Attention Training for Childhood Obsessive Compulsive Disorder
| Status: | Active, not recruiting |
|---|---|
| Conditions: | Psychiatric |
| Therapuetic Areas: | Psychiatry / Psychology |
| Healthy: | No |
| Age Range: | 8 - 17 |
| Updated: | 4/21/2016 |
| Start Date: | April 2013 |
| End Date: | May 2016 |
Voluntary and involuntary attention processes are thought to play an important role in the
development and maintenance of anxiety disorders including OCD. Individuals with OCD pay
greater attention to threat information related to their illness and have difficulty
shifting their attention from such triggers. Studies suggest that a change in attention bias
may lead to a change in anxiety vulnerability. However, few studies have directly examined
the causal role of attention bias in the maintenance of anxiety underlying OCD and whether
modification of such biases may reduce pathological anxiety symptoms particularly in
children. In this proposal, we aim to translate basic findings from research on cognitive
biases in anxiety into a novel computerized intervention for child Obsessive Compulsive
Disorder (OCD). The treatment is designed to target a basic cognitive vulnerability in OCD,
namely the selective processing of threatening OCD-related information. 52 children with OCD
will be randomly assigned to either a 12-session attention modification program (AMP) or an
attention control condition (ACC). Clinical assessment of symptom severity along with a
brief neurocognitive battery will be conducted before and after treatment. We hypothesize
that children in the AMP group at end of treatment will show (1) decreased attention bias to
OCD-related triggers using an independent measure of attention bias to assess change and (b)
reduced OCD severity. This study is an initial step towards demonstrating the feasibility
and efficacy of a novel computerized attention training program for OCD that ultimately may
prove to be a highly transportable and accessible intervention for this childhood
psychiatric disorder. Furthermore, the project will also examine neurocognitive performance
before and after attention training to elucidate possible predictors and mechanisms of
treatment response.
development and maintenance of anxiety disorders including OCD. Individuals with OCD pay
greater attention to threat information related to their illness and have difficulty
shifting their attention from such triggers. Studies suggest that a change in attention bias
may lead to a change in anxiety vulnerability. However, few studies have directly examined
the causal role of attention bias in the maintenance of anxiety underlying OCD and whether
modification of such biases may reduce pathological anxiety symptoms particularly in
children. In this proposal, we aim to translate basic findings from research on cognitive
biases in anxiety into a novel computerized intervention for child Obsessive Compulsive
Disorder (OCD). The treatment is designed to target a basic cognitive vulnerability in OCD,
namely the selective processing of threatening OCD-related information. 52 children with OCD
will be randomly assigned to either a 12-session attention modification program (AMP) or an
attention control condition (ACC). Clinical assessment of symptom severity along with a
brief neurocognitive battery will be conducted before and after treatment. We hypothesize
that children in the AMP group at end of treatment will show (1) decreased attention bias to
OCD-related triggers using an independent measure of attention bias to assess change and (b)
reduced OCD severity. This study is an initial step towards demonstrating the feasibility
and efficacy of a novel computerized attention training program for OCD that ultimately may
prove to be a highly transportable and accessible intervention for this childhood
psychiatric disorder. Furthermore, the project will also examine neurocognitive performance
before and after attention training to elucidate possible predictors and mechanisms of
treatment response.
In this proposal, we aim to translate basic findings from research on cognitive biases in
anxiety into a novel computerized intervention for child OCD. The treatment is designed to
target a basic cognitive vulnerability in OCD, namely the selective processing of
threatening OCD-related information. Briefly, the computerized procedure involves repeatedly
redirecting participants' attention away from OCD-relevant threat cues in order to induce
selective processing of neutral (non-threat) stimuli. This study is an initial step towards
demonstrating the efficacy of a potentially highly transportable and accessible intervention
for OCD. Furthermore, the project will also examine neurocognitive performance before and
after attention modification to elucidate possible predictors and mechanisms of treatment
response.
Aim 1: To examine the preliminary efficacy of a 12-session computerized attention
modification program (AMP) on attention bias and symptom severity in children with OCD.
Hypothesis 1a: AMP treatment compared to the attention control condition (ACC) will be
associated with a decrease in attention bias towards threat-cues in youth with OCD.
Hypothesis 1b: AMP treatment will be associated with a decrease in OCD symptom severity
among OCD youth as measured by clinician-administered diagnostic interview and symptom
rating scales.
Aim 2: To examine the changes in neurocognitive status over the course of treatment with AMP
in children and adolescents with OCD.
Hypothesis 2: Those children who respond to AMP will exhibit improved performance on
relevant neurocognitive measures at post-treatment.
Aim 3: To examine the relationship between baseline neurocognitive status and response to
AMP.
Hypothesis 3: Baseline neurocognitive performance will be associated with greater
AMP-related improvement in symptom severity among youth with OCD.
Exploratory Aim: To investigate the potential relationship between AMP and changes in
behavioral and electrophysiological (EEG) correlates of cognitive control and affect
regulation before and after treatment with AMP or ACC. The objective is to examine the
feasibility, acceptability and suitability of using Error-Related Negativity (ERN), an
evoked response potential (ERP) generated from cognitive activation paradigms assessing
action-monitoring and conflict resolution under neutral and emotional contexts, to elucidate
potential neural mechanisms underlying treatment. Although not powered for formal tests of
mediation, we will explore in a preliminary fashion whether these neural indices may serve
as potential biomarkers for pediatric OCD as well as predictors/mediators of treatment
response.
Preliminary hypotheses: 1) Youth with OCD will be characterized by high amplitude ERN, which
will not change with treatment; 2) AMP treatment will be associated with changes in EEG
reflecting greater engagement of top-down (as indexed by the P3 component) versus bottom-up
(indexed by the P1/N1 components) neural processes, particularly among children who exhibit
improved performance on cognitive control tasks; 3) Baseline executive functioning in
interference control and action monitoring will be associated with greater AMP-related
improvement in OCD severity; 4) We will also explore the relationships of key variables such
as trait anxiety, self-reported attention control, baseline OCD symptom severity and
attention bias with each other and with response to AMP.
OCD is a chronic and often disabling psychiatric condition, affecting 2-4% of children and
adolescents1. In the absence of effective treatment, it is often associated with
considerable social, academic and familial impairment along with considerable psychiatric
comorbidity including Tourette's and other Chronic Tic Disorders. Although a number of
empirically supported treatments, both behavioral and pharmacological, exist for OCD, many
children and their families are either not able to adequately access these treatments or
derive only partial benefit from them. Thus, it is of critical importance to expand
treatment options and develop more effective treatments that have the potential to be widely
accessible to children suffering from OCD.
One etiological model of OCD proposes that symptoms arise from the abnormal processing of
threat-relevant information. According to this model, selective attention to threatening
information heightens anxiety and anxiety-related avoidance of the perceived threat, and the
avoidance behaviors, in turn, prevent disconfirmation of fear-related beliefs and serves to
maintain anxiety. Thus, attention bias towards threat may be causally related to the
behavioral avoidance of the perceived threat. Research indicates that attention bias towards
OCD related material ameliorates after effective cognitive behavioral therapy, thus
highlighting that attention bias is malleable. Nevertheless, the critical question remains
whether a reduction in attention bias causes a reduction in OCD symptoms or whether
attention bias is an epiphenomenon of the symptoms. Recently, studies have begun to directly
manipulate attention bias to address this question. In one such study, attention was trained
in adults with OCD contamination fears by building a contingency between the locations of
the OCD-related word in the active condition and not in the control condition on a modified
dot-probe task. Participants in the attention training group showed significant reductions
in both attention bias for threat and OCD symptom severity. The extension of this research
to clinical patient and child samples with a multi-session treatment protocol has yet to be
conducted. To date, no study has investigated attention training in children with OCD,
although there are data to suggest positive results in adults with OCD as well as Social
Phobia and Generalized Anxiety Disorder.
A number of recent studies have demonstrated that the willful direction of attention in the
presence of threatening stimuli activates prefrontal regions thought to be involved in
attention control, which in turn appears to down-regulate activation of the amygdala, a
structure involved in the emotional processing of fear/threat stimuli. Many of these tasks
have involved techniques like cognitive reappraisal or altering cognitive processing of
threatening. The question remains whether similar neurobiological mechanisms underlie the
effects of attention training. Given the importance of higher-level attention control in
reducing biased attention processing and dampening anxious states, helping anxious
individuals improve attention control may be an important mechanism for reducing the
negative impact and development of psychopathology. In an attempt to gather preliminary data
on the possible neurocognitive predictors and mechanisms of treatment response, we also plan
to assess aspects of response inhibition and memory/learning that have been implicated in
neurocognitive studies of OCD before and after treatment with AMP.
We hypothesize that training attention away from OCD-related threat stimuli will decrease
attention bias towards the threat and based on the assumption that attention bias is
causally related to anxiety symptoms, this decrease in bias would lead to a decrease in
avoidance of threatening stimuli. More specifically, we predict that compared to the control
condition (ACC), AMP will decrease attention bias towards the threat and facilitate
behavioral approach towards the feared stimuli in children with OCD along with an overall
decrease in their symptom severity.
The present study focuses on children and adolescents for two important reasons. First, OCD
typically onsets in childhood, and enhanced understanding of the neuro-developmental
correlates of OCD and mechanisms underlying treatment at this age has the potential to
prevent long-term morbidity. Second, the focus on this age group allows us to study the
disorders prior to the development of significant secondary psychiatric and psychosocial
morbidity, which commonly accompanies OCD in adulthood. Thus far, only limited research on
the effects of attention modification training on OCD severity has been conducted in
children. This study may generate significant new information concerning the neurocognitive
underpinnings of OCD, the commonality of these underpinnings to other neurodevelopmental
disorders of childhood, and the neurocognitive correlates of response to a potentially new
and relatively accessible nonpharmacological treatment intervention. This knowledge will be
used to develop more effective treatments with an eye towards matching interventions to
specific individuals on the basis of characteristic pre-treatment cognitive profiles.
anxiety into a novel computerized intervention for child OCD. The treatment is designed to
target a basic cognitive vulnerability in OCD, namely the selective processing of
threatening OCD-related information. Briefly, the computerized procedure involves repeatedly
redirecting participants' attention away from OCD-relevant threat cues in order to induce
selective processing of neutral (non-threat) stimuli. This study is an initial step towards
demonstrating the efficacy of a potentially highly transportable and accessible intervention
for OCD. Furthermore, the project will also examine neurocognitive performance before and
after attention modification to elucidate possible predictors and mechanisms of treatment
response.
Aim 1: To examine the preliminary efficacy of a 12-session computerized attention
modification program (AMP) on attention bias and symptom severity in children with OCD.
Hypothesis 1a: AMP treatment compared to the attention control condition (ACC) will be
associated with a decrease in attention bias towards threat-cues in youth with OCD.
Hypothesis 1b: AMP treatment will be associated with a decrease in OCD symptom severity
among OCD youth as measured by clinician-administered diagnostic interview and symptom
rating scales.
Aim 2: To examine the changes in neurocognitive status over the course of treatment with AMP
in children and adolescents with OCD.
Hypothesis 2: Those children who respond to AMP will exhibit improved performance on
relevant neurocognitive measures at post-treatment.
Aim 3: To examine the relationship between baseline neurocognitive status and response to
AMP.
Hypothesis 3: Baseline neurocognitive performance will be associated with greater
AMP-related improvement in symptom severity among youth with OCD.
Exploratory Aim: To investigate the potential relationship between AMP and changes in
behavioral and electrophysiological (EEG) correlates of cognitive control and affect
regulation before and after treatment with AMP or ACC. The objective is to examine the
feasibility, acceptability and suitability of using Error-Related Negativity (ERN), an
evoked response potential (ERP) generated from cognitive activation paradigms assessing
action-monitoring and conflict resolution under neutral and emotional contexts, to elucidate
potential neural mechanisms underlying treatment. Although not powered for formal tests of
mediation, we will explore in a preliminary fashion whether these neural indices may serve
as potential biomarkers for pediatric OCD as well as predictors/mediators of treatment
response.
Preliminary hypotheses: 1) Youth with OCD will be characterized by high amplitude ERN, which
will not change with treatment; 2) AMP treatment will be associated with changes in EEG
reflecting greater engagement of top-down (as indexed by the P3 component) versus bottom-up
(indexed by the P1/N1 components) neural processes, particularly among children who exhibit
improved performance on cognitive control tasks; 3) Baseline executive functioning in
interference control and action monitoring will be associated with greater AMP-related
improvement in OCD severity; 4) We will also explore the relationships of key variables such
as trait anxiety, self-reported attention control, baseline OCD symptom severity and
attention bias with each other and with response to AMP.
OCD is a chronic and often disabling psychiatric condition, affecting 2-4% of children and
adolescents1. In the absence of effective treatment, it is often associated with
considerable social, academic and familial impairment along with considerable psychiatric
comorbidity including Tourette's and other Chronic Tic Disorders. Although a number of
empirically supported treatments, both behavioral and pharmacological, exist for OCD, many
children and their families are either not able to adequately access these treatments or
derive only partial benefit from them. Thus, it is of critical importance to expand
treatment options and develop more effective treatments that have the potential to be widely
accessible to children suffering from OCD.
One etiological model of OCD proposes that symptoms arise from the abnormal processing of
threat-relevant information. According to this model, selective attention to threatening
information heightens anxiety and anxiety-related avoidance of the perceived threat, and the
avoidance behaviors, in turn, prevent disconfirmation of fear-related beliefs and serves to
maintain anxiety. Thus, attention bias towards threat may be causally related to the
behavioral avoidance of the perceived threat. Research indicates that attention bias towards
OCD related material ameliorates after effective cognitive behavioral therapy, thus
highlighting that attention bias is malleable. Nevertheless, the critical question remains
whether a reduction in attention bias causes a reduction in OCD symptoms or whether
attention bias is an epiphenomenon of the symptoms. Recently, studies have begun to directly
manipulate attention bias to address this question. In one such study, attention was trained
in adults with OCD contamination fears by building a contingency between the locations of
the OCD-related word in the active condition and not in the control condition on a modified
dot-probe task. Participants in the attention training group showed significant reductions
in both attention bias for threat and OCD symptom severity. The extension of this research
to clinical patient and child samples with a multi-session treatment protocol has yet to be
conducted. To date, no study has investigated attention training in children with OCD,
although there are data to suggest positive results in adults with OCD as well as Social
Phobia and Generalized Anxiety Disorder.
A number of recent studies have demonstrated that the willful direction of attention in the
presence of threatening stimuli activates prefrontal regions thought to be involved in
attention control, which in turn appears to down-regulate activation of the amygdala, a
structure involved in the emotional processing of fear/threat stimuli. Many of these tasks
have involved techniques like cognitive reappraisal or altering cognitive processing of
threatening. The question remains whether similar neurobiological mechanisms underlie the
effects of attention training. Given the importance of higher-level attention control in
reducing biased attention processing and dampening anxious states, helping anxious
individuals improve attention control may be an important mechanism for reducing the
negative impact and development of psychopathology. In an attempt to gather preliminary data
on the possible neurocognitive predictors and mechanisms of treatment response, we also plan
to assess aspects of response inhibition and memory/learning that have been implicated in
neurocognitive studies of OCD before and after treatment with AMP.
We hypothesize that training attention away from OCD-related threat stimuli will decrease
attention bias towards the threat and based on the assumption that attention bias is
causally related to anxiety symptoms, this decrease in bias would lead to a decrease in
avoidance of threatening stimuli. More specifically, we predict that compared to the control
condition (ACC), AMP will decrease attention bias towards the threat and facilitate
behavioral approach towards the feared stimuli in children with OCD along with an overall
decrease in their symptom severity.
The present study focuses on children and adolescents for two important reasons. First, OCD
typically onsets in childhood, and enhanced understanding of the neuro-developmental
correlates of OCD and mechanisms underlying treatment at this age has the potential to
prevent long-term morbidity. Second, the focus on this age group allows us to study the
disorders prior to the development of significant secondary psychiatric and psychosocial
morbidity, which commonly accompanies OCD in adulthood. Thus far, only limited research on
the effects of attention modification training on OCD severity has been conducted in
children. This study may generate significant new information concerning the neurocognitive
underpinnings of OCD, the commonality of these underpinnings to other neurodevelopmental
disorders of childhood, and the neurocognitive correlates of response to a potentially new
and relatively accessible nonpharmacological treatment intervention. This knowledge will be
used to develop more effective treatments with an eye towards matching interventions to
specific individuals on the basis of characteristic pre-treatment cognitive profiles.
Inclusion Criteria:
- Age 8-17 (inclusive) at the time of initial evaluation
- Subject meets Diagnostic and Statistical Manual of Mental Disorders (DSM-IV)
diagnostic criteria for OCD.
- Unmedicated or on stable medication treatment for anxiety, OCD, attention deficit
hyperactivity disorder, tics, and/or depressive disorder for at least 6 weeks prior
to study entry, with no planned changes for duration of study participation.
- Child is fluent English speaker.
- Parental informed consent and child informed assent must be completed. Parents must
agree to their child's participation in this protocol.
Exclusion Criteria:
- Intelligence Quotient < 80 on Wechsler Abbreviated Scale of Intelligence (WASI).
- Excessive or problematic substance use as reported per initial telephone screening,
or DSM-IV Conduct Disorder within the past 3 months.
- Subject has a lifetime DSM-IV diagnosis of pervasive developmental disorder, Mania,
or Psychotic Disorder.
- Subject has any serious psychiatric, psychosocial, or neurological condition (i.e.,
attention deficit hyperactivity disorder, major depressive disorder, anxiety,
anxiety, severe aggression, family discord) requiring immediate treatment other than
that provided in the current study.
We found this trial at
1
site
Click here to add this to my saved trials
