Journal of Obsessive-Compulsive and Related Disorders 26 (2020) 100552

Contents lists available at ScienceDirect

Journal of Obsessive-Compulsive and Related Disorders

journal homepage: www.elsevier.com/locate/jocrd

The effect of transdiagnostic emotion-focused treatment on obsessive- T

compulsive symptoms in children and adolescents
Ashley M. Shaw∗, Elizabeth R. Halliday, Jill Ehrenreich-May
University of Miami, Department of Psychology, 5665 Ponce de Leon Blvd, Coral Gables, FL, 33146, USA

A R T I C LE I N FO A B S T R A C T

Keywords: Obsessive-compulsive disorder (OCD) commonly onsets in childhood. Given OCD's high comorbidity with other
Obsessive-compulsive disorder emotional disorders (e.g., depression, anxiety), transdiagnostic treatment that aims to enhance youth's tolerance
Transdiagnostic and regulation of various negative emotions before starting exposure may facilitate simultaneous treatment of
Treatment engagement multiple comorbid symptoms. The current study examined the effects of transdiagnostic treatment in an open
Pediatric
trial of clinical youth. Children and adolescents (N = 170) with any primary emotional disorder (e.g., an an-
xiety, depressive, or obsessive-compulsive spectrum disorder) started Unified Protocols for Transdiagnostic
Treatment of Emotional Disorders in Children and Adolescents (UP–C/A) treatment. Youth (M age = 12; 50%
female) were primarily white and Hispanic/Latinx. Youth and their parent(s) completed an intake and follow-up
assessments (8, 16, and 24 weeks). The outcome measures were self- and parent-reported obsessive-compulsive
symptoms (OCS), treatment engagement, and client satisfaction. Over the course of the UP-C/A, youths' OCS
decreased significantly, across reporters, regardless of child age or gender. These findings provide preliminary
support for utilizing the UP-C/A to treat OCS in youth. While these results do not imply equivalence with
existent, exposure and response prevention treatments for pediatric OCD, it is possible that the flexible structure
of the UP-C/A may be applied successfully to OCS.

1. Introduction Storch et al., 2007; Wagner, 2003), which include psychoeducation

about OCD, cognitive restructuring, problem-solving, ERP, and relapse
Obsessive-compulsive disorder (OCD) is characterized by obsessions prevention. Family-based treatments for OCD have also been found to
and/or compulsions that are frequent, distressing and/or impairing be effective for youth, and indicate that the more family factors that are
(American Psychiatric Association, 2013). OCD and related disorders targeted, the greater reductions in family accommodation (McGrath &
(OCRDs), such as trichotillomania, excoriation, and hoarding, com- Abbott, 2019). Habit reversal therapy, which involves awareness
monly onset in youth, with an estimated 25–40% of cases exhibiting training, self-monitoring, and applying competing responses is com-
symptoms by age 14 (American Psychiatric Association, 2013; monly used for trichotillomania and excoriation disorder (Piacentini &
Attiullah, Eisen, & Rasmussen, 2000; Chabane et al., 2005). It is es- Chang, 2005).
sential to intervene early with OCD, as accommodation of rituals affects Although there are large effect sizes for the efficacy of cognitive-
the entire family (Wu et al., 2018) and 60% of childhood OCD cases behavioral treatment for pediatric OCD (McGuire et al., 2015), ap-
persist into adulthood (American Psychiatric Association, 2013). Ex- proximately 30–50% of youth who complete ERP respond only partially
posure and response prevention (ERP) is acknowledged as the frontline or not at all (Franklin et al., 2015). Due to the high comorbidity of OCD
treatment for OCD (Koran et al., 2007). Over the last two decades, with other emotional disorders across the lifespan (e.g., anxiety and
many cognitive-behavioral manuals specifically for pediatric OCD have depressive disorders; American Psychiatric Association, 2013; Geller,
been published (Franklin, Freeman, & March 2019; Freeman & Garcia, 2006; Ivarsson, Melin, & Wallin, 2008), research in adults has explored
2008; Kemp & Freeman, 2019; Piacentini, Langley, & Roblek, 2007; the utility of transdiagnostic, emotion-focused approaches for OCD.

Abbreviations: OCD, Obsessive-compulsive disorder; OCRDs, Obsessive compulsive and related disorders; ERP, Exposure and response prevention; GAD, Generalized
anxiety disorder; UP, Unified Protocol for Transdiagnostic Treatment of Emotional Disorders; UP-C/A, UP for Children and Adolescents; OCS, obsessive-compulsive
symptoms; RCADS, Revised Children's Anxiety and Depression Scale; ADIS, Anxiety Disorders Interview Schedule; CSR, Clinical Severity Rating; RMSEA, root mean
square error of approximation; CFI, comparative fit index; TLI, Tucker-Lewis Index
∗
Corresponding author. Florida International University, Center for Children and Families, 11200 SW 8th St., AHC 1, Miami, FL, 33199, USA.
E-mail addresses: asshaw@fiu.edu (A.M. Shaw), [email protected] (E.R. Halliday), [email protected] (J. Ehrenreich-May).

https://doi.org/10.1016/j.jocrd.2020.100552
Received 10 November 2019; Received in revised form 21 May 2020; Accepted 24 May 2020
Available online 12 June 2020
2211-3649/ © 2020 Elsevier Inc. All rights reserved.
A.M. Shaw, et al. Journal of Obsessive-Compulsive and Related Disorders 26 (2020) 100552

This is the first study to examine whether transdiagnostic, emotion-

UP-C/A treatment components and application to OCD. Note. UP-C/A = Unified Protocol for Transdiagnostic Treatment of Emotional Disorders in Children and Adolescents; OCD = obsessive-compulsive disorder.

Compulsions as “emotional behaviors; ” Cycle of avoidance applied to

focused treatment can alleviate obsessive-compulsive symptoms (OCS)

Reducing accommodation of OCD to decrease overprotection and

in youth with a range of emotional disorders.

Identifying physical sensations linked with intrusive thoughts

A major driving force for applying transdiagnostic treatments to

Thinking traps common to OCD (e.g., magical thinking)

OCD is that as many as 80% of youth with OCD experience a comorbid

Using nonjudgmental awareness to let obsessions pass

psychiatric disorder (Geller, 2006; Ivarsson et al., 2008). For example,
between one-fourth and three-fourths of youth with OCD also have an
anxiety disorder (Geller, 2006; Ivarsson et al., 2008; Langley, Lewin,
Bergman, Lee, & Piacentini, 2010; Reddy et al., 2000). Separation an-
Exposure with response prevention xiety disorder is the only anxiety disorder that is more prevalent in
youth (56% in children; 35% in teens) than adults with OCD (Geller,
Acting opposite to compulsions
Top Problems relevant to OCD

2006). Interestingly, the presence of co-occurring anxiety disorders in

obsessions & compulsions

pediatric OCD has been associated with better cognitive-behavioral

treatment outcomes in a recent meta-analysis (McGuire et al., 2015). Of
increase consistency
Application to OCD

greater concern is that over one-third of children with OCD experience

depression, and this comorbidity increases to 62% in adolescence
(Geller, 2006). A major difference between pediatric and adult OCD is
the common comorbidity of pediatric OCD with disruptive behavior
disorders, which are commonly associated with anger, irritability, and
impulsivity (Geller, 2006). Approximately half of youth with OCD also
have oppositional defiant disorder (Geller, 2006). About half of chil-
Criticism and empathy, consistency of rewards and punishment, emotional modeling,

dren and over one-third of adolescents with OCD experience attention

deficit/hyperactivity disorder (ADHD; Geller, 2006). A triad of OCD,
Psychoeducation about emotions, their function, and the cycle of avoidance

Identify emotional behaviors, rationale for exposures, situational exposures

ADHD, and Tourette's Syndrome is also extremely common, and poses

Awareness of physical sensations, body scanning, interoceptive exposures
Opposite action, activity tracking, emotion-focused behavior experiments

challenges in treatment (Geller, 2006). Overall, having more comorbid

disorders overall and having specific comorbid disorders (i.e., depres-
sion, oppositional defiant disorder, and/or ADHD) can make im-
plementing traditional ERP more challenging (Storch et al., 2008).
Transdiagnostic treatments may also be beneficial for pediatric OCD
Present-moment awareness, non-judgmental awareness

because OCD shares common vulnerabilities with depressive and an-

Thinking traps, detective thinking, problem-solving

xiety disorders, that can be targeted in these emotion-focused inter-

Set Top Problems and goals, explore motivation

ventions. Although there are several established specific risk factors for
overprotection and independence granting

OCD (e.g., thought-action fusion), transdiagnostic vulnerability factors

have also been implicated in pediatric OCD. For example, greater OCS
in youth have been linked to greater emotional lability (i.e., experien-
cing negative affect in an inflexible, dysregulated manner), less adap-
Review, relapse prevention

tive emotion regulation skills, and more use of emotional suppression

(i.e., inhibiting emotional expression; Berman, Shaw, Curley, &
Wilhelm, 2018). Distress tolerance and anxiety sensitivity have been
proposed as unique mechanisms that may account for comorbidity
between OCD and depressive symptoms in teenagers (Chasson, Bello,
Luxon, Graham, & Leventhal, 2017; Laposa, Collimore, Hawley, &
Content

Rector, 2015). Additionally, OCD and generalized anxiety disorder

(GAD) demonstrate similar deficits in cognitive flexibility (Kim et al.,
2019). There are also repetitive behaviors seen across emotional dis-
orders (e.g., OCD, depression, and GAD) that aim to reduce distress (at
least temporarily), which can often be challenging to parse out diag-
Typical # of

nostically, including reassurance seeking, question asking, and

Sessions

checking (Parrish & Radomsky, 2010). Over the last decade, trans-
1–2
2–3

1–2
1–2
2–3
1–2

1–3
2+

diagnostic, emotion-focused interventions have been developed to ad-

1

dress these underlying shared vulnerabilities (i.e., emotional lability,

Reviewing Accomplishments and Looking
Emotion-Focused Behavioral Experiments

emotional intolerance, emotional behaviors, and emotional avoidance).

In sum, transdiagnostic treatments that can target comorbid disorders
Parenting the Emotional Adolescents
Awareness of Emotional Experiences
Getting to Know Your Emotions and

and their shared vulnerabilities may be a more efficient treatment ap-

Awareness of Physical Sensations
Building and Keeping Motivation

Being Flexible in Your Thinking

Situational Emotion Exposures

proach for youth with OCD who experience comorbid disorders, rather
than conducting two or more distinct courses of treatment for each set
of symptoms.
For example, the Unified Protocol for Transdiagnostic Treatment of
Emotional Disorders (UP; Barlow et al., 2010; Barlow et al., 2018) has
demonstrated efficacy in treating anxiety and OCD in adults. The UP
Behaviors

approach offers some advantages over an OCD-specific approach in-

Ahead
Title

cluding opportunities to address co-occurring emotional disorders and

more time to build confidence and buy in before beginning exposures.
Module

Thus far, applying the UP to adults with OCD has demonstrated pro-
Table 1

mising results. In a multiple baseline study of adults with primary OCD

P
1
2

3
4
5
6
7
8

(n = 7; Allen & Barlow, 2009), UP skills, specifically emotion

2
A.M. Shaw, et al. Journal of Obsessive-Compulsive and Related Disorders 26 (2020) 100552

regulation training aimed at preventing emotional avoidance, enhan- work could be integrated into treatment at any point during individual
cing emotional awareness, and improving patients’ tolerance for un- treatment (Ehrenreich-May et al., 2018).
comfortable emotions, reduced OCS severity, yielding a stronger effect The efficacy of the UP-C/A has been tested in multiple trials with
on obsessions than compulsions. In a large-scale efficacy trial of the UP flexible inclusion criteria, supporting its use with a wide range and/or
for various emotional disorders, within the sub-sample of 33 adults with combination of emotional disorders (i.e., anxiety disorders, depressive
primary OCD, the UP was equally effective in treating OCD compared to disorders, OCD). The UP-C/A has demonstrated reductions in anxiety
ERP (Barlow et al., 2017). Across any emotional disorder, those who and depressive symptoms, with longer-lasting effects compared to a
received the UP were more likely to be treatment completers (≥75% of waitlist control condition (Bilek & Ehrenreich-May 2012; Ehrenreich,
sessions completed) than those in the single-disorder treatment condi- Goldstein, Wright, & Barlow, 2009; Ehrenreich-May et al., 2017; Queen,
tion (Barlow et al., 2017). Barlow, & Ehrenreich-May 2014; Trosper, Buzzella, Bennett, &
The Unified Protocols for Transdiagnostic Treatment of Emotional Ehrenreich, 2009). The UP-C was compared to an anxiety-focused
Disorders in Children and Adolescents (UP–C/A; Ehrenreich-May et al., cognitive-behavioral manual in a randomized controlled trial for youth
2018) apply the UP theoretical foundation and guiding treatment with principal emotional disorders, including OCD (Kennedy, Bilek, &
principles to youth. The UP-C/A address thoughts, sensations, and be- Ehrenreich-May 2019). Participants in both conditions showed sig-
haviors related to emotion-provoking situations in general emotion- nificant, equivalent changes in anxiety symptoms. Unfortunately, only a
focused language. Its overarching purpose is to target underlying me- small proportion of participants in these trials (0–13.56%) had a clin-
chanisms of emotional disorders, such as emotional reactivity, distress ical diagnosis of OCD and none of the studies examined change in OCS
tolerance, anxiety sensitivity, cognitive inflexibility, and emotional across treatment.
avoidance. Although Table 1 comprehensively discusses each treatment To date, no studies have examined whether the UP-C/A or any other
strategy used in the UP-C/A, opposite action, present-moment aware- transdiagnostic approach can be utilized to ameliorate subclinical and
ness, and nonjudgmental awareness are three techniques that may be clinical OCS in youth with emotional disorders. Additionally, no studies
particularly beneficial for preparing clients with OCS for exposure. have considered moderators of OCS symptom reduction during trans-
Opposite action was first described in dialectical behavior therapy as an diagnostic treatment. A recent meta-analysis reported equivalent effi-
emotion regulation strategy (Linehan, 1993), which encourages clients cacy of individual versus group cognitive behavioral therapy for OCD
who engage in maladaptive behaviors (e.g., self-injury, risky behaviors) (Ost, Riise, Wergeland, Hansen, & Kvale, 2016); thus we did not con-
during strong emotions to implement an alternative action that is more sider individual versus group treatment modality as a moderator. Given
in line with their values and less likely to lead to long-term problems. that OCD presents differently across genders and ages (e.g., age of
Similarly, in the UPs, patients are taught that, rather than acting in line onset, comorbidity patterns, symptom dimensions), we were particu-
with their emotion urges by engaging in certain emotional behaviors larly interested in whether the UP-C/A may differentially target OCS
(e.g., rituals, avoidance) that result in long-term consequences, they can across gender and age. We were interested in gender as a moderator due
engage in opposite actions (e.g., nonjudgmental awareness, ap- to previous mixed findings on symptom remission in boys versus girls
proaching the feared situation). While ERP focuses on response pre- (Ginsburg, Kingery, Drake, & Grados, 2008; Rudy, Lewin, Geffken,
vention, opposite action focuses more on response substitution, similar to Murphy, & Storch, 2014; Stewart, Yen, Stack, & Jenike, 2006). We also
the behavioral principles of competing response training (i.e., habit considered whether child age moderated treatment effects. One pre-
reversal training). Thus, patients with OCS are taught to engage in an vious study found that younger children had more positive treatment
alternative behavior or strategy instead of the ritual. This allows a client outcomes (Torp et al., 2015). Examining age as a moderator of treat-
with OCS to first experiment with engaging in an alternative action ment outcome can help clarify whether the two developmental itera-
when an obsession or urge to ritualize arises, and later move towards tions, the UP-C (generally used for youth 12 and under) and UP-A
exposures more formally. This differs from habit reversal such that the (generally used for youth 12 and older), work equally well at targeting
alternative strategy does not necessarily need to be a competing motor OCS.
response, but could also be an alternative coping behavior, such as a The current study utilized a sample of youth with a range of emo-
cognitive strategy like nonjudgmental emotional awareness (i.e., pic- tional disorders (including anxiety, depression, and OCRDs) rather than
turing one's thoughts come and go by visualizing an image such as limiting the sample to youth with an OCD diagnosis, and studied OCS
leaves moving along a stream). The UP-C/A also aims to enhance dis- along a continuum. This sampling approach was utilized (1) given re-
tress tolerance, largely through encouraging mindful emotional commendations to examine OCS across a range of severity, (2) because
awareness. Specifically, children are taught to practice present-moment more than one-third of youth in the general population experience
awareness by learning techniques to bring themselves back to the here subthreshold OCS, (3) since greater OCS are associated with higher
and now, whenever their mind is pulled to concerns from the past or rates of depression, and (4) because almost 16% of youth with principal
fears about the future. They are also taught nonjudgmental awareness, GAD diagnoses have comorbid OCD (Abramowitz et al., 2014; Barzilay
which teaches them to allow their feelings, thoughts, body sensations, et al., 2019; Comer, Pincus, & Hofmann, 2012). Self and parent-re-
and behavioral urges to come and go without acting on them. ported OCS, rather than a categorical diagnostic variable, were selected
Like many established interventions for OCD, the UP-C/A empha- as the major outcome variables of interest, given growing emphasis on
sizes parental involvement. When UP-C is conducted as a group inter- incorporating dimensional measures into pediatric OCD research (e.g.,
vention, a parent group is conducted simultaneously with the child Ivarsson et al., 2008). We utilized a multi-informant approach to ex-
group. When UP-C or UP-A are conducted individually, it is at the amine change in OCS over the course of UP-C/A treatment (at eight
therapist's discretion how often to include family members in treat- weeks, 16 weeks, and 24 weeks) across youth (Aim 1) and parent (Aim
ment. Generally, in individual UP-C/A treatment, parents are involved 2) reports. For Aim 3, we considered whether gender and age moder-
in every session for at least five to 10 minutes, and likely longer for ated UP-C/A treatment effects. Given previous research, we hypothe-
younger children. Additionally, it is recommended to do at least one to sized that younger children (under 12) would have more positive out-
two parent-only sessions, to teach parents about “emotional parenting comes (Torp et al., 2015). We had no predictions about gender
behaviors,” “opposite parenting behaviors,” and monitoring their re- differences due to lack of consensus in the literature. Our final aim (Aim
sponses to their child's distress. One of the emotional parenting beha- 4) considered whether individuals with an OCRD diagnosis differed
viors targeted in the UP-C/A that is most relevant for OCD is over- from those without an OCRD diagnosis in terms of treatment engage-
protection/over-control. Within this domain, parents are encouraged to ment (number of sessions, drop-out rates) and satisfaction (youth and
reduce accommodation related to anxiety, depression, and OCS. In the parent report). We predicted that patients with OCRDs would be
UP-C group, over-protection is covered in Session 6, but this parent equally engaged and satisfied as patients without an OCRD.

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A.M. Shaw, et al. Journal of Obsessive-Compulsive and Related Disorders 26 (2020) 100552

Fig. 1. Consort diagram.

2. Material and methods premature termination as ending treatment prior to reaching Module 7
(situational exposure). Approximately one-fifth of subjects (n = 36)
2.1. Participants ended treatment prematurely. The modalities of treatment utilized in-
cluded: individual UP-A (41.2%), individual UP-C (28.8%), group UP-C
Treatment-seeking youth (N = 463) ages 5 to 18 and their parent(s) (24.1%), and group UP-A (2.9%). On average, youth attended almost
presented for and completed an initial, pre-treatment evaluation at a 14 therapy sessions (SD = 6.77, Range = 1–37). Participants reported
university research clinic for youth with emotional disorders. Youth the following races: 90.0% White, 3.5% Asian, 1.8% Black, and 4.7%
were deemed eligible to receive UP-C or UP-A treatment in the clinic if Other (e.g., more than one race). Furthermore, 73.5% of our sample
they (1) had a primary diagnosis of an emotional disorder (i.e., anxiety, reported being of Hispanic/Latinx descent, which is representative of
depressive, OCRD, traumatic-stress, or tic disorder), (2) were proficient the larger urban and suburban community in which the study was
in English, and (3) had a parent willing to participate in treatment. conducted. Participants were 12.3 years old on average (SD = 2.97).
Youth with co-occurring diagnoses, such as ADHD, oppositional defiant Almost one-third of youth were taking a psychotropic medication, most
disorder, and autism spectrum disorder were eligible, provided that the commonly a stimulant (n = 26) or a selective-serotonin reuptake in-
emotional disorder was primary. There was no exclusion based on hibitor (n = 15). Average yearly family income was over $126,000.
psychotropic medication or previous cognitive-behavioral therapy. A All participants and their parent(s) completed a diagnostic inter-
consort diagram (Fig. 1) presents full details about study exclusion. We view: 85.3% completed the Anxiety Disorders Interview Schedule Child
excluded subjects without a psychiatric diagnosis or a primary emo- and Parent Versions for DSM-IV or DSM-5 (ADIS IV or 5 C/P; Silverman
tional disorder. Youth with bipolar disorder, severe suicidal ideation, & Albano, 1996) whereas 14.7% completed the MINI International
severe cognitive impairment (i.e., suspected IQ below 80), or with Neuropsychiatric Interview Kid (MINI-Kid) and Parent Versions
treatment-interfering substance use were excluded. Since one of the (Sheehan et al., 2010). Principal diagnoses of the sample included GAD
main outcome measures of the current study, the Revised Children's (41.2%, n = 70), co-principal diagnoses (e.g., persistent depressive
Anxiety and Depression Scale – Child Report (RCADS-C) has only been disorder and social anxiety disorder; 21.8%, n = 37), social anxiety
validated in youth eight and older (Chorpita, Yim, Moffitt, Umemoto, & disorder (10.0%, n = 17), specific phobia (4.1%, n = 7), separation
Francis, 2000), youth under age eight were excluded from the current anxiety disorder (4.1%, n = 7), OCD (3.5%, n = 6), other specified
study. Ineligible youth and their families were provided referrals to anxiety disorder (2.3%, n = 4), persistent depressive disorder (1.8%,
community providers. n = 3), major depressive disorder (1.8%, n = 3), trichotillomania
A portion of eligible subjects (N = 178) started UP-C or UP-A (1.8%, n = 3), disruptive mood dysregulation disorder (1.2%, n = 2),
treatment. The database included eight sibling pairs. Since siblings other-specified depressive disorder (1.2%, n = 2), panic disorder
would be expected to have more similar ratings with each other than (1.2%, n = 2), agoraphobia (1.2%, n = 2), selective mutism (0.6%,
other youth in the sample, only the sibling with the most comprehen- n = 1), illness anxiety disorder (0.6%, n = 1), provisional hoarding
sive data was included (n = 8 members of sibling pairs excluded). disorder (0.6%, n = 1), posttraumatic stress disorder (0.6%, n = 1), or
The final sample consisted of 170 youth (50.0% female). Among persistent motor tic disorder (0.6%, n = 1). In terms of OCRDs, 7.7% of
these subjects, 136 (80.0%) completed at least eight UP-C/A sessions the sample met diagnostic criteria for OCD and 3.5% met diagnostic
(i.e., were deemed as “completers” for analyses). We also examined the criteria for an OCRD (e.g., trichotillomania or hoarding). An additional
percentage of subjects who ended treatment prematurely. We defined 4.8% of subjects were noted by an independent evaluator to have

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A.M. Shaw, et al. Journal of Obsessive-Compulsive and Related Disorders 26 (2020) 100552

subclinical OCS, as indicated by a clinical severity rating (CSR) of be- Salemink, Wolters, & de Haan, 2015; Van Oort, Greaves-Lord, Verhulst,
tween 1 and 3 (on a 0 to 8 scale) on the diagnostic interview. Ap- Ormel, & Huizink, 2009). The RCADS-C/P have six subscales: OCD,
proximately 8.8% were noted to have a “rule-out” of OCD at baseline. A separation anxiety, social anxiety, GAD, panic disorder, and major de-
rule-out was assigned when either the child or parent endorsed OC pressive disorder, although only the 6-item OCD subscale was utilized
symptomatology, but either important information was missing (i.e., in the current report. Youth and their parent report how often each item
the child's endorsement of obsessions driving the compulsions) or the applies to them on a scale from 0 (never) to 3 (always). Psychometric
reports between child and parent were so discrepant that the assessor properties for both measures have been established in community and
elected to obtain more information during treatment before assigning clinical samples (Chorpita et al., 2000; Chorpita, Moffitt, & Gray, 2005;
or ruling out the diagnosis. Approximately three percent of youth met Ebesutani et al., 2010). The RCADS has also been found to be sensitive
criteria for a tic disorder. to change across interventions (Kosters, Chinapaw, Zwaanswijk, van
der Wal, & Koot, 2015). In the current study, internal consistency for
2.2. Procedure the RCADS-OCD subscales at baseline were 0.80 (parent) and 0.81
(child). In this sample, the RCADS demonstrated convergent validity
Prior to completing data collection, we obtained approval from the with the independent evaluator rated OCD CSR (Child: r = 0.30,
University's Institutional Review Board. All parents and youth provided p < .001; Parent: r = 0.39, p < .001).
written informed consent and assent, respectively, before completing The Client Satisfaction Questionnaire (CSQ) is an 8-item survey
any study procedures. We administered diagnostic interviews and adapted for this study to assess child and parent treatment satisfaction
questionnaires at participants' baseline assessment. We then followed (Larsen, Attkisson, Hargreaves, & Nguyen, 1979). We ask participants,
eligible participants who accepted treatment throughout the course of for example, about the degree to which they feel their needs have been
treatment by collecting measures again eight weeks after their first met and if they would recommend the treatment to a friend. There are
treatment session (mid-treatment), 16 weeks after their first treatment four answer choices (e.g., “No definitely not,” “No I don't think so,”
session (post-treatment), and 24 weeks after their first treatment session “Yes I think so,” or “Yes definitely”) for each question, which differ
(follow-up). Families paid for the baseline assessment, which also depending on the question. Items of negative valence are reversed
served as a clinical intake and included diagnostic impressions and scored. The self (α = 0.94) and parent-report (α = 0.87) CSQ de-
treatment recommendations. Families who completed follow-up as- monstrated very good reliability in the current study.
sessments at eight, 16, and 24 weeks were offered either a free therapy
session and a $5 gift card or a $25 gift card for each time-point. A brief 2.4. Data analytic approach
description of the UP-C/A treatment components, and applications to
OCD, are highlighted in Table 1. Missing data for the intent-to-treat sample ranged from 8% (base-
line) to 74% (follow-up). Little's Missing Completely at Random Test
2.3. Measures indicated that data were not missing at random, χ2 (234) = 291.70,
p = .006. This was unsurprising, given that there was substantially
The Anxiety Disorders Interview Schedule, Child Version, Child and more missing data for the 24-week follow-up than all other time-points.
Parent Report The large majority of missing data were due to procedural changes over
(ADIS-IV and 5-C/P; Silverman & Albano, 1996). Youth and their the five-year course of the study. For example, the RCADS was not
parent(s) were interviewed separately using the ADIS-IV or 5-C/P, administered at the 8-week assessment until June 2017 and neither
which are three-to four-hour semi-structured interviews that facilitate follow-up nor client satisfaction data were collected early in the study.
diagnosis of internalizing and externalizing disorders in youth ages In terms of correlates of missingness, the earlier the assessment in time,
seven to 18 years old. The ADIS-5-C/P was adapted from the ADIS-IV- the more likely that self-reported RCADS data at 8-week was missing
C/P to diagnose DSM-5 depressive and anxiety disorders. The ADIS-IV- (r = −0.20). Notably, we originally did not request data from families
C/P has demonstrated excellent inter-rater reliability for principal and after they ended treatment, so we do not have complete follow-up data
anxiety disorder diagnoses, and good inter-rater reliability for comorbid on families who ended or withdrew from treatment prior to week 24.
diagnoses (κ = .65–.77; Lyneham, Abbott, & Rapee, 2007). ADIS-5-C/P Other reasons for missing data included (1) dropping out of treatment
psychometrics are currently under investigation; however, the items and asking to no longer be contacted, (2) non-response to our survey
and structure of this version are similar to those of the ADIS-IV-C/P. request, or (3) referral to a different intervention.
CSRs for each diagnosis were assessed using a scale that ranged from 0 To account for missing data for longitudinal aims 1 through 3,
to 8, with ratings of 4 or higher indicating clinically-significant im- Mplus statistical software version 8 was utilized, incorporating max-
pairment for a given disorder. Our clinical research program has es- imum likelihood estimation with robust standard errors, which pro-
tablished very good interrater agreement for principal diagnoses and vides accurate standard errors even when there are missing data
CSRs (κ = 0.82; Ehrenreich-May et al., 2017). (Muthen & Muthen, 1998). These analyses were conducted using latent
The Mini-International Neuropsychiatric Interview for Children and growth models (LGM) to examine change over time in RCADS-OCD data
Adolescents (MINI-Kid; Sheehan et al., 2010) is a structured diagnostic from baseline across three follow-up time-points measured every eight
interview for DSM-5 mental disorders in youth ages six to 17. Youth and weeks (Kline, 2011). Structural equation modeling was selected over
their parent(s) were interviewed separately and CSRs were obtained to hierarchical linear modeling to allow us to evaluate model fit (Kline,
establish clinical severity of endorsed diagnoses, to parallel procedures 2011). To assess model fit, several indices were used including chi-
we utilized with the ADIS. The interview is divided into diagnosis- square test of exact fit, root mean square error of approximation
specific modules with screening questions. The MINI-KID takes ap- (RMSEA), the comparative fit index (CFI), and the Tucker-Lewis Index
proximately 90–120 minutes to administer. Interrater reliability has (TLI). A non-significant chi-square test of exact fit is indicative of a
been found to be excellent (Sheehan et al., 2010). We reviewed and well-fitting model (Bentler & Bonett, 1980). The RMSEA is a measure of
finalized all diagnoses and CSRs during a weekly diagnostic consensus poor model fit, with values greater than 0.10 indicating poor model fit,
meeting led by a doctoral-level clinician. 0.08 to 0.05 indicating mediocre model fit, and below 0.05 indicating
The Revised Children's Anxiety and Depression Scale-Child and Parent close model fit (Hu & Bentler, 1999). The CFI and TLI result in values
Reports (RCADS-C/P; Chorpita et al., 2000; Ebesutani et al., 2010) are ranging from 0 to 1, with values greater than 0.90 indicating adequate
47-item self and parent-report measures, respectively, that measure model fit, and greater than 0.95 indicating good model fit (Hu &
internalizing symptoms in youth. The RCADS is a commonly used Bentler, 1999).
outcome measure for pediatric OCD research (e.g., Chasson et al., 2017; Analyses for Aim 4 were conducted in SPSS Version 24 using t-tests

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A.M. Shaw, et al. Journal of Obsessive-Compulsive and Related Disorders 26 (2020) 100552

and chi-square difference tests. Youth were coded as having a clinically- 3.2. Aim 1: change in youth-reported RCADS-OCD over the course of UP-
significant OCRD if they met criteria for OCD, trichotillomania, and/or C/A treatment
hoarding on the ADIS or MINI (based on a CSR greater than or equal to
4) or if the independent evaluator noted a rule-out of OCD based on Using LGM, we examined a path diagram modeling a linear effect
information obtained during the diagnostic interview. for change over time in self-reported RCADS-OCD scores through 24
weeks (Fig. 3). However, the proposed functional form was not con-
sistent with the data in either the intent-to-treat (χ2 (7) = 26.62,
3. Results p < .001; RMSEA = 0.13; CFI = 0.83; TLI = 0.86) or the completers
(χ2 (7) = 24.60, p < .001; RMSEA = 0.14; CFI = 0.85; TLI = 0.88)
3.1. Preliminary analyses sample. No modification indices were suggested.
Since missing data was most extensive for self-reported RCADS-OCD
To better understand the generalizability of our sample, we com- at follow-up (74% of data missing), we examined a path diagram
pared those who started their first treatment session (n = 178), to those modeling a linear effect for change over time excluding the follow-up
who were referred out (i.e., n = 125; those who were deemed too se- timepoint (Fig. 4). This proposed functional form was consistent with
vere or inappropriate for the UP-C/A, those who opted for private the data in the intent-to-treat sample (χ2 (1) = 0.09, p = .76;
treatment, or those who were treated with another intervention). Using RMSEA = 0.00; CFI = 1.00; TLI = 1.00). For every eight weeks up
a series of t-tests, we compared subjects on age, clinical severity, OCS through 16 weeks, there was a significant decline of 0.22 units
severity (independent-evaluator, self, and parent rated), and number of (SE = 0.04, p < .001) in self-reported RCADS-OCD scores. Adoles-
clinical diagnoses. Subjects who started UP-C/A treatment did not differ cents with greater self-reported OCS at baseline exhibited steeper de-
from those who were referred out on age, overall clinical severity, self clines in self-reported OCS across treatment (B = −0.56, SE = 0.13,
or parent-rated RCADS-OCD, or number of clinical diagnoses (all p < .001). See Table 3 for additional parameters of treatment effects.
p's > .10). However, at pre-treatment, those who were referred out Notably, there was significant variability in individuals’ rate of change
(M = 1.39, SD = 2.43, Range = 0–7) were rated by an independent over treatment.
evaluator as experiencing significantly more severe OCD than those We conducted the same modified model for the completer sample;
who started UP-C/A treatment (M = 0.52, SD = 1.47, Range = 0–6), t the proposed functional form was consistent with the data (χ2
(308) = −3.90, p < .001. (1) = 0.004, p = .95; RMSEA = 0.00; CFI = 1.00; TLI = 1.00). For
Descriptive statistics for primary variables (across reporters and every eight weeks up through 16 weeks, there was a significant decline
timepoints) are included in Table 2. Fig. 2 depicts change over time in of 0.21 units (SE = 0.04, p < .001) in self-reported RCADS-OCD
RCADS-OCD scores. Within our sample, baseline RCADS-OCD were scores. Adolescents with greater self-reported OCS at baseline experi-
elevated in comparison to previous samples of clinical youth (Chorpita enced steeper declines in self-reported OCS across treatment
et al., 2005) and a community sample of school-aged children (Muris & (B = −0.53, SE = 0.14, p < .001). See Table 3 for parameters of
Meesters, 2002). Notably, 35.3% of youth scored above the proposed treatment effects. In the completer sample, there was not significant
clinical cut-off score (raw score of 5) on the RCADS-OCD child report variability in self-reported RCADS-OCD scores across treatment, sug-
(Chorpita et al., 2005), suggesting that a substantial portion of youth in gesting that the rate of change in self-reported RCADS-OCD was fairly
our sample endorsed self-reported OC symptomatology. By follow-up, homogeneous across the completer sample.
both self- and parent-reported RCADS-OCD scores were similar to mean
scores for nonclinical school aged children (Muris & Meesters, 2002).
Child- and parent-reported RCADS-OCD scores at baseline were mod- 3.3. Aim 2: change in parent-reported RCADS-OCD over the course of UP-
erately correlated (r = 0.31, p < .001). C/A treatment
Examination of the data suggested that two of the variables
(RCADS-OCD parent-report at eight and 16 weeks) violated normality Using LGM, we examined a path diagram modeling a linear effect
assumptions, and were positively skewed and leptokurtic (Kline, 2011). for change over time in parent-reported RCADS-OCD scores through 24
For consistency, we conducted a transformation on all RCADS-OCD weeks (Fig. 3). For the intent-to-treat sample, the proposed functional
scores, by adding a constant of one to all scores, and applying a square form was consistent with the data (χ2 (7) = 7.21, p = .41;
root transformation, a recommended approach to addressing positive RMSEA = 0.01; CFI = 1.00; TLI = 1.00). Every eight weeks up to 24
skew (Kline, 2011). weeks, parent-reported RCADS-OCD scores significantly decreased by
0.14 units (SE = 0.02, p < .001). Adolescents with greater parent-
reported OCS at baseline exhibited steeper declines in parent-reported
OCS across treatment (B = −0.65, SE = 0.17, p < .001). See Table 3
Table 2
Descriptive statistics for primary variables across reporters and timepoints. for parameters of treatment effects. There was not significant variability
in parent-reported RCADS-OCD scores across treatment, suggesting that
N M (SD) Range Skew Kurtosis
the rate of change in parent-reported RCADS-OCD was fairly homo-
RCADS-OCD SR BL 157 4.32 (3.97) 0–18 1.35 2.05 geneous across the sample.
RCADS-OCD SR Mid 71 3.45 (4.06) 0–18 1.60 2.43 Next, we examined a linear effect for change over time in parent-
RCADS-OCD SR Post 94 2.83 (3.80) 0–18 1.80 3.82 reported RCADS-OCD scores in the completers sample; the proposed
RCADS-OCD SR FU 44 2.52 (2.98) 0–12 1.22 1.11 functional form was consistent with the data (χ2 (7) = 7.48, p = .38;
RCADS-OCD PR BL 156 2.64 (3.31) 0–17 2.01 4.64
RCADS-OCD PR Mid 76 1.95 (2.71) 0–17 3.02 12.79
RMSEA = 0.02; CFI = 1.00; TLI = 1.00). Every eight weeks up
RCADS-OCD PR Post 106 1.40 (2.09) 0–13 2.46 8.81 through 24 weeks, RCADS-OCD scores significantly decreased by 0.14
RCADS-OCD PR FU 51 1.29 (2.07) 0–8 1.96 3.21 units (SE = 0.02, p < .001). Adolescents with greater parent-reported
CSQ SR Post 68 27.00 (5.17) 8–32 −1.59 3.16 OCS at baseline exhibited steeper declines in parent-reported youth
CSQ PR Post 74 28.91 (3.27) 20–32 −1.00 −0.12
OCS across treatment (B = −0.62, SE = 0.20, p = .002). See Table 3
Note. RCADS = Revised Child Anxiety and Depression Scale; OCD = Obsessive- for parameters of treatment effects. Again, there was not significant
Compulsive Disorder; SR = Self-report; PR = Parent-report; BL = Baseline; variability in parent-reported RCADS-OCD scores during treatment.
Mid = Mid-point assessment 8 weeks into treatment; Post = Post-treatment
assessment 16 weeks into treatment; FU = Follow-up assessment 24 weeks into
treatment; CSQ = Client Satisfaction Questionnaire.

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A.M. Shaw, et al. Journal of Obsessive-Compulsive and Related Disorders 26 (2020) 100552

Fig. 2. Change over time in RCADS-OCD scores.

Note. RCADS-OCD = Revised Children's Anxiety and Depression Scale-Child and Parent Report obsessive-compulsive disorder subscale; Wk = Week.

Table 3
Parameters for treatment effects: Fixed (mean) and random (variance) effects.
Variable Sample (N) Mean Variance

Aim 1 Final Model Intent-to-Treat (170)

Baseline 2.16*** .63***
Treatment (w/o FU) -0.22*** .13*
Aim 1 Final Model Completers (136)
Baseline 2.15*** .62***
Treatment (w/o FU) -0.21*** .11
Aim 2 Model Intent-to-Treat (170)
Baseline 1.76*** .34***
Treatment −0.14*** .01
Aim 2 Model Completers (136)
Baseline 1.74*** .32***
Treatment −0.14*** .01
Fig. 3. Path diagram of the Proposed Linear Effect of Change in Obsessive-
Compulsive Symptoms Across All Time-points. ***p < .001.
Note. RCADS-OCD = Revised Children's Anxiety and Depression Scale-Child **p < .01.
and Parent Report obsessive-compulsive disorder subscale. *p < .05.
Note. w/o FU = Treatment Effect without the Follow-up Timepoint.

gender onto the treatment latent variable. The interaction effect was
not significant (b = 0.10, SE = 0.07, p = .16), which indicates that
males and females had similar rates of improvement across UP-C/A
treatment. Next, to examine age as a moderator, we regressed age onto
the treatment latent variable. The interaction effect was not significant
(b = 0.04, SE = 0.08, p = .61), which indicates that younger (under
12; receiving UP-C) and older children (12 and older; receiving UP-A)
had similar rates of improvement.

Fig. 4. Revised Path Diagram of the Proposed Linear Effect of Change in Self- 3.5. Aim 4: treatment engagement and satisfaction in those with and
reported Obsessive-Compulsive Symptoms across Baseline, Mid-treatment, and without OCRDs
Post-treatment.
Note. RCADS-OCD = Revised Children's Anxiety and Depression Scale-Child To understand whether UP-C/A treatment is acceptable to youth
and Parent Report obsessive-compulsive disorder subscale. with OCRDs, we compared youth with (n = 30) and without (n = 140)
OCRDs on treatment engagement (number of sessions attended, pre-
3.4. Aim 3: moderators of change in self-reported RCADS-OCD across mature drop-out, treatment completion) and satisfaction. As predicted,
16 weeks of treatment youth with OCRDs did not differ from youth without OCRDs in terms of
number of sessions, drop-out/completion rates, or treatment satisfac-
Since there was significant variability during the treatment phase tion (Table 4). We also conducted analyses comparing those with
for self-reported OCS in the intent-to-treat sample, we next examined (n = 13) and without (n = 157) an OCD diagnosis, and results were
whether the rate of change (slope) of self-reported OCS between base- similar, with no significant differences between groups. In subjects with
line and 16 weeks differed as a function of gender or age (below or an OCD diagnosis, almost 17 sessions were completed, 92% completed
above 12 years old). To examine gender as a moderator, we regressed at least eight sessions, and 23% dropped out prematurely.

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A.M. Shaw, et al. Journal of Obsessive-Compulsive and Related Disorders 26 (2020) 100552

Table 4 However, qualitative feedback from the participants with OCD in-
Comparison of Treatment Engagement and Satisfaction in those with and dicated that opposite action, nonjudgmental awareness, and present-
without OCRDs. moment awareness were particularly beneficial. Opposite action is in-
Subjects with Non-OCRD Statistic troduced in Module 3 and may be a good first step for patients with OCS
OCRDs Subjects who feel unprepared to engage in full response prevention, without
some sort of coping skill or specific action to do instead. For example,
Number of Sessions 14.38 (6.82) 13.82 (6.86) t (161) = −0.40
for an 11-year-old client with OCD who texted her Mom repeatedly
% Drop Before 30% 29% χ2 (1) = 0.00
Exposure throughout the school day to check on her to make sure she was OK, her
% Completers 81% 79% χ2 (1) = 0.07 opposite action included chatting with her friends at school when she
Satisfaction (SR) 24.08 (7.04) 27.83 (4.30) t (14.27) = 1.84 had the urge to engage in this checking compulsion. Additionally,
Satisfaction (PR) 28.08 (3.68) 29.15 (3.16) t (71) = 1.08
several clients felt that Module 6 skills (i.e., nonjudgmental and pre-
sent-moment awareness) were particularly helpful in letting obsessions
Note. OCRDs = Obsessive-Compulsive and Related Disorders; SR = Self-report;
PR = Parent-report; % Completers = the percentage of youth who completed pass without engaging in a compulsion. Fortunately, based on an up-
at least eight sessions. For the analysis comparing subjects with and without dated edition of one gold standard treatment approach to pediatric OCD
OCRDs on self-reported treatment satisfaction, Levene's test for equality of (Franklin et al., 2019), it is clear that the pediatric OCD field is be-
variances was significant, and thus the statistic when equal variances are not ginning to recognize the promise of acceptance-based strategies (i.e.,
assumed is reported here. “Letting Obsessions Go”) for youth with OCD.
Given established gender and developmental differences in OCD
4. Discussion across childhood and adolescence (Ginsburg et al., 2008; Rudy et al.,
2014; Stewart et al., 2006), we examined whether gender or age
This represents the first study to examine the utility and accept- moderated change in OCS across treatment. Consistent with previous
ability of the UP-C/A for OCRDs. The current study expanded on pre- literature that examined predictors of treatment response in pediatric
vious efficacy research on the UP-C/A for youth with mood and anxiety OCD (Ginsburg et al., 2008), neither gender nor age moderated treat-
disorders (Ehrenreich-May et al., 2017; Kennedy et al., 2019), by un- ment effects. Our findings contrast one previous study (Torp et al.,
derscoring the applicability of the UP-C/A for youth with OCS. In line 2015) and our original prediction that children would benefit more
with predictions, we found that the UP-C/A led to significant reductions than adolescents. Despite this unexpected finding, it is promising that
in self- and parent-reported OCS. The trajectory of change was linear, the UP-C and UP-A appear to be equally beneficial for ameliorating
indicating that symptoms steadily reduced across eight and 16 weeks. OCS, no matter the developmental level of the child.
Parents reported that youth continued to improve at the 24-week Our final aim examined the acceptability of the UP-C/A for OCD and
follow-up. Neither age nor gender moderated change trajectories, in- related disorders, by examining treatment engagement and satisfaction.
dicating that children, adolescents, girls, and boys all benefited equally Although OCD, but not anxiety or depression, has been found to predict
from the intervention. There were no significant differences between prolonged treatment duration and treatments often last up to 20 ses-
youth with and without OCRDs (or those with and without OCD) in sions (Bernaldo-de-Quiros et al., 2015; Koran et al., 2007), we found
treatment engagement (number of sessions attended or premature drop- that youth with OCRDs attended a similar number of sessions as youth
out) or satisfaction. Overall, this open trial provides preliminary evi- without OCRDs. Given that youth exhibited significant reductions in
dence that the UP-C/A may be effective and acceptable when applied to OCS by eight weeks and average duration of treatment was 14–17
OCRDs. sessions (14 for youth with any OCRD and 17 for youth with OCD), UP-
Our primary aims utilized a multi-informant approach to examine C/A could present a first step in stepped care for youth with OCRDs,
change in OCS across UP-C/A treatment. Youth reported significant, whereby any youth who does not respond to UP-C/A would step up to
steady reductions in OCS across eight and 16 weeks of treatment. more intensive ERP. The equivalent number of sessions, rates of treat-
Unfortunately, substantial missing data for youth at follow-up pre- ment completion, and rates of treatment drop-out between those with
cluded including the 24-week timepoint in LGM analyses. However, and without OCRD highlight the high levels of treatment engagement
graphically (Fig. 2), youth appeared to report a similar change trajec- for youth with OCRDs. Approximately four-fifths of youth with any
tory as parents, with OCS continuing to decline between 16 and 24 OCRD and 92% of youth with OCD completed at least eight sessions and
weeks. Given that the average number of sessions was 14, it is notable less than a third of youth with any OCRD and less than one-fourth of
that OCS continued to improve further after treatment for most youth youth with OCD ended treatment prematurely. Youth and parents of
had ended. Most widely used evidence-based interventions for pediatric youth with OCRDs were also equally satisfied with treatment, when
OCD (e.g., March 1998) focus heavily on situational exposure, with compared to youth and parents of youth without OCRDs. Overall, the
some focus on cognitive restructuring. The finding that there was sig- UP-C/A appears to have equivalent engagement and satisfaction, re-
nificant reduction in OCS by eight weeks suggests that youth benefitted gardless of the presence of an OCRD diagnosis.
substantially from both early (e.g., motivation, emotion education, This research has implications for dissemination of effective inter-
opposite action, and interoceptive exposure) and later (e.g., problem- ventions to providers in the community. Another major rationale for the
solving, cognitive restructuring, emotional awareness, situational ex- UPs is to reduce therapist barriers to administering evidence-based
posure) UP-C/A skills. Although much of Modules 5 through 8 overlap approaches, by developing interventions that can be flexibly applied to
with established OCD interventions (e.g., cognitive restructuring, ERP), a wide range of children and adolescents. Unless patients present to a
the finding that youth may have benefitted from Modules 1 through 4 specialty OCD program, their therapist may not have training in ERP.
content is novel. However, the modularity and flexibility with which Community therapists report that concerns about treatment attrition
the UP-C/A can be applied suggests the possibility that the order that and satisfaction make them less likely to treat pediatric OCD using ERP
intervention components were applied could have varied across parti- (McGuire, Wu, Choy, & Piacentini, 2018). Therapists also commonly
cipants. For example, even though situational exposure is not formally report fears about leading exposures and managing their client's distress
introduced until Module 7, one-third of the participants with a clinical (Gillihan, Williams, Malcoun, Yadin, & Foa, 2012; Pittig, Kotter, &
diagnosis of OCD completed at least one exposure related to OCS within Hoyer, 2019). Training therapists in a transdiagnostic approach that
the first eight weeks of treatment. teaches a range of emotion regulation skills prior to exposure may be an
Unfortunately, due to the design of the study, we cannot confirm the acceptable and efficient alternative to address these therapist barriers
efficacy of specific UP-C/A skills for OCD. Future research is warranted to implementing evidence-based treatment for OCD in the community.
to clarify which UP-C/A skills are most beneficial to youth with OCRDs. Despite its implications, the current study should be interpreted in

8
A.M. Shaw, et al. Journal of Obsessive-Compulsive and Related Disorders 26 (2020) 100552

light of several methodological limitations. First, we did not include a community providers express concerns about primarily exposure-based
comparison group or a waitlist control, which precludes confirming the interventions (Pittig et al., 2019), future implementation work should
efficacy of the UP-C/A in comparison to no treatment or an alternative also examine whether the UP-C/A is more acceptable to community
treatment. Second, although we addressed missing data by using providers than ERP. Overall, future work is needed to understand how
Maximum Likelihood Estimation, the current study had a substantial UP-C/A compares to ERP for youth, parents, and providers.
amount of missing data, especially for the CSQ and the follow-up
timepoint. Relatedly, we also did not collect data on medication Role of the funding source
changes over the course of treatment, and because this was an open
trial, youth had no restrictions on needing to be on a stable dose of This research did not receive any specific grant from funding
medication prior to starting treatment. Third, while we included mul- agencies in the public, commercial, or not-for-profit sectors.
tiple informants, we did not collect independent evaluator reported
diagnostic and severity data at follow-up assessments. Fourth, the Author statement
current study only included a unidimensional measure of OCD. Given
that OCD is heterogeneous (Boerema et al., 2019; Hybel et al., 2017; Ashley Shaw: Conceptualization; Data curation; Formal analysis;
Ortiz et al., 2016), future studies should include a measure that con- Visualization; Writing - Original draft of the Method, Results, and
siders the major subdimensions of pediatric OCD (e.g., harm/sexual Discussion, as well as Reviewing and Editing.
obsessions, symmetry/hoarding, contamination/cleaning) (Hojgaard Elizabeth Halliday: Conceptualization; Data curation; Visualization;
et al., 2017). Given that harm/sexual obsessions are significantly cor- Writing - Original draft of the Introduction & Method.
related with anxiety and symmetry/hoarding is correlated with both Jill Ehrenreich-May: Conceptualization; Methodology; Writing –
anxiety and depression (Hojgaard et al., 2017), future studies should Reviewing and Editing.
consider whether the UP-C/A is more beneficial for these subdimen-
sions than others (e.g., contamination). Fifth, the RCADS was not spe- Declaration of competing interest
cifically developed as a measure for pediatric OCD, but rather, was
developed to efficiently measure a broad array of internalizing symp- The authors declare the following financial interests/personal re-
toms, including OCD. Thus, it would be useful to replicate this study lationships which may be considered as potential competing interests:
utilizing an evidence-based assessment specifically designed for OCD, In accordance with Journal of Obsessive-Compulsive and Related Disorders
such as the Obsessive-Compulsive Inventory-Child Version (Foa et al., policy and our ethical obligation as researchers, both Drs. Shaw and
2010) or the Children's Yale-Brown Obsessive Compulsive Scale (Scahill Ehrenreich-May report that they have received financial compensation
et al., 1997). from Trillium Health Partners for a training on the Unified Protocols for
Although we included a large sample of youth with emotional dis- Transdiagnostic Treatment of Emotional Disorders in Children and
order diagnoses, there are some sample limitations that should be Adolescents. Furthermore, Dr. Ehrenreich-May is the first author of the
considered when interpreting our findings. Rather than examining Unified Protocols for Transdiagnostic Treatment of Emotional Disorders in
change in OCS only in a subsample of youth with OCD, we included all Children and Adolescents therapist guide and workbooks, and thus re-
youth from our clinic, including those without clinical OCS. While our ceives royalties from these books. Dr. Ehrenreich-May also serves as a
findings allow us to understand how the UP-C/A affects OCS across a consultant and principal investigator on several grant-funded projects
continuum of symptoms and diagnostic presentations, our sample pri- examining the Unified Protocols for Transdiagnostic Treatment of
marily included youth with a primary anxiety disorder (e.g., GAD) ra- Emotional Disorders in Children and Adolescents. Drs. Shaw and
ther than OCD. Despite its limitations, this sampling approach allowed Ehrenreich-May have disclosed these interests fully to Journal of
us to understand how OCS changes across subclinical and clinical Obsessive-Compulsive and Related Disorders.
manifestations, and parallels approaches used to examine OCS change
in previous studies of transdiagnostic interventions (e.g., Timpano, References
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sub-sample who started UP-C/A was comparable to those we referred (2014). The relevance of analogue studies for understanding obsessions and com-
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