The hypothesis that neurocognitive dysfunction may mediate obsessive and compulsive behaviour in OCD has challenged researchers to have a better understanding about brain-behaviour relationships that exist in this disorder. Research suggests that adults with OCD have more difficulty than healthy controls with specific executive functioning tasks, visual-spatial memory, and constructional skills. Yet, the literature in pediatric OCD is limited by small sample sizes, inconsistent methods across studies and contradictory findings. Beyond providing improved understanding of OCD underpinnings, clarity regarding whether neurocognitive deficits are present in individuals with OCD has important clinical implications. Without awareness of neurocognitive risks, these areas of dysfunction may remain overlooked and unaddressed. Because OCD symptoms tend to remain in approximately 40% of cases after CBT, having knowledge about potential neurocognitive deficits in pediatric OCD could help enhance treatment effectiveness and improve youth’s functioning at school and at home.
Research conducted at the British Columbia Children’s Hospital Provincial OCD Program (POP) suggests that 8-18-year-old OCD-affected youth present with deficits in planning and spatial memory when compared to their healthy peers. How can we translate this information into clinical practice? Teaching youth compensatory strategies to mitigate the effects of such impairments should be considered. In my clinical work, I’ve been incorporating planning skill development and visual memory supports as a means to facilitate Exposure and Response Prevention (E/RP) practice. In my sessions, I tend to coach youth on how to set goals for E/RPs, and collaboratively develop a plan to achieve such goals. Breaking the “big E/RP task” into smaller steps and using visuals (e.g., handouts, charts, checklists) and verbal supports (e.g., clear and specific explanations) seem to help. Some of the specific strategies that other clinicians may already intuitively use include: establishing a regular time for E/RPs, having the materials needed for exposure ready, determining the length of the exposures and using a timer, selecting a reward for task completion, and filling out a tracking sheet during and after each practice. Although this process can be time-consuming at the beginning, youth often become more proficient at planning and successfully completing E/RPs, mitigating the need for reminders, such that supervision can be gradually faded out.
Findings from the same POP study also suggest that while standardized assessment revealed two areas of neurocognitive difficulty in pediatric OCD (planning and visual memory), parent/youth report indicated that youth experience significant challenges with daily behaviour associated with all executive function domains. How can this information be useful for clinicians? Discrepancies between performance under ‘ideal’ settings and parent/youth reports regarding daily function suggest that conducting more comprehensive assessments can increase our understanding about youth’s unique needs. Having knowledge about performance on standardized testing may inform clinicians about youth’s strengths and weaknesses in the areas assessed. Keep in mind that IQ is correlated with some neurocognitive tests, and this could mask potential deficits. Knowing how youth perform on real-life tasks, such as when completing a project (e.g., planning) or tolerating change (e.g., cognitive flexibility), could be even more informative for designing interventions and tracking behavioural changes. Comprehensive neurocognitive assessments can be expensive and I am not advocating for all OCD-affected youth to receive one. Instead, I am taking this opportunity to raise awareness about potential neurocognitive deficits in pediatric OCD and to stimulate a discussion on how this could inform our clinical practice.
Dr. Juliana Negreiros is a registered psychologist who has extensive clinical and research experience working with children and youth with OCD and anxiety disorders in community, school, and hospital settings. She is a contributor to the AnxietyBC website and, currently, is a postdoctoral fellow at the British Columbia Children's Hospital Provincial OCD Program (Vancouver, Canada). As part of her fellowship, Dr. Negreiros participates in numerous aspects of research that investigate neurocognitive and academic functioning and treatment outcomes in pediatric OCD.