1996). Children’s Depression Rating Scale-Revised (CDRS-R) manual. Los Angeles, CA: Western Psychological Services.

    Google Scholar 

  48. 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.

    PubMed  Article  Google Scholar 

  49. 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.

    PubMed  Article  Google Scholar 

  50. 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.

    PubMed  Article  Google Scholar 

  51. 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.

    PubMed  Article  Google Scholar 

  52. 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.

    PubMed  Article  Google Scholar 

  53. Singer, J. D., & Willett, J. B. (2003). Applied longitudinal data analysis: modeling change and event occurrence. Oxford: Oxford University Press.

    Google Scholar 

  54. 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.

    PubMed  Article  Google Scholar 

  55. 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.

    PubMed  Article  Google Scholar 

  56. 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.

    PubMed  Article  Google Scholar 

  57. 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.

    PubMed  Article  Google Scholar 

  58. 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.

    Article  Google Scholar 

  59. 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.

    Google Scholar 

  60. 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.

    PubMed  Article  Google Scholar 

  61. 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.

    Article  Google Scholar 

  62. Zohar, A. H. (1999). The epidemiology of obsessive-compulsive disorder in children and adolescents. Child and Adolescent Psychiatric Clinics of North America.

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Acknowledgments

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.

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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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Correspondence to Adam M. Reid.

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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

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Keywords

  • Obsessive-compulsive disorder
  • Children
  • BRIEF
  • Cognitive behavioral therapy
  • Serotonin reuptake inhibitors
  • Treatment outcome