Attention Training for Childhood Obsessive Compulsive Disorder
Condition: Obsessive Compulsive Disorder
MeSH terms: Compulsive Personality Disorder; Obsessive-Compulsive Disorder
Study type: Interventional

Summary: 
      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.
    

Detailed description: 
      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.
    

Intervention name(s): Attention Modification Program; Attention Control Condition
Intervention type(s): Behavioral; Behavioral
Intervention description(s): Each trial begins with a fixation cross presented in the center of the computer screen for 500 ms. The cross is then replaced by a word pair presented in the center of the screen for 500 ms. The word pair disappears and a probe (i.e., the letter "E" or "F") appears immediately in the location of one of the two words. Participants will be instructed to decide whether the letter is an E or an F and press the corresponding mouse button. This paradigm has been modified to facilitate an attention bias away from threatening material. In this case, the probe always replaces the neutral word. Thus, although there will be no specific instruction to direct attention away from the threat word, on all trials, the position of the neutral word will indicate the position of the probe.; Each trial begins with a fixation cross presented in the center of the computer screen for 500 ms. The cross is then replaced by a word pair presented in the center of the screen for 500 ms. The word pair disappears and a probe (i.e., the letter "E" or "F") appears immediately in the location of one of the two words. Participants will be instructed to decide whether the letter is an E or an F and press the corresponding mouse button. This paradigm is not intended to facilitate an attention bias away from threatening material. In this case, the probe randomly replaces the threat or neutral word.
Other intervention name(s): AMP, attention bias modification, attention training; ACC
Allocation: Randomized
Intervention model: Crossover Assignment
Masking: Quadruple (Participant, Care Provider, Investigator, Outcomes Assessor)
Primary purpose: Treatment
Keywords: obsessive compulsive disorder; children; adolescents; attention bias modification