Avoidance Related to Cognitive Behavioral Therapy Response in Pediatric Obsessive-Compulsive Disorder

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Cognitive behavioral therapy response rates in pediatric obsessive-compulsive disorder may be related to avoidance and impairment recognition, but not to poor insight.

Avoidance has a more pronounced relationship to cognitive behavioral therapy (CBT) response potential in children with obsessive-compulsive disorder (OCD) than poor insight, according to research published in Journal of the American Academy of Child & Adolescent Psychiatry.

Researchers collected data from 573 OCD-affected youth enrolled in CBT trials and used the Children’s Yale-Brown Obsessive-Compulsive Scale items to measure treatment response, insight, and avoidance ( 53.2% female; mean age, 12.67 years). Avoidance was defined as the extent to which youth avoid activities or interactions because of obsessions or compulsions. Insight was related to beliefs that their concerns or behaviors are reasonable. To calculate impairment recognition concordance, researchers used standardized differences between child and parent ratings of impairment. In addition, binary logistic regression identified variables associated with treatment response.

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No significant relationship was found between baseline insight and response rates. However, worsening avoidance was related to lower response rates, with a 48.3% (n=14) response rate for those with extreme avoidance compared with 71.9% (n=69) for those with no avoidance. Treatment was associated with improved insight and reductions in avoidance, with significant improvements in youth who had poor or absent baseline insight (d=2.85; n=60) or severe/extreme baseline avoidance (d=2.36; n=127).

The posttreatment cohort consisted of 510 participants, with lower response rates corresponding to declining insight and increasing avoidance. Of 287 youth with excellent insight, a response rate of 78.0% was reported vs 23.5% in youth with poor insight (n=17). When evaluated by avoidance, the response rates were 87.6% of youth with no avoidance (n=250) compared with 3.4% in youth with severe/extreme avoidance (n=29).

The study sample was recruited from OCD specialty centers, which may affect the generalizability of the findings. In addition, CBT delivery varied by site.

“[Avoidance], insight, and parent-child concordance on impairment, all appear to be variables relevant to CBT. As a result, it is recommended that clinicians assess and monitor these factors prior to, and throughout, treatment,” researchers wrote.

“Future studies are needed to understand the emergence of problematic presentations, such as limited child impairment recognition, and extreme avoidance, in youth prior to treatment,” they concluded.

Disclosures: See source for complete disclosure information.


Selles RR, Højgaard DRMA, Ivarsson T, et al. Avoidance, insight, impairment recognition concordance, and cognitive-behavioral therapy outcomes in pediatric obsessive-compulsive disorder [published online June 19, 2019]. J Am Acad Child Adolesc Psychiatry. doi:10.1016/j.jaac.2019.05.030