Novel treatment approaches for children and adolescents with obsessive-compulsive disorder

Background: Obsessive-compulsive disorder (OCD) is a prevalent and disabling condition with typical onset during childhood. The recommended treatment is cognitive behavioral therapy (CBT), but it is seldom available to young people. Previous research has indicated that internet- delivered CBT (ICBT) is an efficacious treatment for adolescents with OCD, but little is known about its feasibility for children and if the treatment is transferrable to other contexts. Further, ICBT has been proposed as a possible first intervention in a stepped care model, but knowledge is lacking about the efficacy and cost-effectiveness of such a model.

Aims: The overall aim of this thesis was to develop and evaluate novel approaches to deliver and scale up the treatment for children and adolescents with OCD. More specifically, the aims were to evaluate (1) the feasibility of ICBT for children 7-11 years with OCD, (2) if the ICBT program is transferrable to clinical units in different countries, and (3) if ICBT in a stepped care model has comparable effects as, and using less resources than, face-to-face CBT for children and adolescents with OCD.

Methods: Study I was an open pilot study where 11 children and their parents received 12 weeks of therapist-guided ICBT (aim 1). In Study II, ICBT was provided to 31 families at three different clinical units located in Gothenburg, London, and Brisbane, to investigate if the treatment is transferrable to other contexts outside the clinic in Stockholm where it was originally developed (aim 2). Study III was a two-site randomized non-inferiority trial where 152 children and adolescents with OCD either received ICBT in a stepped care approach (ICBT for 16 weeks and non-responders were offered face-to-face CBT between the 3-month and 6-month follow-up), or standard face-to-face CBT (16 weeks of face-to-face CBT and non-responders were offered additional face-to-face CBT between the 3-month and 6-month follow-up). The non-inferiority was evaluated at the 6-month follow-up using the Children’s Yale-Brown Obsessive-Compulsive Scale (CY-BOCS) as the main outcome and the trial incorporated a full economic evaluation (aim 3).

Results: In Study I, the treatment completion was high and both children and their parents were overall very satisfied with the treatment. The results showed a large reduction of OCD symptom severity and improvements on secondary outcomes (e.g., general functioning and family accommodation) after treatment, which were maintained during the follow-up period of three months. In Study II, the number of treatment completers and therapist time differed somewhat between the sites. Overall, results indicated large reductions of OCD symptoms, with additional improvements up to the 3-month follow-up. Further, the therapists reported both advantages and challenges with the online format. In Study III, we could demonstrate that the stepped care treatment was as efficacious as the face-to-face treatment with an estimated mean difference of 0.91 points on the CY-BOCS (95% CI, -1.46 to 3.28, p = .45; 68% responders in both groups), but to a lower cost for the health care provider (average cost saving of -$2104 [95% CI, -3006 to -1202] per participant in the stepped care treatment compared with the face-to-face treatment). Results remained largely the same also when broadening the economic evaluation to the health care organization perspective and the societal perspective.

Conclusions: Therapist-guided ICBT is a feasible intervention for both children and adolescents with OCD, also when delivered in other settings and countries than the clinic in Stockholm (Sweden). ICBT can be provided as a first treatment step where patients who do not respond sufficiently subsequently receive face-to-face CBT. This stepped care approach provides equal treatment effect as standard face-to-face CBT while at the same time being cost-saving for the health care provider. Though most importantly, ICBT could greatly increase access to evidence- based treatment so more children and adolescents with OCD can get the help they need and deserve.

List of scientific papers

I. Aspvall, K., Andrén, P., Lenhard, F., Andersson, E., Mataix-Cols, D., & Serlachius, E. (2018). Internet-delivered cognitive behavioural therapy for young children with obsessive–compulsive disorder: development and initial evaluation of the BIP OCD Junior programme. BJPsych Open. 4(3), 106-112.
https://doi.org/10.1192/bjo.2018.10

II. Aspvall, K., Lenhard, F., Melin, K., Krebs, G., Norlin, L., Näsström, K., Jassi, A., Turner, C., Knoetze, E., Serlachius, E., Andersson, E., & Mataix-Cols, D. (2020). Implementation of internet-delivered cognitive behaviour therapy for pediatric obsessive-compulsive disorder: Lessons from clinics in Sweden, United Kingdom and Australia. Internet Interventions. 20, 100308.
https://doi.org/10.1016/j.invent.2020.100308

III. Aspvall, K., Andersson, E., Melin, K., Norlin, L., Eriksson, V., Vigerland, S., Jolstedt, M., Silverberg-Mörse, M., Wallin, L., Sampaio, F., Feldman, I., Bottai, M., Lenhard, F., Mataix-Cols, D., & Serlachius, E. Stepped-care internet-delivered versus face-to-face cognitive-behavior therapy for pediatric obsessive-compulsive disorder: a randomized clinical non-inferiority trial. [Manuscript]