Executive Functioning, Familial Accommodation, and Treatment Response in Youth with OCD and Comorbid ADHD

doi:10.21203/rs.3.rs-4830800/v1

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Executive Functioning, Familial Accommodation, and Treatment Response in Youth with OCD and Comorbid ADHD

https://doi.org/10.21203/rs.3.rs-4830800/v1

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Few studies have examined differential treatment response, rates of familial accommodation (FA), and executive functioning (EF) in youth with OCD vs. OCD + ADHD, particularly in a partial hospitalization program. The current study includes 138 youth diagnosed with OCD only and 102 youth diagnosed with OCD + ADHD for a total sample of 240 youth (and their families). Families and clinicians completed several measures assessing child and parent variables of interest. Findings of ANCOVA analyses suggest poorer treatment response and executive functioning in children with comorbid OCD + ADHD compared to their counterparts with OCD only. No significant differences emerged between groups in baseline levels of symptom severity, functional impairment, or familial accommodation. Given the high rate of comorbidity between OCD + ADHD, clinicians and researchers should be aware of the need to modify treatment approaches for children with comorbid OCD + ADHD and/or EF deficits.

accommodation

executive functioning

obsessive compulsive disorder

attention deficit hyperactivity disorder

family

Obsessive compulsive disorder (OCD) affects up to 4% of children and adolescents (Nazeer et al., 2020) and, in the United States alone, roughly 500,000 youth live with OCD (March & Benton, 2007). Childhood OCD impairs overall quality of life (Storch et al., 2007), particularly in familial (Barrett et al., 2002; Cooper, 1996; Stewart et al., 2017), social (Allsopp & Verduyn, 1990; Storch et al., 2006) and academic settings (Piacentini et al., 2003; Toro et al., 1992; Weidle et al., 2014). For individuals with OCD, obsessions—unwanted, intrusive thoughts, images, or impulses that cause distress—are subsequently reduced by compulsions, which are behaviors that are designed to assuage the distress of the obsessions, according to set rules or senses of completion (American Psychiatric Association, 2013). Common obsessions surround core fears of harm avoidance (Summerfeldt et al., 2014), disgust (Olatunji, 2005), and/or a sense of incompleteness (Summerfeldt et al., 2014), leading to common compulsions of repeating, checking, avoidance, and/or other rituals (Stein et al., 2019).

OCD is treatable and a robust body of research has demonstrated the effectiveness of cognitive behavioral therapy (CBT), specifically exposure with response prevention (E/RP), in the meaningful reduction of OCD symptoms, either alone or in tandem with serotonin reuptake inhibitor medication (Garcia et al., 2010; O’Kearney, 2007). Nevertheless, some OCD cases remain difficult to treat (Krebs & Heyman, 2010; Masi et al., 2006; Storch et al., 2008; Sukhodolsky et al., 2005), and many youth do not achieve remission following treatment (Farrell et al., 2020). Although many factors are implicated in the suboptimal treatment response of some youth, high rates of other psychiatric comorbidities are common in youth with OCD, and research has demonstrated poorer treatment response in these individuals (Storch et al., 2008). Nearly 80% of youth with OCD meet criteria for at least one other psychiatric disorder, and over half meet criteria for two or more comorbid conditions (Farrell et al., 2012). Pediatric OCD commonly co-occurs with anxiety and mood disorders and attention deficit/hyperactivity disorder (ADHD; e.g. Storch et al., 2008). ADHD is a neurodevelopmental disorder characterized by excessive inattention and/or hyperactivity (American Psychiatric Association, 2013) that affects roughly 10% of children and adolescents between the ages of 4 and 17 years. It is marked by dysfunction and dysregulation in a myriad of settings, including deficits in social, familial, and school arenas (DuPaul et al., 2001), and is comorbid in up to 30% of OCD cases (Garcia et al., 2010; Geller et al., 2002; Masi et al., 2006; Storch et al., 2008).

While both ADHD and OCD alone cause considerable interference in functioning, children with these comorbid conditions have greater impairment than their counterparts with OCD only (Farrell et al., 2020; Geller et al., 2002; Masi et al., 2006; Sukhodolsky et al., 2005) and demonstrate poorer treatment response (Stewart et al., 2004; Storch et al., 2008). Specifically, children with comorbid OCD and externalizing disorders—including ADHD—have earlier OCD onset (Masi et al., 2006), greater OCD symptom severity (Langley et al., 2010), exacerbated school and social impairment (Geller et al., 2002; Geller et al., 2003; Langley et al., 2010; Sukhodolsky et al., 2005) and elevated levels of anxiety and depressive symptoms (Geller et al., 2004) than their OCD only counterparts. Youth with comorbid OCD and ADHD have poorer treatment response (Stewart et al., 2004; Storch et al., 2008) and remission rates at post-treatment (Storch et al., 2008) and 6-month follow-up (Farrell et al., 2012) compared to youth with OCD.

Research suggests several factors that may contribute to youth with comorbid OCD and ADHD having poorer treatment outcomes. One important factor is deficits in executive functioning (EF). While both OCD and ADHD are neurologically different and involve different patterns of brain activity, they share similar cognitive effects in EF (Abramovitch et al., 2012, 2013). EF is broadly defined as the ability to focus attention, plan and switch tasks, inhibit impulses, and utilize cognitive flexibility. EF deficits are common in a variety of psychiatric disorders, including both ADHD and OCD (Barkley, 1997; Malloy et al., 1989; Delis et al., 2001; Hybel et al., 2017; Ornstein et al., 2010). Moreover, recent research suggests even greater EF deficits in children with comorbid OCD and ADHD (Farrell et al., 2020; Schatz & Rostain, 2006). For example, Farrell and colleagues (2020) found that youth with comorbid OCD and ADHD had significantly higher EF deficits than youth with OCD, and that EF deficits in youth with comorbid OCD and ADHD were associated with greater overall impairment and poorer treatment response in this population compared to their counterparts with OCD only. Given that the gold-standard treatment for OCD is E/RP, which relies on the ability to focus on feared stimuli, EF deficits may decrease exposure effectiveness (Benito et al., 2012; Grayson et al., 1982). Specifically, youth with both OCD and ADHD may particularly struggle with set-shifting, attention, and cognitive flexibility, all of which are often necessary to engage with exposure-based treatment (Wu et al., 2014).

Another factor that may be implicated in poorer treatment response in youth with comorbid OCD and ADHD relates to family accommodation (FA) of symptoms. FA refers to modifications to a caregiver’s behavior or statements that are designed to decrease or eliminate a child’s distress when exposed to feared stimuli (e.g. Amir et al., 2000; Barrett et al., 2002). Common FA examples include a parent aiding in ritual completion, providing reassurance, or facilitating avoidance of feared situations. A robust body of literature demonstrates high rates of FA in pediatric OCD, with 60 to 96% of caregivers accommodating their children’s OCD symptoms (e.g. Rosa-Alcázar et al., 2021, Peris et al., 2008; Storch et al., 2007). Higher FA relates to increased familial dysfunction (Amir et al., 2000; Peris et al., 2008), symptom severity (Amir et al., 2000; Francazio et al., 2016) and poorer CBT response (e.g. Garcia et al., 2010; Lavell et al., 2016, O’Connor, 2023). Although accommodation is well-intended, it results in family members inadvertently reinforcing the child’s symptoms by temporarily decreasing their distress but preventing them from engaging in the learning process of habituating to the anxiety caused by OCD triggers. This contradicts the primary method utilized in exposure with response prevention, which involves approaching feared situations to promote habituation and increase distress tolerance (Bipeta et al., 2013).

Although limited, prior research suggests higher levels of FA in youth with OCD and externalizing symptoms (Farrell et al., 2020; Storch et al., 2018). Storch and colleagues (2018) found a positive relationship between FA and symptom severity in both children with internalizing and externalizing symptoms and Farrell and colleagues (2020) demonstrated that comorbid OCD and ADHD is associated with higher FA. Similarly, comorbid OCD and disruptive or coercive-disruptive behaviors are associated with high FA (Lebowitz et al., 2015; Storch et al., 2010). These disruptive behaviors (e.g., demands placed on parents by youth to make decisions for them) share clinical characteristics with ADHD symptomatology, and research has suggested that higher FA is associated with the avoidance of potential negative interactions if the family does not accommodate. When families feel as though they are “walking on eggshells,” they are likely to accommodate to reduce the likelihood of triggering distress and, as such, potential negative interactions.

Extant literature observing differential treatment responses, rates of FA, and EF in youth with OCD vs. OCD+ADHD is minimal, and previous studies within this domain have primarily occurred at the outpatient level of care. Thus, our study aims to advance understanding about treatment response, FA, and EF in youth with OCD and OCD+ADHD in a partial hospitalization program. As such, we hypothesized that (1) treatment response would be significantly poorer for youth with OCD+ADHD in comparison to youth with OCD only; (2) FA would be significantly greater in families of youth with OCD+ADHD compared to OCD only; and (3) youth with OCD+ADHD would demonstrate greater deficits in EF compared to youth with OCD only. Additionally, (4) exploratory analyses were used to investigate possible associations between various facets of EF (i.e., behavioral regulation, metacognition) in relation to treatment response and family accommodation in youth with OCD+ADHD when compared to youth with OCD.

Participants

The current sample included 240 youth between 5 and 18 years old (M_Age = 12.2 years, SD_Age = 3.2) who were admitted to a 20 to 30-hour week partial hospitalization program (PHP) specializing in E/RP for OCD and anxiety-related disorders between August 2015 and March 2020. Youth were included if they and their parents consented to participate in research and received a primary diagnosis of OCD with or without comorbid ADHD. Exclusionary criteria included the presence of an intellectual disability or psychosis, although no patients in the PHP had diagnoses within these categories. Most of the sample identified as White (90.4%) and non-Latinx (90.5%), and slightly more than half of the sample identified as female (50.4%). Approximately 57.5% (n = 138) of participants were diagnosed with OCD only, and 42.5% (n = 102) were diagnosed with OCD and comorbid ADHD. For participants with OCD only, many had comorbid anxiety disorder (30.4%) and mood disorder (39.1%) diagnoses, and 83.3% were on serotonin reuptake inhibitors while 13% were on stimulants during PHP admission. For youth with comorbid OCD and ADHD, 32.4% had a comorbid anxiety disorder, 31.4% had a comorbid mood disorder, and 81.4% were on serotonin reuptake inhibitors while 78.4% were on stimulants during PHP admission. Refer to Table 1 for additional descriptive statistics, which include demographic variables, comorbidity, medication use at PHP admission, and length of PHP stay.

Table 1

Descriptive statistics by group.
Variable	M (SD) or %
	OCD Only	OCD + ADHD
Age	12.5 (3.0)	11.9 (3.4)
Biological Sex	Female (58.0%)	Female (40.2%)
	Male (42.0%)	Male (59.8%)
Race	White (88.0%)	White (93.6%)
	Black (1.6%)	Black (2.1%)
	Asian (0.8%)	Asian (1.1%)
	Other (4.0%)	Other (1.1%)
	More than one race (2.4%)	More than one race (1.1%)
	Declined (2.4%)	Declined (1.1%)
Ethnicity	Latinx (5.5%)	Latinx (7.7%)
	Not Latinx (91.7%)	Not Latinx (89.0%)
	Declined (2.8%)	Declined (3.3%)
Comorbidity	Anxiety disorder (30.4%)	Anxiety disorder (32.4%)
	Mood disorder (39.1%)	Mood disorder (31.4%)
	Autism spectrum disorder (11.6%)	Autism spectrum disorder (18.6%)
	Tic disorder (7.2%)	Tic disorder (15.7%)
Medication during admission	Benzodiazepine (17.4%)	Benzodiazepine (14.7%)
	Stimulant (13.0%)	Stimulant (78.4%)
	Antipsychotic (27.7%)	Antipsychotic (30.4%)
	SRI (83.3%)	SRI (81.4%)
Length of Stay	39.7 (22.5)	35.2 (17.7)

Measures

The Children’s Yale-Brown Obsessive Compulsive Scale (CYBOCS; Scahill et al., 1997) is a clinician-rated, semi-structured interview designed to rate the severity of obsessive and compulsive symptoms in children and adolescents ages 6 to 17 years old. The severity of obsessive and compulsive symptoms is each rated on five scales, which include Time Spent, Distress, Resistance, Interference, and Degree of Control. These scales are rated on a 5-point Likert-type scale, with options ranging from “None” (0) to “Extreme” (4). The scale scores are then added together to yield a total score (0 to 40), with scores ranging from 0 to 7 marking subclinical obsessive compulsive symptoms, 8 to 15 marking mild obsessive compulsive symptoms, 16 to 23 marking moderate obsessive compulsive symptoms, 24 to 31 marking severe obsessive compulsive symptoms, and 32 to 40 marking extreme obsessive compulsive symptoms. The CYBOCS has demonstrated high internal consistency (r = .87), good to excellent interrater reliability (r = .66 to .91), and high convergent validity with other measures assessing childhood obsessive compulsive symptoms (r = .62 for the Leyton survey) (Scahill et al., 1997). In the present study, the CYBOCS Total Score was used to assess OCD symptom severity and treatment response. Based on previous research, treatment response was classified as 30% reduction in CYBOCS symptoms from baseline to post-treatment (Storch et al., 2010; Farrell et al., 2012).

The Clinical Global Impressions Scale (CGI; Guy, 1976) is a 2-item clinician report measure for symptom severity (CGI-S) and improvement (CGI-I). Both severity and improvement ratings are ranked on a 7-point scale. CGI-S scores range from 1 (“not at all ill”) to 7 (“among the most extremely ill patients”), while improvement ratings also range from 1 (“very much improved since the initiation of treatment”) to 7 (“very much worse since the initiation of treatment”). CGI-S scores correlate with CYBOCS total scores (r = .75; Storch et al., 2004); CGI-S and CGI-I show adequate reliability and validity (Garvey et al., 1999; Perlmutter et al., 1999) and are used in treatment studies for OCD (Freeman et al., 2012). In the present study, CGI-S was used to assess functional impairment.

The Behavior Rating Inventory of Executive Function – Parent Version (BRIEF – Parent Version; (Gioia et al., 2000) is an 86-item parent report measure that assesses different aspects of EF in children and adolescents between 5 and 18 years old. The measure takes approximately 10–15 minutes to complete and yields eight clinical scales (Inhibit, Shift, Emotional Control, Initiate, Working Memory, Plan/Organize, Organization of Materials, Monitor) and two validity scales (Inconsistency and Negativity). The eight clinical scales form two broader Indices (Behavioral Recognition and Metacognition), as well as an overall score (Global Executive Composite). Raw scores on each individual clinical scale are converted to t-scores. Standard scores have a mean of 50, standard deviation of 10, and higher t-scores indicate poorer EF. Scores greater than or equal to 65 are considered clinically significant. The BRIEF – Parent Version has demonstrated high internal consistency (α = 0.8–0.98), good test-retest reliability (rs = 0.82), and divergent and convergent validity (Gioia et al., 2000). In the present study, the Global Executive Composite (GEC) score was used to assess overall executive functioning.

The Pediatric Accommodation Scale – Parent Report (PAS-PR; Benito et al., 2015) is a 5-item parent report measure of family accommodation for youth with a primary anxiety disorder. The PAS-PR asks parents to rate how often over the past week they engaged in various accommodating behaviors, and responses are rated on a 0 to 4 scale ranging from “Never” (0) to “Always” (4). Parents are also asked to rate the amount of interference due to accommodation over the past week, with responses also being rated on a 0 to 4 scale ranging from “None” (0) to “Extreme” (4). Total scores range from 0 to 40, with higher scores reflecting more accommodation. The PAS-PR has demonstrated good internal consistency (PAS-PR-F α = .84), convergent validity, and discriminant validity. In the present study, the PAS-PR was used to assess family accommodation of symptoms.

Procedures

The present study was a secondary data analysis from an existing database. Data were initially collected at both admission and at discharge from the PHP (see Table 2). All procedures were approved by the Institutional Review Board at the hospital in which the program is located. Parents and clinicians completed a battery of measures, including those used in this study. The measures took approximately 35–45 minutes to complete, and children and their families were informed that they could withdraw from the study at any time. Given that data collected for this study was part of the routine clinical information gathered for treatment, no compensation was offered to participants.

Table 2. Descriptive information for measures.
Scale	Construct	Time Point	N	Range	M(SD)
CGI-S	Functional Impairment	Admission
OCD			88	3–7	4.92 (.79)
OCD + ADHD			68	3–7	4.85 (1.01)
CGI-S	Functional Impairment	Discharge
OCD			79	2–7	4.08 (.93)
OCD + ADHD			65	3–7	4.09 (.90)
CGI-I	Symptom Improvement	Discharge
OCD			77	1–5	2.25 (.85)
OCD + ADHD			65	1–5	2.34 (.78)
PAS-PR Total Score	Familial Accommodation	Admission
OCD			45	1–40	22.16 (10.46)
OCD + ADHD			44	2–38	22.30 (9.23)
PAS-PR Total Score	Familial Accommodation	Discharge
OCD			36	0–26	9.83 (6.89)
OCD + ADHD			33	0–23	9.85 (5.86)
CYBOCS Total Score	Symptom Severity	Admission
OCD			93	18–40	29.09 (4.72)
OCD + ADHD			67	10–40	27.99 (5.07)
CYBOCS Total Score	Symptom Severity	Discharge
OCD			85	1–36	18.21 (6.35)
OCD + ADHD			64	0–30	18.17 (5.37)
BRIEF Behavioral Regulation Index	Behavioral Regulation	Admission
OCD			69	27–62	45.59 (8.86)
OCD + ADHD			55	33–71	54.87 (9.16)
BRIEF Metacognitive Index	Metacognitive Abilities	Admission
OCD			57	27–66	45.76 (9.52)
OCD + ADHD			50	38–71	55.17 (7.12)
BRIEF Global Executive Composite	Overall Executive Functioning	Admission
OCD			56	25–67	45.29 (8.87)
OCD + ADHD			47	39–73	55.84 (7.24)
Note. CGI-S = Clinical Global Impressions - Severity of Illness; CGI-I = Clinical Global Impressions - Global Improvement; PAS-PR = Pediatric Accommodation Scale - Parent Report; CYBOCS = Children’s Yale-Brown Obsessive Compulsive Scale; BRIEF-PR = Behavior Rating Inventory of Executive Functioning - Parent Version.

Data Analysis

All data management and analyses were conducted in SPSS. Data were examined for normality and patterns of missingness, and listwise deletion was used for missing data. We hypothesized EF differences between the OCD and OCD + ADHD groups such that youth with OCD + ADHD would demonstrate greater deficits in EF compared to youth with OCD only, and one-way ANCOVA analyses were used to investigate EF differences across groups. Additionally, chi square analyses were used to test the hypothesis that treatment response would be significantly poorer for youth with OCD + ADHD in comparison to youth with OCD only. T-test analyses were used to analyze FA differences between youth with OCD + ADHD vs OCD only, and we predicted that FA would be significantly greater in families of youth with OCD + ADHD compared to OCD only.

Preliminary Results

Basic assumptions of the general linear model were assessed to confirm that data met assumptions of normality, linearity, homoscedasticity, and homogeneity of regressions. Skewness and kurtosis values (Skewness < 2; Kurtosis < 7) were within normal limits for all variables of interest (West, Finch, & Curran, 1995). Data were also examined for outliers by examining the distribution of each variable, and data points with z-scores above 3.0 or below − 3.0 were removed. Based on an observation of z-scores, three outliers were detected for the variable measuring overall symptom severity at discharge (CGI-S), one outlier was detected for the variable measuring OCD symptom severity at admission (CYBOCS Total Score), and one outlier was detected for the variable measuring OCD symptom severity at discharge (CYBOCS Total Score) (Cousineau & Chartier, 2010). Primary analyses were conducted both with and without the outliers, and results did not differ significantly; therefore, all analyses are based on the original dataset.

T-tests and chi square analyses were conducted to examine associations between diagnostic group (i.e., OCD v. OCD + ADHD) and key demographic variables. No associations were observed between diagnostic group and age (t(238) = 1.24, p = .22), race (ꭓ²(6, N = 219) = 3.80, p = .71), ethnicity (ꭓ²(2, N = 200) = 0.46, p = .80), or length of stay (t(238) = 1.67, p = .10); however, analyses revealed a significant association between diagnostic group and gender, such that males were significantly more likely to be diagnosed with OCD + ADHD in comparison to females (ꭓ²(1, N = 240) = 7.41, p = .01). However, gender was not significantly associated with any of the primary outcome variables, and therefore was not included as a covariate in any of the primary analyses. Diagnostic groups also differed in the total number of comorbid diagnoses, with participants in the OCD + ADHD group having significantly more comorbid diagnoses than youth with OCD only (t(188.30) = 6.63, p < .001).

Primary Results

One-way ANCOVAs were used to investigate differences in EF between the OCD and OCD + ADHD groups when controlling for the number of comorbid diagnoses. Three separate ANCOVAs were conducted to investigate differences in executive functioning across the three main indices as assessed by the BRIEF – Parent Version (see Table 3). When controlling for the number of total comorbid diagnoses, results revealed that the youth in the OCD + ADHD group were rated as having significantly poorer EF when compared to youth with OCD only. Youth with OCD + ADHD were rated as significantly higher in deficits on the behavioral regulation index (F(1,121) = 22.84, p < .001, η_p² = .16), metacognitive index (F(1,104) = 24.17, p < .001, η_p² = .19), and global executive composite (F(1,100) = 31.22, p < .001, η_p² = .24) compared to youth with OCD only.

Table 3

Executive functioning differences between OCD v. OCD + ADHD when controlling for number of comorbid diagnoses.
BRIEF-PR Scale	OCD Only		OCD + ADHD		F	η_p²
	M	SD	M	SD
Behavioral Regulation Index	45.59	8.86	54.87	9.16	F(1,121) = 22.84***	0.16
Metacognitive Index	45.76	9.52	55.17	7.12	F(1,104) = 24.17***	0.19
Global Executive Composite	45.29	8.87	55.84	7.24	F(1,100) = 31.22***	0.24
Note. BRIEF-PR = Behavior Rating Inventory of Executive Functioning - Parent Version. p < .05, p < .01, ** p < .001.

Regarding treatment response, findings also indicated that youth with OCD + ADHD were significantly less likely to respond to treatment when compared to youth with OCD only (χ² (1, N = 135) = 4.77, p = .03). Results are presented in Table 4. Regarding FA, no significant differences emerged between the OCD and OCD + ADHD groups at admission (t(87) = − .07, p = .95) or at discharge (t(67) = − .01, p = .99).

Contrary to our initial hypotheses, bivariate correlations revealed no relationship between EF and baseline symptom severity, as assessed by the CYBOCS (r(65) = .05, p = .69) or baseline functional impairment, as assessed by the CGI-S (r(73) = .004, p = .97).

Table 4

Treatment response for OCD v. OCD + ADHD group.
	Treatment Responder
	Yes	No
OCD	n = 54 (70.1%)	n = 23 (29.9%)
OCD + ADHD	n = 30 (51.7%)	n = 28 (48.3%)

The present study offers preliminary evidence of meaningful differences between groups that have implications for modifying treatment approaches for youth with OCD and comorbid ADHD. Consistent with current study hypotheses and previous research (Farrell et al., 2020), poorer EF and an attenuated treatment response were observed in youth with primary OCD + ADHD compared to youth with OCD only. Previous research has widely reported EF deficits in ADHD (e.g. Barkley, 1997) and OCD (e.g. Purcell et al., 1998), which coincides with this study’s observation of poorer EF in youth with comorbid OCD and ADHD. EF deficits are linked to inattention, and CBT with E/RP—the gold standard treatment for OCD—requires the capacity to sustain attention to focus on and habituate to feared stimuli. Previous literature has noted that distractibility and inattention decreases exposure effectiveness, meaning untreated EF deficits may impair the efficacy of exposure-based treatment (Benito et al., 2012; Grayson et al.,1982). As such, our findings support previous research documenting attenuated treatment responses in children and adolescents with comorbid OCD + ADHD (Farrell et al., 2012; Stewart et al., 2004; Storch et al., 2008).

Given attentional control’s role in EF, we hypothesized that greater EF deficits would relate to poorer treatment response. However, contrary to study predictions, EF did not predict treatment response. There are several possible reasons for this finding. First, it is possible that the EF measure, the BRIEF – Parent Version (Gioia et al., 2000), may not have fully captured EF deficits. Given that the BRIEF – Parent Version relies on parental reports of children’s EF abilities (Gioia et al., 2000), EF was not assessed directly. The observations noted in the BRIEF–Parent version largely factor behaviors parents see at home, thus not directly factoring children’s behaviors outside the home, such as in school or extracurricular environments. It is possible that a more direct measure that factors children’s home, school, and extracurricular behaviors—aggregated with reports from teachers, extracurricular providers, other sets of caregivers, and the child themselves—could demonstrate EF as a treatment response predictor. Additionally, we did not parse out ADHD by severity or subtype. Research has demonstrated EF differences by subtype such that children with combined-type ADHD display more verbal working memory and category shifting deficits than children with inattentive-type ADHD (Bahçivan Saydam et al., 2015). It could be that the severity level and specific EF deficits of our ADHD sample might not relate to treatment response.

Contrary to study hypotheses and previous research (e.g., Farrell et al., 2020), no differences were found in FA between participants with OCD + ADHD versus those with OCD only. In Farrell and colleagues’ (2020) outpatient level of care study, parents of children with comorbid OCD + ADHD reported significantly higher levels of FA than parents of children with OCD only. Other studies at the outpatient level of care report increased FA in families of children with comorbid OCD and disruptive or coercive-disruptive behaviors (Lebowitz et al., 2015; Storch et al., 2010). At higher levels of care (intensive outpatient, partial hospitalization and residential), a recent study on FA in youth with OCD and anxiety found elevated FA levels (La Buissonnière-Ariza et al., 2018), indicating baseline scores greater than twice that of outpatient samples on the Family Accommodation Scale – Anxiety (Lebowitz et al., 2013). Additionally, La Buissonnière-Ariza and colleagues (2018) found that anxiety severity was not a significant predictor of FA when other factors, such as age and depression severity, were accounted for. The present study did not take into account other comorbidities besides ADHD (such as depression), and severity of other symptoms, which may explain the similar FA scores in participants with OCD vs. OCD + ADHD. Further, because of the different sample sizes between the two groups (more youth with OCD + ADHD vs OCD only), our study may have been unable to detect FA differences between groups. In addition, because the present study did not analyze ADHD subtype, it could be that youth in the OCD + ADHD group exhibit more inattentive symptoms of ADHD that may interfere with E/RP but are less likely to elevate FA. Our study also did not analyze medication management of ADHD due to inconsistencies across if and when patients started medication, so it is possible that many in the OCD + ADHD had symptoms that were so well managed with medication that there were no notable FA differences between the OCD vs OCD + ADHD groups.

Interestingly, no differences between FA and baseline symptom severity were observed between groups at both admission and discharge. These findings may be partially explained by the limited range of scores due to the high level of baseline symptom severity of the overall sample in this study. In general, research reveals higher rates of FA with increased symptom severity (Lebowitz et al., 2012, 2016). However, these studies typically employ services at the outpatient level of care with lower acuity patients. Given the greater severity in OCD symptoms in patients at higher levels of care, there may be less sensitivity to detect differences. We would anticipate a greater range of scores that is more representative of the overall population of youth with OCD in an outpatient sample.

Limitations and Future Directions

Although the present study offers a meaningful contribution to existing literature, there are several limitations that warrant acknowledgement. First, generalizability of these findings is limited by the homogeneous nature of the sample. Most youth included in this study identified as White and non-Latinx, and racial and ethnic minority populations were underrepresented. Given that previous research indicates that CBT treatment response for anxiety and OCD varies among racial background, with some studies indicating that racial minority youth exhibit poorer CBT treatment response compared to White youth (Garcia et al., 2023; Ginsburg et al., 2011), future research should work to recruit more inclusive samples. Second, the present study’s small sample size and unequal groups likely restricted power, limiting the ability to detect small effects (Maxwell, 2000) between groups. We recommend that future studies employ larger group sizes to adequately detect differences between groups. Third, because these data were collected from a PHP rather than within the context of a controlled research study, there were significant amounts of missing data. With these missing data, the current study used listwise deletion, and future studies may benefit from imputing missing data to create a more robust dataset. Additionally, youth who consent to research as part of a PHP may not be representative of the program population as a whole.

Another study limitation is the utilization of parental reports to assess youth EF. Our study used the BRIEF- Parent Version (Gioia et al., 2000), which is an indirect measure of children’s EF that relies on parental behavioral observations of their children that are typically limited to the home setting. As such, we did not gather information about ADHD impairment and symptomatology in other settings, from other sources or using other measures, which would have been useful in creating a more complete symptomatic picture in addition to validating and reinforcing parental reports. Taken together, the BRIEF-Parent Version may not fully capture children’s EF across all functional domains. Future studies could benefit from directly measuring children’s EF with assessments such as the ROCF (Osterrieth, 1944), Wisconsin Card Sorting Test (Grant & Berg, 1948), or Conners Continuous Performance Test (Conners et al., 2000), and aggregating those results with the BRIEF-Parent version.

Some existing research suggests a dual misdiagnosis of OCD and ADHD where symptoms of inattention possibly resulting from OCD lead to a misdiagnosis of ADHD (Abramovitch et al., 2012). This is explained by the Executive Overload model wherein people with OCD experience an overflow of obsessive thoughts, resulting in an overload on the executive system which mirrors executive dysfunction symptoms of ADHD (Abramovitch et al., 2012). Another line of research highlights greater comorbidity rates of OCD and ADHD in childhood, but not during adulthood. Research suggests greater comorbidity rates in childhood due to OCD symptoms fitting the symptomatic presentation of ADHD that then dissipates overtime as brains develop (Abramovitch et al., 2013). Given that the present study did not have information about when an ADHD diagnosis occurred, it is possible that youth with comorbid diagnoses were misdiagnosed with ADHD. Future research may benefit from longitudinally following children with comorbid diagnoses of OCD and ADHD across the lifespan to further elucidate the developmental process of these disorders.

Future research should investigate correlates contributing to differential treatment response in youth with OCD and comorbid ADHD. Given OCD’s heterogeneous presentation and expression, we suggest investigating whether there are more nuanced differences in EF and treatment response based on OCD subtypes (e.g., core fears of harm avoidance, disgust, and incompleteness) and clinical expression. Our study examined the number of comorbid diagnoses on treatment response, and we recommend that future research analyze not only the number of comorbid diagnoses, but also the type of comorbid diagnoses.

The current study advances understanding of differential treatment responses, family accommodation, and EF between children with OCD and comorbid OCD + ADHD. This study expands on previous literature by examining these constructs in a partial hospitalization program. Findings suggest poorer treatment response and EF in children with comorbid OCD + ADHD compared to their counterparts with OCD only. No significant differences emerged between groups in baseline levels of symptom severity, functional impairment, or familial accommodation. Given the high rate of comorbidity between OCD + ADHD, these findings have meaningful implications for modifying treatment approaches for children with comorbid ADHD and/or EF deficits + OCD. Treatment targeted towards children with comorbid OCD + ADHD might include more structured breaks and scaffolding of exposures to increase E/RP effectiveness.

Author Contribution

M.M. and B.K. wrote the main manuscript text. B.K. came up with study design and prepared all tables. E.O. and J.F. assisted with study design. All authors reviewed the manuscript.

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Executive Functioning, Familial Accommodation, and Treatment Response in Youth with OCD and Comorbid ADHD

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