Background
Method
Search strategy
Inclusion and exclusion criteria
Inclusion criteria
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Children and adolescents aged 4–18
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Primary diagnosis of obsessive-compulsive disorder diagnosed by a psychologist or psychiatrist according to DSM or ICD criteria
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All treatment settings
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Any cultural background, ethnicity, and sex
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CBT with Internet technology components
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No restrictions on therapist involvement or additional treatment
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Studies with and without comparators
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No restrictions were set on comparators.
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Treatment acceptability refers to the degree to which an individual perceives a treatment protocol as appropriate, fair, and reasonable for a given population or problem and any acceptability test is accepted as an outcome [26].
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Feasibility refers to whether treatment works in practice and drop-outs are accepted as main outcome [26].
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Treatment efficacy refers to the capacity to improving health-outcomes. Children’s Yale-Brown Obsessive-Compulsive Scale (CY-BOCS) is accepted as the golden standard for its assessment [9].
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Randomized controlled trial, blind trial, non-blind trial, adaptive clinical trial, non-randomized trial, interrupted time series design, cohort study, case-control study, and cross-sectional study published in English [27].
Exclusion criteria
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Adults
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Diagnosis of obsessive-compulsive disorder not determined by a qualified specialist (psychologist or psychiatrist) or not according to DSM or ICD criteria
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Other than CBT
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Studies with and without comparators are accepted.
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No restrictions were set on comparators.
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Not reporting on acceptability, feasibility, and efficacy.
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Qualitative study, commentary, correction, editorial letter (unless research letter reporting data), and single-case reports
Results
Search results
Reference | Study design | Control group | Participants | Parent involvement | Communication methods | Therapist involvement | Intervention | Outcome | ||
---|---|---|---|---|---|---|---|---|---|---|
Intervention contents | Intervention duration | Primary outcomes | Time of assessment | |||||||
Comer et al. (USA) [28] | Case series | Not Applicable | Children aged 4-8 (M = 6.5; SD = 0.9) 3 boys 2 girls | (a) Parents were trained as coaches, (b) treatment addresses parental accommodation of child symptoms, and (c) treatment had an exposure component for parents. | Video-teleconference sessions | Regular contact through video-teleconference | “Internet-delivered Family-based -CBT”: -Video teleconferencing -Interactive computer games, feeling thermometer, exposure hierarchy and exercises | 12 sessions in 14 weeks | Treatment efficacy, feasibility, and acceptability | Baseline, post-treatment |
Comer et al. (USA) [30] | RCT | Family-based CBT delivered in clinic | Children aged 4–8 (M = 6.7; SD = 1.3) 6 boys 5 girls | (a) Parents were trained as coaches, (b) treatment addresses parental accommodation of child symptoms, and (c) treatment had an exposure component for parents. | Video-teleconference sessions | Regular contact through video-teleconference | “Internet-delivered Family-based -CBT”: -Video teleconferencing -Interactive computer games, feeling thermometer, exposure exercises and hierarchy | 12 sessions in 14 weeks | Treatment efficacy, feasibility, and acceptability | Baseline, post-treatment, 6-month follow up |
Farrell et al. (Australia) [31] | Single-case, non-concurrent multiple-baseline design | Not Applicable | Adolescents aged 11–16 (M = 13.6; SD = 1.8) 6 boys 4 girls | Parents were involved in education session, at the end of their child’s intensive face-to-face sessions, and during all e-therapy maintenance sessions. | One face-to-face education session, two intensive face-to-face CBT sessions, therapy maintenance sessions via video-teleconferencing | Regular contact through video-teleconferencing | Two intensive face-to-face CBT sessions followed by e-therapy maintenance | Psychoeducation and 2 intensive CBT sessions during 3 weeks, followed by a 3-week therapy maintenance program | Treatment efficacy and feasibility | Pre-intervention, weekly assessments during 1- or 2-week baseline period, post-CBT, 1-month follow up (after e-therapy), 6-month follow up |
Lenhard et al. (Sweden) [32] | Open trial | Not Applicable | Adolescents aged 12–17 (M = 14.4; SD = 2.6) 8 boys 13 girls | Parents participated in treatment through parent-specific chapters, with varying degrees of parental involvement depending on the child’s age. | “Internet Project for Children”: a self-help protocol through an Internet platform containing texts, films, animations and exercises; telephone calls or messages | Occasional contact through telephone calls or messages to a therapist | “Internet Project for Children” Internet platform for educative texts, films, and exercises | 12 treatment chapters in 12 weeks | Treatment efficacy, feasibility, and acceptability | Baseline, 3-month, post-treatment, 6-month follow up |
RCT | Waitlist | Adolescents aged 12-17 (M = 14.2; SD = 1.7) 16 boys 17 girls | Parents participated in the treatment through parent-specific chapters, with varying degrees of parental involvement depending on the child’s age | “Internet Project for Children”: a self-help protocol through an Internet platform containing texts, films, animations and exercises; telephone calls or messages. Smartphone application support for ERP exercises | Occasional contact through telephone calls or messages to a therapist | “Internet Project for Children” Internet platform for educative texts, films, and exercises | 12 treatment chapters in 12 weeks | Treatment efficacy, feasibility, and acceptability | Baseline, post-treatment, 3-month follow up | |
Storch et al. (USA) [34] | RCT | Waitlist | Children and adolescents between 7 and 16 (M = 11.1; SD = 2.6) 10 boys 6 girls | Parents were instructed on coaching their child through exposure. | Video-teleconference sessions, email | Regular contact through video-teleconference | Web camera-delivered cognitive behavioral therapy (video-teleconference) | 14 sessions in 12 weeks | Treatment efficacy, feasibility, and acceptability | Baseline, post-treatment |
Acceptability
Reference | Measure | Pre-treatment M (SD) | Post-treatment M (SD) | Within group Significance Pre-post | Within group Size effect (d) Pre-post | Follow-up M (SD) |
---|---|---|---|---|---|---|
Comer et al. (USA) [28] | Efficacy | |||||
CY-BOCS | 24.2 (5.2) c | 17.4 (5.9) c | Not Reported | 2.54 | Not Applicable | |
ADIS-IV-C/P (OCD CSR) | 6.2 (1.1) c | 4.0 (1.4) c | Not Reported | 5.88 | Not Applicable | |
CGAS | 51.8 d | 58.6 d | Not Reported | 2.87 | Not Applicable | |
CGI-S | 5.2 d | 3.6 d | Not Reported | Not Reported | Not Applicable | |
CGI-I | Not Applicable | 2.2 (0.8) c | Not Reported | Not Reported | Not Applicable | |
Acceptability | ||||||
CSQ-8 (First Item) | Not Applicable | All mothers rated quality as “Excellent” | Not Applicable | Not Applicable | Not Applicable | |
Feasibility | ||||||
Treatment dropout | Not Applicable | Dropout = 0 | Not Applicable | Not Applicable | Not Applicable | |
Farrell et al. (Australia) [31] | Efficacy | |||||
CYBOCS | 29.1 (4.2) | 14.8 (7.7) | p< 0.001 | 2.09 | 11.8 (8.9) b | |
CY-BOCS-SR (Parent) | 24.1(3.3) | 12.9 (7.3) | p< 0.001 | 1.94 | 11.5 (9.5) b | |
ADIS-IV-C/P (OCD CSR) | 6.6 (0.5) | 3.5 (2.0) | p< 0.001 | 2.28 | 3.3 (1.9) b | |
NIMH GOCS | 10.7 (1.8) | 6.3 (3.1) | p< 0.005 | 1.36 | 5.8 (3.6) b | |
CGI-S | 5.6 (0.5) | 3.1 (1.5) | p< 0.001 | 2.25 | 2.7 (1.6) b | |
CDI-S | 13.6 (10.9) | 10.3 (7.9) | p< 0.05 | 0.34 | Not Reported | |
MASC | 83.6 (35.0) | 60.1 (26.1) | p= n.s. | 0.76 | Not Reported | |
PEDSQL | 35.3 (12.1) | 18.5 (14.9) | p< 0.05 | 1.23 | Not Reported | |
Feasibility | ||||||
Treatment dropout | Not Applicable | Dropout = 0 | Not Applicable | Not Applicable | Not Applicable | |
Lenhard et al. (Sweden) [32] | Efficacy | |||||
CY-BOCS | 21.3 (3.5) | 12.1 (4.5) | p< 0.001 | 2.29 | 8.8 (5.1) a 9.1 (6.4) b | |
ChOCI –symptom Parent | 12.4 (6.8) | 6.5 (5.1) | p< 0.001 | 0.94 | 5.3 (5.6) a 4.5 (4.3) b | |
ChOCI –impairment Parent | 24.9 (7.0) | 17.8 (10.0) | p< 0.001 | 0.79 | 12.4 (8.1) a 11.5 (6.4) b | |
ChOCI –symptom child | 13.6 (8.7) | 6.4 (6.6) | p< 0.001 | 0.92 | 5.3 (6.7) a 5.0 (6.6) b | |
ChOCI – impairment child | 22.6 (8.1) | 11.6 (6.3) | p< 0.001 | 1.51 | 9.9 (8.9) a 10.4 (9.1) b | |
COIS-R Parent | 25.3 (16.1) | 16.8 (17.2) | p< 0.05 | 0.45 | 13.0 (15.7) a 13.9 (15.0) b | |
COIS-R Child | 17.3 (15.5) | 6.6 (7.9) | p< 0.001 | 0.88 | 5.2 (8.4) a 6.0 (9.0) b | |
CGI-I | Not Applicable | 52% “Much Improved” or “Very Much Improved” | Not Applicable | Not Applicable | 71 % “Much Improved” or “Very Much Improved” a b | |
CGAS | 56.1 (6.3) | 71.5 (9.3) | p< 0.001 | -1.94 | 74.0 (9.0) a 73.5 (9.7) b | |
CDI-S | 9.6 (1.4) | 9.9 (1.2) | p= n.s. | -0.19 | 2.5 (2.7) a 2.2 (2.1) b | |
FAS | 14.6 (8.4) | 9.6 (7.1) | p<0.05 | 0.60 | 6.9 (8.1) a 6.5 (6.9) b | |
SDQ Parent | 12.0 (6.7) | 10.3 (6.3) | p= n.s. | 0.29 | 10.3 (6.6) a 9.7 (6.4) b | |
SDQ child | 13.5 (5.5) | 10.6 (4.0) | p= n.s. | 0.61 | 10.7 (4.2) a 10.5 (4.8) b | |
SCAS without OCD Parent | 25.2 (15.7) | 16.0 (13.5) | p<0.001 | 0.63 | 16.4 (12.2) a 15.7 (14.1) b | |
SCAS OCD Child | 9.1 (5.0) | 4.1 (3.4) | p<0.001 | 1.17 | 2.9 (3.8) a 3.3 (4.0) b | |
SCAS without OCD Child | 30.4 (16.9) | 20.2 (13.5) | p<0.001 | 0.67 | 18.9 (14.0) a 18.3 (14.2) b | |
Acceptability | ||||||
Not Applicable | Not Applicable | Not Applicable | Not Applicable | Not Applicable | Not Applicable | |
Feasibility | ||||||
Treatment dropout | Not Applicable | 8.3/12 Chapters completed by patients (3.0) | Not Applicable | Not Applicable | Not Applicable | |
4.7/5 Chapters completed by parents (0.8) |
Reference | Measure | Pre-treatment M (SD) | Post-treatment M (SD) | Between groups Significance (WL-CBT) | Between groups Significance (iCBT-CBT) | Within group Significance PRE-POST | Between groups Effect size (d) | Follow-up M (SD) |
---|---|---|---|---|---|---|---|---|
Comer et al. (USA) [30] | Efficacy | |||||||
CY-BOCS | 22.9 (4.1) | 14.9 (7.3) | Not Applicable | p=n.s | Not Reported c | 0.09 | 11.8 (9.5) b | |
ADIS-IV-C/P (OCD CSR) | 5.1 (0.8) | 3.4 (1.2) | Not Applicable | p=n.s | Not Reported c | 0.24 | 2.4 (2.6) b | |
CGI-S | 4.9 (0.7) | 3.2 (1.5) | Not Applicable | p=n.s | Not Reported c | -0.06 | 2.6 (2.5) b | |
CGAS | 48.0 (8.0) | 61.4 (12.0) | Not Applicable | p=n.s | Not Reported c | -0.06 | 66.6 (15.9) b | |
FAS | 29.5 (7.8) | 19.5 (9.7) | Not Applicable | p=n.s | Not Reported c | 0.56 | 15.6 (14.2) b | |
Acceptability | ||||||||
CSQ-8 | Not Applicable | Mother 28.6 (4.5) | Not Applicable | p=n.s. | Not Applicable | Not Applicable | Not Applicable | |
WAI | Not Applicable | Mother 223.5 (34.8) Therapist 226.1 (32.9) | Not Applicable | p=n.s. p=n.s. | Not Applicable | Not Applicable | Not Applicable | |
Feasibility | ||||||||
Treatment drop-out | Not Applicable | Dropout = 1 | Not Applicable | Not Applicable | Not Applicable | Not Applicable | Not Applicable | |
Efficacy | ||||||||
CY-BOCS | 23.0 (4.3) | 17.0 (6.3) | p<0.001 | Not Applicable | Not Reported | 0.69 | 14.2 (5.9) a | |
ChOCI-R child | 24.5 (6.7) | 20.0 (7.8) | p=0.014 | Not Applicable | Not Reported | 0.64 | 19.3 (8.3) a | |
ChOCI-R parent | 24.4 (7.6) | 19.3 (9.9) | p=0.012 | Not Applicable | Not Reported | 0.59 | 17.7 (8.7) a | |
CDI | 4.7 (3.4) | 4.6 (4.0) | p=n.s. | Not Applicable | Not Reported | -0.01 | 4.7 (4.2) a | |
SCAS parent | 10.7 (5.8) | 8.3 (5.9) | p=0.004 | Not Applicable | Not Reported | 0.67 | 8.4 (5.6) a | |
SCAS child | 12.9 (6.4 ) | 11.4 (7.4) | p=n.s. | Not Applicable | Not Reported | 0.27 | 10.4 ( 6.4) a | |
EWSAS child | 14.8 (9.2) | 12.8 (9.7) | p=n.s. | Not Applicable | Not Reported | 0.27 | 10.7 (9.1) a | |
EWSAS parent | 16.1 (8.6) | 11.4 (8.5) | p<0.001 | Not Applicable | Not Reported | 0.43 | 11.1 (9.2) a | |
FAS | 15.8 (11.3) | 11.2 (9.2) | p=0.003 | Not Applicable | Not Reported | 0.54 | 10.6 (10.2) a | |
Acceptability | ||||||||
Self-made questionnaire | Not Applicable | 46% of the patients were satisfied with internet- delivered format, 50% would have liked to meet a clinician 4% would have preferred face-to-face treatment Patients’ treatment rating: 32% Very Good, 32% Good 36% Ok, 0% Bad | Not Applicable | Not Applicable | Not Applicable | Not Applicable | Not Applicable | |
Feasibility | ||||||||
Treatment drop-out | Not Applicable | 8.5/12 chapters completed (2.9) Dropout = 1 | Not Applicable | Not Applicable | Not Applicable | Not Applicable | ||
Storch et al. (USA) [34] | Efficacy | |||||||
CY-BOCS | 25.4 (3.6) | 11.1 (10.5) | p<0.001 | Not Applicable | Not Reported | 1.36 | 11.3 (9.4) a | |
COIS Parent | 42.8 (23.4) | 16.8 (24.5) | p=0.005 | Not Applicable | Not Reported | 0.99 | Not Reported | |
COIS child | 38.8 (24.1) | 16.1 (19.0) | p=0.03 | Not Applicable | Not Reported | 0.46 | Not Reported | |
CGI-S | 3.8 (0.9) | 1.6 (1.8) | p<0.001 | Not Applicable | Not Reported | 1.48 | 1.4 (1.3) a | |
CGI-I | Not Applicable | 13/16 participants (81%) responder (a ≥30% reduction in CY-BOCS score and a CGI-I score of 1 or 2) | p<0.001 | Not Applicable | Not Reported | Not Applicable | Not Reported | |
CDI | 8.9 (6.7) | 7.5 (8.0) | p=n.s. | Not Applicable | Not Reported | 0.43 | Not Reported | |
MASC | 39.9 (14.8) | 33.4 (14.8) | p=n.s. | Not Applicable | Not Reported | 0.46 | Not Reported | |
FAS | 25.7 (8.6) | 16.1 (13.9) | p=0.003 | Not Applicable | Not Reported | 0.37 | Not Reported | |
Acceptability | ||||||||
PWA | Not Applicable | 19.4 (1.3) Parents’ Satisfaction | Not Applicable | Not Applicable | Not applicable | Not applicable | Not Applicable | |
Feasibility | ||||||||
Treatment drop-out | Not Applicable | Dropout = 2 | Not Applicable | Not Applicable | Not applicable | Not applicable | Not Applicable |
Feasibility
Efficacy
Risk of bias
Random sequence generation bias (selection bias) | Allocation concealment (selection bias) | Blinding of participants and personnel (performance bias) | Blinding of outcome assessment (detection bias) Patient-reported outcomes | Blinding of outcome assessment (detection bias) Evaluator-reported outcomes | Incomplete outcome data (attrition bias) Post-treatment | Incomplete outcome data (attrition bias) Follow-up | Selective reporting (reporting bias) | ||
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Comer et al. (USA) [28] | Non-RCT | Not applicable | Not applicable | Not applicable | Unclear risk | Low risk | Low risk | Not applicable | Low risk |
Comer et al. (USA) [30] | RCT | Low risk | Low risk | Unclear risk | Unclear risk | Low risk | Low risk | Low risk | Unclear risk |
Farrell et al., 2016 (Australia) [31] | Non-RCT | Not applicable | Not applicable | Not applicable | Unclear risk | Low risk | Low risk | Low risk | Low risk |
Lenhard et al., 2014 (Sweden) [32] | Non-RCT | Not applicable | Not applicable | Not applicable | Unclear risk | Unclear risk | Low risk | Low risk | Low risk |
Lenhard et al., 2017 | RCT | Low risk | Low risk | Unclear risk | Unclear risk | Low risk | Low risk | Low risk | Low risk |
Storch et al., 2011 (USA) [34] | RCT | Low risk | Low risk | Unclear risk | Unclear risk | Unclear risk | Low risk | Low risk | Low risk |