SMART ERP for the Behavioral Treatment of Youth With Obsessive Compulsive Disorder (OCD)
Condition: Obsessive-Compulsive Disorder
MeSH terms: Compulsive Personality Disorder; Obsessive-Compulsive Disorder
Study type: Interventional

Summary: 
      This randomized pilot study examines a graduated behavioral treatment approach for youth with
      obsessive compulsive disorder. Youth will be randomized to receive treatment in the community
      or at the hospital. In the first stage, youth receive an intro session and two 3-hour ERP
      sessions. Youth will be assessed for OCD recovery. Recovered youth enter follow-up. Still
      affected youth enter the second stage, where they will can select to receive up to four
      additional ERP sessions (one per week). In follow-up, youth will receive three 30 minute
      weekly calls and will be reassessed at 1- and 6-months following treatment.
    

Detailed description: 
      Obsessive compulsive disorder (OCD) is a highly debilitating psychiatric disorder that
      affects many youth. Despite strong empirical support that exposure and response prevention
      (ERP) is an efficacious and tolerable treatment of pediatric OCD including when presented in
      intensive formats, most individuals simply do not access or receive this treatment.

      The dissemination of efficient interventions is of high public health priority, and
      graduated, or stepped care, models may be the answer. However, initial interventions within a
      graduated approach must be appropriate for the severity of the condition, given that
      unnecessary delays to an optimal dose may result in escalating burden on families and
      ultimately health services. Indeed, low intensity online CBT and self-help have so far had
      limited efficacy with less than one third of patients deemed responsive to treatment.

      In contrast, brief intensive ERP is likely an efficient and effective alternative to flexibly
      dosing the level of intervention to the participant's needs. In fact, a recent pilot study (n
      = 10) providing two 3-hour ERP sessions to youth with OCD observed 60% post-treatment, and
      70% 6-month follow-up, remission rates among participants. Extending on this study's
      findings, by utilizing more conservative remission criteria and providing access to
      additional doses of intensive ERP to youth not yet achieving remission, holds promise in
      identifying the level of services utilized by families to achieve meaningful treatment
      outcomes.

      Above and beyond the use of a graduated dose model, many questions remain regarding optimal
      implementation methods for the behavioral treatment of pediatric OCD. In particular, the
      impact of treatment setting (i.e. community versus clinic) on response has not been
      systematically studied within this population. Given increased setting relevance and
      opportunity for in vivo learning, community exposures may be expected to be more effective;
      however, as they are associated with additional challenges (e.g., transportation time), their
      contribution to improvement needs to be directly verified and weighed against these costs.

      Therefore, the present study seeks to determine the feasibility of implementing a sequential,
      multiple assignment, randomized trial (SMART) for the behavioral treatment of youth with OCD.
      The study focuses on evaluating the benefits from a minimum initial dose of intensive
      exposure and response prevention (ERP) as well as the demand for, and benefits from,
      additional ERP sessions by still-affected OCD families. In addition, via randomization, the
      study examines the influence of treatment setting (community vs hospital) on response.
      Primary outcomes include the impact of treatment on symptom severity and other relevant
      clinical outcomes (e.g., quality of life, youth- and family-functioning) as well as patient
      decisions/treatment utilization. Participant perspectives on study/treatment procedures
      (e.g., acceptability, optimal components) as well as cost-effectiveness (e.g., travel
      expenses, staff time, service utilization) will also be recorded.
    

Intervention name(s): Phase One: Standardized Brief Intensive ERP; Phase Two: Flexible Patient Driven Intensive ERP; Follow-Up Phase: Booster Calls
Intervention type(s): Behavioral; Behavioral; Behavioral
Intervention description(s): Participants will be randomized to receive ERP sessions at the hospital or at relevant community locations. In the introductory session, participants will be provided with psychoeducation about OCD and the treatment model, will develop a list of potential exposures, and will attempt initial exposure and response prevention (ERP) exercises. The session will end with an assignment of ERP homework. In the seven days following the introductory session, youth and parents will receive two 3-hour sessions, separated by a three day break. The sessions will begin with a brief review of homework completion and success. Following this, with parent observation, the clinician will guide the youth through escalating ERP exercises. The session will end with ERP homework planning. Other evidence-based treatment strategies (e.g., addressing motivation, discussing parental accommodations) may be implemented as deemed necessary by the clinician in order to encourage effective engagement in ERP exercises.; Families will have the opportunity to access up to four additional once/week 3-hour intensive ERP sessions.
Three days prior to each additional ERP session (sessions 3-6), families will be prompted to fill out online forms and decide how to proceed with treatment for that week with the following options:
They may select that they would like to receive and complete the next ERP session, and up to four 3-hour ERP sessions during Phase Two. Completion of all four ERP session will automatically end Phase Two.
They may opt to delay receiving a treatment session by one week for any reason. Families will be allowed to take a week off up to two times during Phase Two. If both weeks off are utilized, at the next decision point families must either opt to complete an ERP Session or end their participation in Phase Two.
They may select to end their participation in Phase Two at any decision point and for any reason (e.g., don't perceive it as helpful, have improved substantially).; Upon achieving remission at any remission assessment or completion of remission assessment five, youth will enter the follow-up phase. Youth will receive three weekly 30 minute post-treatment booster phone calls. Calls will focus on homework completion, ERP planning, and relapse prevention skills.
Allocation: Randomized
Intervention model: Parallel Assignment
Masking: Single (Outcomes Assessor)
Primary purpose: Treatment
Keywords: Exposure and Response prevention ERP; Cognitive-behavioural therapy; Pediatric OCD; Childhood-onset OCD