Psychiatry Research 199 (2012) 115–123

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Psychiatry Research
journal homepage: www.elsevier.com/locate/psychres

Comorbidity and treatment response in pediatric obsessive-compulsive

disorder: A pilot study of group cognitive-behavioral treatment
Lara Farrell a,n, Allison Waters b, Ella Milliner a, Thomas Ollendick c
a
School of Applied Psychology, Griffith Health Institute, Griffith University, Gold Coast Campus, Brisbane, QLD 4222, Australia
b
Griffith Health Institute, Griffith University, Mount Gravatt Campus, Australia
c
Child Study Centre, Virginia Tech University, Blacksburg, VA, USA

a r t i c l e i n f o abstract

Article history: This pilot study evaluated the effectiveness of group cognitive-behavioral treatment (CBT) on treatment
Received 30 June 2011 outcomes for children and adolescents who presented with obsessive–compulsive disorder (OCD) and
Received in revised form complex comorbid conditions, including depression, attention deficit/hyperactivity disorder and
24 April 2012
pervasive developmental disorders (PDD). Specifically, the impact of comorbidity on treatment
Accepted 29 April 2012
response rates and remission rates was examined. Forty-three youth (aged 7–17) with OCD partici-
pated in group family-based CBT. Assessments were conducted at pre- and post-treatment and
Keywords: 6 months. Eighty-six percent of youth presented with a secondary psychiatric disorder, and 74%
OCD presented with a tertiary psychiatric condition. Contrary to the expected, comorbidity was not
Children
associated with poorer treatment outcomes at post-assessment. At longer term follow-up (6 months),
Youth
however, treatment outcomes were poorer for youth with multiple comorbid conditions and for those
Treatment response
Group CBT with attention deficit/hyperactivity disorder. The finding that group CBT is largely effective for youth
Comorbidity with comorbid conditions is of clinical and practical significance. Group delivery of CBT provides an
efficient and cost-effective approach, and alleviates strain on services and service providers. Continued
efforts are needed to improve long-term outcomes for youth with multiple comorbid conditions and
attention deficit/hyperactivity disorder. Examining treatment response as a function of comorbidity
with larger clinical samples is important to extend this research.
& 2012 Elsevier Ltd. All rights reserved.

1. Introduction children affected having at least one comorbid diagnosis (Swedo

Pediatric obsessive–compulsive disorder (OCD) is a debilitat-
ing neurobehavioral anxiety disorder affecting between 1% and 4%
of children and youth (Douglass et al., 1995; Valleni-Basile et al.,
1995; Shaffer et al., 1996; Zohar, 1999). During childhood, the
condition is associated with impairment and dysfunction across
multiple domains, including family relationships and household
routines (Cooper, 1996; Barrett et al., 2001), school functioning (Toro
et al., 1992; Piacentini et al., 2003) and peer relationships (Allsopp
and Verduyn, 1990; Storch et al., 2006), leading to lifelong suffering if
left untreated (Stewart et al., 2004). The high rate of comorbidity
associated with pediatric OCD is one reason why this disorder is so
debilitating and why it is so often described as a complex psychiatric
disorder and often times difficult to treat (Geller et al., 2003; Masi
et al., 2004; Sukhodolsky et al., 2005; Masi et al., 2006; Termine et al.,
2006; Storch et al., 2008; Krebs and Heyman, 2010). In fact,
comorbidity is the norm in this clinical sample, with up to 80% of
n
Corresponding author. Tel.: þ1 617 5552 8224; fax: þ 1 617 5552 8291.
E-mail address: l.farrell@griffith.edu.au (L. Farrell).
et al., 1989; Geller et al., 1996; Storch et al., 2008; Lewin et al., 2010),
and as many as 50–60% of youth experiencing two or more other
mental disorders during their lifetime (Rasmussen and Eisen, 1990).
Some of the most commonly co-occurring psychiatric condi-
tions associated with pediatric OCD include other anxiety dis-
orders (affecting 26–70% of children with OCD), depression
(10–73% of children with OCD), tics and Tourette’s Syndrome
(17–59% of children with OCD), attention deficit/hyperactivity
disorders (10–50% of children with OCD), disruptive behavioral
disorders (10–57%), and pervasive developmental disorders (PDD)
(e.g., Flament et al., 1990; Thomsen, 1994; Geller et al., 1996;
2001a, 2001b; Ivarsson et al., 2008). In addition to these more
frequently co-occurring conditions, youth with OCD may also
present with comorbid eating disorders, body dysmorphia and
trichotillomania (King et al., 1995; Geller et al., 2001a; Phillips
et al., 2005). Studies have suggested that certain comorbid psy-
chiatric disorders associated with OCD (e.g., disruptive behavioral
disorders, depression, attention deficit disorder) not only impact
upon the severity of a child’s OCD but also have a negative effect on
children’s psychosocial functioning and response to treatment (see
Storch et al., 2008, 2010). Understanding the unique correlates of

0165-1781/$ - see front matter & 2012 Elsevier Ltd. All rights reserved.
http://dx.doi.org/10.1016/j.psychres.2012.04.035
116 L. Farrell et al. / Psychiatry Research 199 (2012) 115–123
specific comorbid conditions and the impact of such on OCD
treatment outcomes is important in both the assessment of OCD
and the prescription of individualized treatments.
Cognitive-behavioral treatment (CBT), including exposure and
response prevention (ERP), has been designated as probably
efficacious for pediatric OCD based on a recent systematic review
of the psychosocial treatment literature (see Barrett et al., 2008).
Combined with the recommendations included in the OCD Expert
Consensus guidelines (March et al., 1997a,b) and other recent
meta-analyses (e.g., O’Kearney et al., 2010), the general consensus
in the literature and among experts in the field is that CBT
combined with ERP, either alone or in combination with a
serotonin reuptake inhibiting (SRI) medication is both an effective
and acceptable treatment for children and youth with OCD (see
Barrett et al., 2004a,b, 2008; Abramowitz et al., 2005; O’Kearney
et al., 2010).
Despite the fact that CBT produces impressive treatment effect
sizes (i.e., between-group effect sizes of 0.99–2.84; Barrett et al.,
2008) and that the majority of children and adolescents with OCD
experience clinically significant reduction in OCD symptoms
following CBT, the outcomes in terms of actual remission rates
provide less than optimal results. Across published studies and
across sites within studies (e.g., POTS, 2004), remission rates vary.
However, based on results from the largest multi-site RCT to date
(Pediatric OCD Treatment Study (POTS), 2004), as many as 60% of
children receiving CBT alone, 50% receiving combined CBT and
serotonergic medication, and almost 80% receiving serotonergic
medication failed to fully remit following treatment. These find-
ings suggest that one in two treatment-seeking children and
youth will continue to suffer clinically significant OCD even after
combined CBT and SRI treatment. There is therefore a pressing
need to understand the predictors and moderators of treatment
response in pediatric OCD, in order to determine which children
will respond optimally to current generation treatments, and to
identify ways to augment or refine these treatments for those
who do not. Based on a recent review of predictors and mod-
erators of treatment response (Farrell et al., in press) a consensus
is emerging in regards to specific comorbid conditions that might
attenuate treatment response for children with OCD.
To date, severity of OCD at pre-treatment, family dysfunction
(Ginsburg et al., 2008; Garcia et al., 2010) and family accommo-
dation (Garcia et al., 2010) have all been shown to be associated
with poorer response to CBT. Conversely, in medication alone
studies, comorbid tics have been associated with poorer outcome
(Ginsburg et al., 2008), whilst across treatment modalities,
externalizing disorders have been found to be associated with
poorer response (Garcia et al., 2010). Gender, age and duration of
illness do not appear to differentially predict treatment outcome
(Ginsburg et al., 2008; Garcia et al., 2010).
In a recent study, Storch and colleagues (2008) specifically
examined the impact of comorbidity on response to CBT in a sample
of 96 youth with a primary diagnosis of OCD. In this study, it was
found that having one or more comorbid conditions was associated
with a poorer response to CBT outcome, and that the number of
comorbid conditions was negatively related to outcome. Moreover,
and consistent with both Garcia et al. (2010) and Ginsburg et al.
(2008), Storch and colleagues found that the presence of comorbid
externalizing disorders (i.e., attention deficit/hyperactivity disorder,
oppositional defiant disorder (ODD), and conduct disorder) was
associated with a poorer treatment response, and that both exter-
nalizing disorders and depressive disorders were associated with
lower treatment remission rates. The authors of this study did
not find evidence to suggest that comorbid anxiety disorders or
comorbid tic disorders were associated with a poorer response to
CBT, even though these co-occurring disorders were seen in a number
of the youth.
Few studies have examined the important issue of moderators
of treatment response in pediatric OCD. March and colleagues
(2007) reported on the impact of comorbid tic disorder on out-
comes in the POTS trial (2004), examining treatment response for
the 15% of the POTS sample (n¼17 of 112) who had a comorbid
tic disorder. In patients without tic disorders, outcomes were
consistent with the entire intent-to-treat sample (POTS, 2004)
with combined treatment (CBTþsertraline) being superior to CBT
alone, which was superior to sertraline alone, which was superior to
the placebo condition (POTS, 2004). However, for the sample with
comorbid tic disorders, sertraline alone did not differ significantly
from the placebo condition, whilst combined treatment (CBTþ
sertraline) remained superior to CBT, and CBT remained superior
to PBO. This finding, consistent with Ginsburg et al. (2008), provides
a strong evidence that children with comorbid OCD and tic disorders
respond differentially to medication alone versus cognitive-beha-
vioral treatments. Based on this finding, March and colleagues
(2007) recommend that children with OCD and comorbid tic
disorder should begin treatment with CBT alone or a combined
treatment of CBT and SRI, given that medication alone does not
provide benefit over a placebo pill.
The issue of treatment response as a function of comorbidity in
pediatric OCD warrants further consideration in terms of: (a) an
examination across a broader array of comorbid diagnoses, and (b) an
examination of treatment response to group-based CBT—which to
date has not been systematically examined. Whilst our understand-
ing about specific comorbidties is advancing, we still know very little
about the impact of other commonly co-occurring psychiatric condi-
tions PDD, including autism spectrum disorders (ASD), given that
these disorders are frequently excluded from randomised controlled
treatment trials and to date have not been systematically examined
as potential predictors of treatment response. In particular, CBT might
be more difficult to deliver with children who have comorbid PDD
and/or ASD, due to poor emotional understanding and cognitive
rigidity characteristic of these disorders (Krebs and Heyman, 2010).
Furthermore, whilst group-based CBT has been established as possibly
efficacious and provides an alternative to individual CBT for children
and youth with OCD (see Barrett et al., 2008) we do not yet know
what impact comorbidity may have on group treatment outcomes.
Group CBT is a favorable modality of therapy, with evidence so f
ar providing comparable outcomes to individual CBT in a random-
ised controlled trial at post-treatment and at 18 months follow-up
(Barrett et al., 2004a,b, 2005). In fact, group CBT offers an efficient and
economical alternative, which improves both access to treatment and
reduces treatment costs and therapist time. Moreover, group therapy
arguably provides additional benefits for children and families
beyond the technical aspects of CBT, by providing peer normalization
and peer support in a positive group setting. However, to date little is
known about the impact of comorbidity on CBT outcomes for
children treated in groups. Given that certain comorbid disorders
would likely have a negative impact on the group therapy
process—for e.g., disruptive behavioral disorders or ASD, it is impor-
tant to establish the impact of such on group CBT outcomes for
pediatric OCD.
The present study aims to: (1) evaluate the effectiveness of group
CBT in an open pilot trial design, to specifically examine the impact
of comorbidity on outcome, using a highly comorbid sample of
children with OCD up to 6 months following treatment; and (2) to
examine the effect of specific comorbidity’s on treatment response
and treatment remission in a children and youth with OCD (aged 7–
17 years). Based on studies involving signal detection analysis to
identify optimal cut-offs on the Yale-Brown Obsessive–Compulsive
Scale (Y-BOCS; Goodman et al., 1989; Child Y-BOCS; Scahill et al.,
1997) for predicting treatment response and clinical remission
(Tolin et al., 2005; Storch et al., 2010), this study uses criteria of at
least 25% reduction in CY-BOCS scores for determining treatment
 L. Farrell et al. / Psychiatry Research 199 (2012) 115–123 117

response, and a reduction of 50% on the CY-BOCS combined with a

post-treatment CY-BOCS score of o14 for determining treatment
remission (Storch et al., 2010).
Given that comorbidity with other anxiety disorders has not
previously been identified as a significant predictor of response to
treatment, nor have tics or Tourette’s in the case of CBT, this study
aims to examine other arguably more complex comorbidity—that is,
comorbid conditions that have previously been indicated to possibly
attenuate treatment response or to date have not yet been ade-
quately studied, including (a) depression (DEP), (b) attention deficit/
hyperactivity disorders (ADHD) and (c) PDD, including ASD. This
paper examines the impact of comorbidity on group treatment
response and remission at post-treatment and at 6 months follow-
up following a standardised group cognitive-behavioral treatment.
Based on previous research (e.g., Storch et al., 2008, 2010), it was
hypothesized (a) based on pre-treatment comparisons, the presence
of comorbid conditions (i.e., DEP, ADHD, PDD) would be associated
with significantly worse OCD and higher functional impairment at
baseline relative to children without these comorbid conditions (i.e.,
no comorbid DEP, ADHD, or PDD); (b) group treatment would be
effective for the overall sample; however, (c) specific comorbidity Fig. 1. Percentage of the total sample within each of the comorbid groups.
(i.e., DEP, ADHD, PDD) would be associated with poorer treatment
response and treatment remission following group-based CBT, rela- the upper range of moderate severity. Sixty-seven percent of the sample were
stabilised on an SRI medication prior to enrollment into this study, and they did
tive to children without comorbidity.
not alter their medication during this trial.
In regards to the comorbidity groups of interest in the current study, Fig. 1
displays the frequency of each comorbidity group, including also the proportion of
2. Method
the current sample who did not present with any of the three comorbid conditions
of interest (i.e., no comorbid n¼23) within the PDD group, 60% (n¼9) were
2.1. Participants diagnosed PDD Not Otherwise Specified, and 40% (n ¼6) were diagnosed with
Asperger’s Syndrome.
Participants were 43 children and adolescents (aged 7–17 years), with a mean
age of 11.09 years (S.D. ¼ 2.52), comprised of 30 males and 13 females, who were 2.2. Measures
consecutively referred for treatment of OCD to Griffith University and who
completed the assessment and participated in treatment. There were a further
2.2.1. Interview measures
four participants who were referred to the program, who were eligible for
participation, but who withdrew prior to completion of assessment or prior to
treatment commencing and were therefore excluded for these reasons. Partici- 2.2.1.1. The Anxiety Disorders Interview Schedule for Children—Parent version (ADIS-
pants were selected into this study on the basis of a Diagnostic and Statistical P; Silverman and Albano, 1996). The ADIS-P was developed specifically to diagnose
Manual (DSM-IV; American Psychiatric Association, 2000) diagnosis of OCD. anxiety disorders in children (Silverman and Eisen, 1992), and possesses good
Exclusion criteria included psychosis, intellectual disability, mental retardation, inter-rater and retest reliability. The ADIS-C/P has demonstrated good sensitivity
or currently receiving psychotherapy. There were no referrals to the project during to treatment effects in both childhood anxiety (Kendall, 1994; Barrett et al., 1996;
this time that met exclusion criteria. All children were offered treatment following Ollendick et al., 2009) and childhood OCD research (Albano et al., 1996; Waters
their assessment. et al., 2001; Barrett et al., 2004a,b). This interview was administered to the child’s
Based on ADIS-P diagnostic interview (ADIS-P; Silverman and Albano, 1996), parent/s to ascertain an OCD diagnosis and confirm secondary and tertiary com-
this sample was deemed typical of pediatric OCD, consisting of high comorbidity, orbid diagnoses, including other anxiety disorders, mood disorders (including
with 86% presenting with a secondary psychiatric diagnosis and 74% presenting major depressive disorder (MDD) and dysthymia), externalizing disorders (includ-
with a tertiary diagnosis. Eighty-six percent of the sample presented with primary ing attention deficit/hyperactivity disorder [AD/HD] and ODD) and to screen for
OCD, whereas the remainder (n¼6) had OCD as either secondary or tertiary. PDD. Each diagnosis receives a Clinician Severity Rating (CSR) based on clinician
Table 1 presents diagnostic information for the sample, including principal, judgment, scored 0–8, with a score of 4 indicating a clinically significant diagnosis.
secondary and tertiary diagnoses. On assessment, the mean CY-BOCS (Scahill Any child who scored positive on the ADIS-P screen for a PDD diagnosis and who
et al., 1997) rating was 21.36 (S.D. ¼ 6.63) indicating the sample was overall within also had a confirmed diagnosis of PDD or an ASD (including Asperger’s Syndrome)
by a community pediatrician or child psychiatrist was deemed to have a diagnosis
of PDD in the current study.1 For tics and Tourette’s syndrome, as the ADIS-P does
Table 1
not screen specifically for these disorders, a diagnosis was based on a brief
Participant diagnoses at pre-treatment based on ADIS-P Interviews.
structured clinical interview devised by the first author for this purpose. Forty
percent (n¼17) of the sample had a tic disorder at pre-treatment. Inter-rater
Diagnosis Principal diagnosis N Secondary diagnosis N Third diagnosis N
reliability has been conducted across 20% of the video-taped diagnostic interviews
(%) (%) (%)
by an independent rater, with results indicating excellent reliability (primary
diagnosis k ¼1.0; secondary diagnosis k ¼0.84; tertiary diagnosis k ¼ 0.83).
OCD 37 (86) 4 (9) 2 (5)
GAD 1 (2) 9 (21) 6 (14)
SAD 1 (2) 1 (2) 2 (5)
SoPH 0 5 (12) 3 (7)
SpPH 1 (2) 7 (16) 3 (7)
1
MDD 0 1 (2) 2 (5) PDD was used as a broad category for children with a diagnosis of PDD,
DYS 0 1 (2) 1 (2) autistic spectrum disorder or Asperger’s syndrome that was confirmed by a
ADHD 1(2%) 1 (2) 6 (14) community psychiatrist or pediatrician—which is the standard requirement for
ODD 0 1 (2) 0 national health fund rebates and school ascertainment in QLD, Australia. Full
PDD 2 (5) 6 (14) 7 (16) diagnostic interviews were not conducted for ASD and/or PDD given the training
TOTAL 43 (100) 36 (84) 32 (74) required and length of time required for these standard diagnostic assessment
tools, and given that it was outside the scope of the current study. If a child was
Abbreviations: GAD ¼generalized anxiety disorder, SAD ¼ separation anxiety dis- positive to the ADIS-P screen and didn’t yet have a diagnosis by a community
order, SoPH¼ social phobia, SpPH ¼specific phobia, MDD ¼major depressive dis- pediatrician or psychiatrist, the referral was made for this purpose. All families
order, DYS ¼dysthymic disorder, ADHD ¼attention deficit/ hyperactivity disorder, followed up on this referral when this was the case (n¼ 2) and all received a
ODD¼ oppositional defiant disorder, PDD ¼ pervasive developmental disorder. PDD diagnosis.
118 L. Farrell et al. / Psychiatry Research 199 (2012) 115–123
2.2.1.2. National Institute of Mental Health Global Obsessive-Compulsive Scale (NI-
MH—GOCS; Insel et al., 1983). This clinician-rated device consists of a single item
measuring global diagnostic severity on a scale from 1 (minimal symptoms, within
normal range) to 15 (very severe). The GOCS also provides a scale of clinical global
improvement (CGI), ranging from 1 (very much improved) through to 7 (very
much worse), with 4 indicating no change. The GOCS has demonstrated good to
excellent retest reliability (Kim et al., 1992, 1993), and adequate to good con-
vergent validity with the SCL-90 OC scale and the CY-BOCS (see Taylor, 1998).
2.2.1.3. Children’s Yale-Brown Obsessive-Compulsive Scale (CY-BOCS; Scahill et al.,
1997). The CY-BOCS is a widely used, clinician-rated, semi-structured interview,
assessing severity of OCD symptomatology. The CY-BOCS rates severity of obses-
sions and compulsions across five scales: (a) time occupied by symptoms, (b) in-
terference, (c) distress, (d) resistance, and (e) degree of control over symptoms,
and also provides a total severity score. The CY-BOCS shows reasonable reliability
and validity, with good to excellent inter-rater agreement and high internal co-
nsistency for total score (Scahill et al., 1997). This interview was administered to
children (including parents for the younger sample, 7–11 years) to assess overall
OCD symptom severity.
2.2.2. Self-report measures
2.2.2.1. Child OCD Impact Scale—Child/Adolescent Report and Parent Report (COIS—C/P;
Piacentini et al., 2001). The Child OCD Impact Scale (COIS) assesses the impact of
OCD on psychosocial functioning from child and parent report. This measure
includes 20 items each across three domains, rated on 4-point likert-scales. The
COIS-C/P assesses three domains of impairment including school, social, and
family/home. Four additional items assess the global impact of OCD on school/work,
home, social, and going out. Studies using the child COIS have shown excellent
internal consistencies for the three subscales and the total score (range r¼ 0.78–0.85;
Piacentini et al., 2001), and good convergent validity between the COIS total score
and the CY-BOCS (r¼ 0.46; Piacentini et al., 2001).
2.2.2.2. Multidimensional Anxiety Scale for Children (MASC; March, 1997). This self-
report measure assesses anxiety symptoms in children across a number of scales,
including physical symptoms, harm avoidance, social anxiety and separation/pa-
nic. The MASC is comprised of 39 items assessing frequency of anxiety symptoms/
concerns, with items being scored 0 (not at all) to 3 (often), and provides a total
anxiety score. Research has indicated that the MASC has good internal reliability
and convergent validity (March, 1997; March et al., 1997a, 1997b).
2.2.2.3. Children’s Depression Inventory (CDI; Kovacs, 1992). The CDI is comprised of
27 items assessing symptoms of depression, scored 0 (absence of symptom), 1
(mild symptom), or 2 (definite symptom), with higher scores indicating increasing
severity and a total score that ranges from 0 to 54. The extensive use of the CDI in
clinical and experimental research has provided ample evidence to support its
reliability and validity (see Kovacs, 1992).
2.2.2.4. Family Accommodation Scale (FAS; Calvocoressi et al., 1995). This measure
assesses the frequency and severity of parental accommodation to OCD, and
provides a total by summing eight of the 12 items, which are scored as 0 (never/no
accommodation) to 4 (daily/extreme accommodation). There is an additional item
that rates the parents distress associated with accommodation, and a further three
items which assess the consequences of not participating in accommodation to
their child’s OCD behaviors. A recent psychometric evaluation of the FAS used with
a child sample of OCD patients (n ¼96) provides evidence for good internal con-
sistency, as well as good convergent and divergent validity of the measure
(Flessner et al., 2011).
2.3. Procedure
All procedures and protocols used in this study received institution review
board approval through the university human research ethics committee. Follow-
ing referral into this study, participants were screened via a brief parent interview
assessing for obsessive–compulsive symptomatology. If eligible, families attended
an assessment at the university psychology clinic, conducted by the first author
and postgraduate clinically trained clinicians. On attending this interview, the
research aims were explained to all participants and written informed consent
was gained from parents. Initial assessment interviews involved ADIS-P inter-
views with parents and the CY-BOCS interview with children (including parents
for younger children 7–11 years). Interviewers were trained in diagnostic inter-
views and CY-BOCS interviews through observation of the first author, followed by
supervision of their interviewing skills by the first author. Assessment also
included the completion of a number of self-report questionnaires, including the
OCD Impact Scale (child and parent version). Complete assessments were
conducted at pre- and post-treatment in the clinic, and brief versions of these
assessments were conducted at 6 months follow-up over the telephone (including
the ADIS-P—OCD section only, the interviewer also rated NIM-GOCS, and the child
CY-BOCS interview at this time). When a sufficient number of youth (within a
similar age range) had entered the study and been assessed, a treatment group
was formed.
2.3.1. Treatment protocol
The treatment program entitled OCD Busters (Child and Adolescent Versions)
(Farrell and Waters, 2008) was a manualised family-based CBT treatment protocol,
based on March and colleagues’ individual CBT protocol (‘‘How I ran OCD off My
Land’’; March et al., 1994; March and Mulle, 1998). Children aged 7–12 years
participated in the child version of the program and those aged 13–17 years
completed the adolescent program. The treatment involved 13 weekly child group
sessions and 2 booster sessions (1 month and 3 months post-treatment), each
running for approximately 1.5 h, with each session including a brief parental
involvement/family review of progress at the end of the child group session
(15 min). In addition to the child group sessions, there were three structured
parent group sessions (1 h each), and two individual family review sessions, each
1 h in duration scheduled at week 5 and week 10 of the program (including the
child and his/her parents and siblings if desired). Individual family review sessions
allowed for the therapist to engage the child in therapist-assisted ERP, and address
family accommodation and any issues that were not being addressed in the group
sessions (i.e., family conflict). There were six trained therapists who delivered the
program at the clinic in group format with two therapists implementing each
group program under the supervision of the first author. Therapists were all
postgraduate level clinicians with previous experience in CBT treatment of child
anxiety disorders, but not specifically OCD. At least one therapist for each group
however had some previous experience in delivering CBT treatment for child OCD.
All clinicians received formal weekly supervision wherein clinicians reported on
client progress, adherence to the treatment protocol, and provided an opportunity
to ask questions/problem solve treatment difficulties or group process issues.
Treatment fidelity was assessed by an independent rater, who viewed 20%
of group sessions (random selection), and rated each session on a likert scale
from 0–5 (0 ¼ very poor fidelity—5¼ excellent fidelity). This approach is consistent
with other treatment studies (e.g., Tolin et al., 2005; Storch et al., 2010); results in
the current study found excellent adherence to the treatment protocol (m¼ 4.76;
S.D. ¼0.44).
The child group sessions focused on psychoeducation, cognitive training,
anxiety management training, developing stimulus hierarchies, graded ERP
(including in session group ERP exercises, and establishing homework ERP),
building buffer zones with support networks, and relapse prevention. Parent
group sessions were conducted by one therapist from the child group following
the child sessions at weeks 2, 5 and 10, and focused on psychoeducation, problem-
solving skills, strategies to reduce parental involvement in the child’s symptoms,
along with encouraging family support of home-based ERP trials. At least one
parent from each family was required to attend each parent session. In the
majority of cases (87% of the sample) mothers attended the parent session. The
program emphasized that the coping strategies taught needed to be practiced as a
family on a daily basis. Children could miss up to two sessions provided that
missed sessions were caught up with the therapist before the group session. No
family missed more than two sessions. The two booster sessions provided
additional opportunities for children to gain assistance in generalizing the skills
learnt in previous sessions. There were at least four children in every group with a
maximum of seven children per group.
3. Results
All statistical analyses were conducted using SPSS version
19.0. Initial data analyses compared baseline demographics and
clinical characteristics across two groups—those children with a
comorbid diagnosis of interest (i.e., DEP, ADHD, PDD: n ¼20) and
those children without any of the three comorbid conditions of
interest (n ¼23). Independent samples t-tests (t) were computed
for continuous variables and chi-square (w2) analyses were
computed for categorical data. Treatment outcome was examined
at post-treatment and 6-month follow-up across the comorbid
versus non-comorbid groups by way of repeated measures
mixed-factorial ANOVAs, including a two group (comorbid versus
non-comorbid)  three time point design (pre-, post-, follow-up).
As noted earlier, treatment response was defined as at least a
25% reduction in CY-BOCS scores at post-treatment and 6 month
follow-up, whereas treatment remission was defined as a reduction
of 50% on the CY-BOCS combined with a post-treatment/follow-up
CY-BOCS score of o14 (see Tolin et al., 2005; Storch et al., 2010).
w2 analyses examined treatment response and treatment remission
 L. Farrell et al. / Psychiatry Research 199 (2012) 115–123 119

at post-treatment and 6 month-follow-up across the separate
comorbid conditions of interest (i.e., DEP, ADHD, PDD) relative to
children without each of the comorbid conditions. Analyses were
conducted in two ways—firstly, comparing children who had one of
the three comorbid conditions of interest, versus children who did
not have that comorbid condition (but may have had another
comorbid condition); as well as examining children with each of
the comorbid conditions relative to children without any of the
three comorbid conditions of interest. The results of both sets of
analyses did not differ; hence the first approach is presented here
(as these analyses allowed for a larger n in the non-comorbid group).
3.1. Pre-treatment comparisons
Baseline demographics (including age, gender, and combined
family income) and clinical characteristics (diagnostic severity,
OC severity, anxiety, depression, functional impairment, family
accommodation) were examined across the two groups—those
children with a comorbid diagnosis of interest (i.e., DEP, ADHD,
PDD: n¼20) and those children without any of the three comorbid
conditions of interest (n ¼23). On demographic variables, there
were no significant group differences on age or income; however,
the comorbid group was comprised of significantly less females
(i.e., 23%) than the non-comorbid group (77%), w2 ¼4.11 (1);
p o0.05.
On clinical characteristics, the comorbid group did not differ
significantly from the non-comorbid group on most severity
ratings of OCD (measured by the NIMH GOCS, NIMH CGI and
CY-BOCS scores), self-reported anxiety (MASC), or child rated
functional impairment (COIS-P/C). The comorid group was how-
ever significantly higher on self-report ratings of depression (CDI),
t¼ 3.37 (33); p o0.005, parent ratings of functional impairment
(COIS-P), t ¼2.74 (34); p o0.01, and on parent-rated family
accommodation t ¼2.67 (34); p o0.01. Given the comorbid group
included children with a diagnosis of depression (n ¼5), group
differences on self-reported depression were also examined
excluding the children with a diagnosis of MDD or dysthymia.
Results demonstrated the comorbid group continued to be sig-
nificantly higher on self-reported depression even after excluding
the children with a diagnosis (CDI), t ¼2.59 (28); p o0.02. Table 2
displays the baseline demographics and clinical characteristics
data. With an increase in the number of comorbid diagnoses
present at pre-treatment (i.e., one to three comorbid conditions
were recorded), there were significant positive correlations
observed with diagnostic severity (CSR; r ¼0.32, p o0.05), family
accommodation (FAS; r ¼0.35, p o0.05), depression (CDI; r ¼0.45,
po0.01) and anxiety (MASC; r¼ 0.37, p o0.05).
3.2. Group treatment outcome
The effectiveness of group CBT was evaluated by way of repeated
factorial analyses of variance (ANOVAs)—with a Time (pre-, post-, 6-
month follow-up)  Group  group (comorbid versus non-comor-
bid group) design across primary outcome measures of OCD
diagnostic severity (ADIS-P CSR; NIMG GOCS; CGI), OCD symptom
severity (CY-BOCS) and OCD functional impairment (COIS-C/P). The
multivariate Time  Group interaction was not significant; however,
there were significant Time main effects across each variable. The
same repeated measures ANOVAs were conducted also across each
of the specific diagnostic comorbidities (i.e., DEP versus no-DEP;
ADHD versus no-ADHD; PDD versus no-PDD) and there were also no
significant Time  Group Interactions.

Table 2
Baseline demographic and clinical characteristics across comorbid versus non-comorbid groups.

Comorbidity Mean S.D. t or v2 p

Age Comorbid 11.95 2.86 1.91 0.07

Non-comorbid 10.48 2.08

Gender (female) % Comorbid 23% – 4.11 0.04n

Non-comorbid 77% –

Combined Family Income Comorbid 61–70 K 3.57 –1.02 0.31

Non-comorbid 71–80 K 2.80

ADIS-P CSR Comorbid 6.35 0.81 2.33 0.02n

Non-comorbid 5.55 1.37

NIMH GOCS Comorbid 9.42 2.06 1.12 0.27

Non-comorbid 8.73 1.88

NIMH CGI Comorbid 4.44 1.15  0.717 0.49

Non-comorbid 4.68 0.95

Total CYBOCS Comorbid 22.00 5.96 0.65 0.52

Non-comorbid 20.65 7.18

Family Accommodation Comorbid 25.44 12.63 2.67 0.01nn

Non-comorbid 15.38 4.84

Total CY-BOCS Comorbid 15.00 8.93 3.37 0.002nnn

Non-comorbid 7.13 4.19
MASC Total Comorbid 63.87 16.18 1.65 1.04
Non-comorbid 54.08 17.80
COIS-P Comorbid 38.93 24.91 2.74 0.009nn
Non-comorbid 32.00 27.26

COIS-C Comorbid 46.44 20.90 0.76 0.45

Non-comorbid 28.95 18.28

ADIS-P CSR: ADIS-P Clinician Severity Rating 0–8; NIMG GOCS: NIMH Global OC Scale 0–15; NIMH CGI: NIMH Clinical Global Improvement 0–7; CY-BOCS: Child Yale-
Brown Obsessive–Compulsive Scale; CDI: Children’s Depression Inventory; MASC: Multidimensional Anxiety Scale for Children; COIS-P: Child OCD Impact Scale—Parent
report; COIS-C: Child OCD Impact Scale—Child Report.
n
p o 0.05.
nn
p o0.010.
nnn
p o0.005.
120 L. Farrell et al. / Psychiatry Research 199 (2012) 115–123

Post-hoc analyses of the significant multivariate time main At post-treatment, 47% of the entire sample was classified as
effects demonstrated that group CBT was effective regardless of achieving treatment remission. This response was largely main-
comorbidity, with significant reductions for the entire sample tained to 6-month follow-up with 44% of the sample classified as
from pre- to post-treatment on the ADIS-PCSR t (36)¼10.937; in remission at follow-up. Fig. 3 presents the percent of children
p o0.001, on the NIMH GOCS, t (36) ¼9.843; po0.000, on the classified as treatment remitters for each comorbidity group at
CY-BOCS, t (37)¼5.93; po0.001, on COIS-P, t (36)¼4.766, post-treatment and follow-up.
po0.001, and on the child COIS, t (36)¼3.056; po0.005, with all At post-treatment, there was no significant difference in the
outcomes associated with moderate (i.e., COIS-C) to large effect percent of children classified as being in remission of their OCD
sizes in the range of D¼0.69–1.65. between the comorbid versus non-comorbid groups. Further-
Gains were maintained to 6-month follow-up, with no significant more, across each of the comorbidity groups, there were no
differences from post-treatment to 6-month follow-up across pri- significant differences in the percentage of children classified as
mary outcome measures. Table 3 presents the means, standard remitters, relative to children without that comorbid condition. At
deviations and t-tests for the time main effects from pre- to post- 6-month follow-up, there was likewise no significant difference in
treatment (including means at follow-up). the percent of children classified as remitters between the
comorbid versus non-comorbid groups. There was, however, a
significant difference in the precent of children classified as being
3.3. Treatment response as a function of comorbidity
treatment remitters at 6 months follow-up for children with
At post-treatment, there was an overall mean reduction in
CY-BOCS ratings of 45% (mean reduction CY-BOCS¼ 8.08;
S.D. ¼8.39). Furthermore, at post-treatment 60.5% of the entire
sample was classified as responders (i.e., 425% reduction in -
CYBOCS). This response was largely maintained to 6-month
follow-up with 56% of the sample classified as responders at
follow-up. Fig. 2 presents the percent of responders for each
comorbidity group at post-treatment and follow-up.
At post-treatment, there was no significant difference in the
percent of children classified as responders between the comorbid
versus non-comorbid groups. Furthermore, across each of the
comorbidity groups, there were no significant differences in the
percentage of children classified as responders, relative to children
without that comorbid condition. At 6-month follow-up, there was
likewise no significant difference in the percent of children classified
as responders between the comorbid versus non-comorbid groups. Fig. 2. Percent classified as responders at post-treatment and follow-up.
There was a significant difference in the percent of children
classified as responders for children with ADHD (43% responders)
versus children without ADHD (81% responders), w2 ¼3.99 (1);
p¼0.06. There were, however, no differences across DEP or PDD
groups relative to children without comorbidity.
The impact of the number of comorbid conditions (i.e., one to
three comorbid conditions) on outcome was examined by way of
a correlation with percent reduction on CY-BOCS scores from pre-
to post-treatment, and pre- to 6-month follow-up. Correlations
amongst the frequency of comorbid diagnoses and CY-BOCS
reduction was significant at 6month follow-up only, with a
moderate negative correlation (r ¼ 0.37; p o0.05).

3.4. Treatment remission as a function of comorbidity

Remission was defined as a score of less than 14 on the

CY-BOCS combined with at least a 50% reduction on the CY-BOCS. Fig. 3. Percent classified as remitters at post-treatment and follow-up.

Table 3
Treatment outcome main effects of time across primary outcome measures.

Measure Pre-mean (S.D.) Post-mean (S.D.) F-UP Mean (S.D.) Cohen’s d (pre - post) Significance
(Pre- to Post-Treatment)

NIMH GOCS 8.89 (1.92) 4.83 (2.44) 4.66 (2.24) 1.65 t (36)¼ 9.843nnn
ADIS-P CSR 5.89 (1.92) 2.08 (2.28) 2.54 (2.33) 1.61 t (36)¼ 10.937nnn
CY-BOCS 20.45 (6.82) 12.43 (8.18) 10.32 (7.37) 0.92 t (37)¼ 5.93nnn
COIS-P 35.32 (21.07) 21.36 (20.19) – 0.90 t (36)¼ 4.766nnn
COIS-C 29.00 (17.07) 16.17 (19.41) – 0.69 t (36)¼ 3.056nn

Abbreviations—ADIS-P CSR: ADIS-P Clinician Severity Rating 0–8; NIMG GOCS: NIMH Global OC Scale 0–15; CY-BOCS: Child Yale-Brown Obsessive–Compulsive Scale;
COIS-P: Child OCD Impact Scale—Parent report; COIS-C: Child OCD Impact Scale—Child Report.Cohen’s d is calculated correcting for dependence between means
(associated with repeated measures design) using Morris and De Shon (2002) procedure (equation 8).
nnn
po 0.010.
nn
p o0.005.
 L. Farrell et al. / Psychiatry Research 199 (2012) 115–123
ADHD (25% as remitters) versus children without ADHD (65% as
remitters), w2 ¼4.05 (1); p o0.05. There were no differences
across DEP or PDD groups relative to children without
comorbidity.
4. Discussion
This pilot study evaluated the effectiveness of group CBT on
outcomes for children and youth with OCD who presented with
complex comorbidity, including depression (DEP), attention deficit/
hyperactivity disorder (ADHD) and PDD, including ASD). Specifically,
this study examined the correlates of complex comorbidity at
baseline (including severity, and impairment), as well as group
treatment outcomes at post-treatment and 6-month follow-up, by
way of remission rates and treatment response as a function of
comorbidity. It was expected that: (a) the presence of comorbidty
(i.e., DEP, ADHD, PDD) would be associated with significantly worse
OCD and higher functional impairment at baseline; (b) group CBT
would be effective for children with OCD; however, (c) comorbidty
(i.e., DEP, ADHD, PDD) would be associated with poorer treatment
response and treatment remission following group-based CBT relative
to children without this comorbidity.
This sample was a highly comorbid sample, with comorbidity
rates above those reported in most previous studies (e.g., Rasmussen
and Eisen, 1990; Storch et al., 2008)—with 86% of the sample
presenting with a secondary psychiatric disorder, and 74% presenting
with a tertiary psychiatric condition. This sample was also un-
characteristically predominantly male, with 79% of the sample
male—differing from past pediatric treatment samples, which usually
report equal (or close to equal) gender ratios (e.g., Barrett et al.,
2004a,b; POTS, 2004; Storch et al., 2008). The high rates of comor-
bidity and the male predominance in this sample may be attributable
to the relatively high rates of comorbid ADHD (21%) and PDD (35%)
within the current sample. In regards to baseline characteristics of
the children classified as having one of the three comorbid condi-
tions, relative to children without one of these comorbid conditions,
the comorbid group were significantly higher on self-report ratings of
depression and on ratings of family accommodation to their OCD
symptoms providing evidence in line with previous investigations
(e.g., Storch et al., 2008), which tends to support higher impairment
associated with higher rates of comorbidity. Furthermore, the
comorbid children were consistently more severe across measures
of diagnostic severity and OC severity, as well as parental report of
functional impairment—although not statistically significant, which
may have been a function of limited power in the current study.
In regards to treatment outcome following group CBT, the
current study demonstrated that there were no significant time-
 comorbid condition interactions, suggesting that overall children
did not respond differentially to group-based CBT as a function of
their comorbidity. Importantly, group CBT involving children with a
range of comorbid conditions, including comorbid PDD, produced
favorable outcomes across all primary outcome variables com-
parable to those reported in the POTS trial (2004)—the largest,
most rigorous multi-site RCT to date. In fact, the current study of
group CBT demonstrated an overall mean reduction of 47% on the
CY-BOCS—which is largely equivalent to POTS outcomes (i.e., 46%
mean reductions for CBT and 53% for combined CBTþSRI). In terms
of the overall response to group CBT, the current study found 47%
remission rate, which is also comparable to that reported in the
POTS trial (i.e., 39% remission defined by CY-BOCSo10). These
outcomes are very promising and suggest that overall group based
CBT including parental involvement, with a highly comorbid sample
was largely effective—for all children.
Whilst the current findings provide support for group CBT in
treating OCD with complex comorbidity, the results also suggest
121
that the number of comorbid conditions was negatively associated
with outcomes at longer term follow-up. That is, the most compli-
cated cases, including more than one comorbid condition, was
associated with a significant decline in treatment response over
time. The data presented in the current study did not provide
evidence for differential effects on treatment response or treatment
remission rates for children who had comorbid depression or PDD;
however, the results did suggest that comordid attention deficit/
hyperactivity disorder was associated with a significantly poorer
response and remission rate by 6-month follow-up. This finding is
consistent with previous research that has found that externalizing
disorders predict a poorer response to CBT (Storch et al., 2008;
Garcia et al., 2010).
Overall, the current study provides promise for the treatment
of OCD, including complex comorbidity, within group-based
delivery of CBT. Contrary to hypotheses, the presence of depres-
sion and PDD (including ASD) was not associated with a poorer
response to treatment up to 6-month follow-up. Furthermore, the
overall quality of outcomes for children involved in this group
treatment study did not appear to be eroded by having more
complex cases present within the group. Moreover, given that
none of specific comorbidity’s had a negative effect on outcomes
at post-treatment, the results of the current study are suggestive
that group CBT may actually offer additional benefits for arguably
more complex cases, characterized by high comorbidity. Group
based CBT provides normalization of OCD, as well as provides
peer support, and arguably increased compliance with treatment
and motivation for change, driven by in-group norms that under-
lie group therapy. In our clinical experience of running groups, we
found that children who were finding ERP difficult did actually
make very positive progress (even if slightly delayed), once they
witnessed others in their peer-group making significant change
and being rewarded for such. The finding that group CBT is largely
effective in children with comorbid conditions is of clinical and
practical significance given the recent push in health and medical
research to enhance patient access to evidence-based treatments.
Group delivery of CBT provides an efficient and cost-effective
means of providing treatment to patients, and alleviates strain on
services and service providers. The results do suggest however,
that outcomes for children with multiple comorbid conditions,
and for children with comorbid attention deficit/hyperactivity
disorder, were attenuated at 6-month follow-up. This finding
highlights the need to determine if outcomes might be improved
for these more complex (i.e., numerous comorbid conditions)
or ‘‘difficult-to-treat’’ cases through increased booster sessions
following treatment, and/or by tailoring treatments to address
comorbid psychopathology. For example, one approach might be
a modular treatment program for children with comorbid OCD
and externalizing disorders, which differentially targets OCD
symptoms, as well as behavior management, emotion regulation
and parental contingency management of child behavior, and is
delivered on a flexible, individualized basis.
There are a number of limitations to this study that require
highlighting. Firstly, this study was an open clinical pilot study;
hence it was not possible to quantify the relative response to CBT
versus a control condition. Furthermore, the examination of
multiple comorbid conditions within this clinical sample resulted
in relatively small samples for each group. Further research with
larger clinical sub-samples across each comorbid group is neces-
sary to confirm outcomes reported in this pilot trial with greater
statistical confidence. This was particularly evident in the depres-
sion group; hence, analyses are likely to be affected by limited
power, potentially leading to type 2 errors and therefore require
replication with larger samples. Additionally, this study did not
use structured, psychometrically validated interviews for diag-
noses of PDD. This may have implications for the validity of these
122 L. Farrell et al. / Psychiatry Research 199 (2012) 115–123
diagnoses in the current study; however, this study did attempt to
address this limitation by developing semi-structured clinical inter-
view questions, and sought confirmation of PDD diagnoses by
external pediatric specialists. Reliance on parent-only ADIS interviews
is a limitation in the current study; however, past research demon-
strates good convergence between parents and clinicians, which is
frequently higher than with child report (Grills and Ollendick, 2003).
Future research investigating the impact of comorbidity on treatment
response with large samples, examining multiple treatments, and
including children with complex comorbid condition is warranted to
advance our understanding about moderators of treatment res-
ponse in pediatric OCD.
In sum, this study provides an evaluation of group-based CBT
up to 6 months following treatment for children with OCD and
co-occurring psychiatric conditions, including clinical depression,
attention deficit/hyperactivity disorder and PDD. Group-based
CBT, which incorporates individual parental involvement, indivi-
dual family review sessions, in-session group exposure exercises
and booster sessions at 1- and 3-month follow-up, appears both
feasible and effective for children with arguably more ‘‘difficult-
to-treat’’ OCD, defined by a range of complex comorbid condi-
tions. Treatment outcomes are attenuated at follow-up for chil-
dren with two or more comorbid conditions and for children with
attention deficit/hyperactivity disorder. Efforts to improve treat-
ment for these children are warranted through innovation to
current CBT approaches.
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