Cognitive Control in Pediatric Obsessive-Compulsive and Anxiety Disorders: Brain-Behavioral Targets for Early Intervention

doi:10.1016/j.biopsych.2020.11.012

Biological Psychiatry

Volume 89, Issue 7, 1 April 2021, Pages 697-706

https://doi.org/10.1016/j.biopsych.2020.11.012 Get rights and content

Abstract

The DSM provides distinct criteria for obsessive-compulsive disorder (OCD) and various types of anxiety disorders, but phenomenological overlap, high rates of comorbidity, and early onset suggest common underlying mechanisms. This notion is further supported by use of the same treatments—cognitive behavioral therapy and serotonin reuptake inhibitor medication—for managing both OCD and non-OCD anxiety disorders in clinical settings. While early intervention with these gold standard treatments is recommended for pediatric OCD and anxiety disorders, young patients often remain symptomatic even after treatment. To guide the development of novel, mechanistically targeted treatments to better resolve OCD and anxiety symptoms, the identification of neural circuits underlying psychological constructs with relevance across disorders has been recommended. One construct that may be relevant for understanding pediatric OCD and anxiety disorders is cognitive control, given the difficulty that young patients experience in dismissing obsessions, compulsions, and worry despite recognition that these symptoms are excessive and unreasonable. In this review, we examine findings from a growing body of literature implicating brain-behavioral markers of cognitive control in pediatric OCD and anxiety disorders, including before and after treatment. We conclude by suggesting that interventions designed to enhance the functioning of the task control circuits underlying cognitive control may facilitate brain maturation to help affected youth overcome symptoms.

Section snippets

Obsessive-Compulsive and Anxiety Symptoms: Relevance of Cognitive Control?

Distinctions between obsessive-compulsive disorder (OCD) and non-OCD anxiety disorders are codified by categorical diagnostic systems, but common underlying mechanisms are suggested by repetitive, distressing thoughts (i.e., obsessions, worries, and fears) and related avoidance behaviors across presentations. The obsessions of OCD tend to be more intrusive, bizarre, and ego-dystonic than the worries and fears of anxiety disorders, which are typically provoked by a triggering stimulus or

Cognitive Control: Definition, Development, and Focus on Relevant Subcomponents

Cognitive control is a set of capacities that support goal-directed behaviors in the face of difficulties (10). Common control processes include inhibitory control (withholding prepotent but task-irrelevant responses), conflict processing (resolving competition between response options), task switching (flexibly adjusting between tasks), and working memory (holding information in mind while carrying out a task). In addition, error monitoring (detecting and adjusting to response errors) supports

Cognitive Control in Pediatric OCD and Anxiety Disorders: A Frame for Reviewing the Evidence

Here, we focus on the inhibitory control and error-monitoring subcomponents of cognitive control that have received the most attention in the broader literature and our own work on pediatric OCD and anxiety disorders. In addition, we consider OCD across symptom clusters and the pediatric anxiety disorders across diagnostic categories (i.e., social, separation, and generalized anxiety disorders), consistent with other clinical (43,44) and neuroimaging (45) research and the commingling of OCD and

Obsessive-Compulsive Disorder

Deficient response inhibition has long been posited in OCD, given patients’ inability to suppress inappropriate thoughts and compulsive behaviors (49). Indeed, longer reaction times and more errors on tasks requiring inhibitory control are noted in affected youth and adults (12). In pediatric OCD, deficient response inhibition is most consistently evident on anti-saccade tasks (50,51). By contrast, a meta-analysis of performance across a wider variety of cognitive control subprocesses revealed

Opportunities for Clinical Translation

Collectively, the extant literature suggests that TC network alterations in pediatric OCD and anxiety could be targeted to enhance cognitive control and thereby help young patients to overcome symptoms. Given that TC networks are still developing during childhood and adolescence (20,27,31,32), an early intervention such as cognitive control training (CCT) that is targeted to more plastic TC networks may facilitate the maturation of these systems. Indeed, younger age in pediatric patients with

Conclusions

In sum, altered cognitive control and/or TC network function has been demonstrated in youth with OCD and anxiety disorders, suggesting that TC-based cognitive control alterations may underlie expression of symptoms. However, extant cross-sectional correlational data are insufficient to establish causal roles of TC networks in disease pathophysiology. Yet, data suggesting that TC networks predict and change with treatment (107,108,111) implicate these circuits in the expression of OCD and

Acknowledgments and Disclosures

This work was supported by National Institute of Mental Health Grant No. R01 MH114958 (to KDF) and Grant No. R01 MH115024 (to RM).

We thank Lana Khamash and Jenna Patterson for their assistance with formatting of this manuscript.

The authors report no biomedical financial interests or potential conflicts of interest.

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Functional alterations of tripartite neural networks during cognitive control (i.e., frontoparietal network [FPN], cingulo-opercular network, and default mode network) occur in patients with obsessive-compulsive disorder (OCD) and may contribute to illness expression. However, the degree to which changes in these networks are elicited by gold standard treatment (e.g., exposure and response prevention [EX/RP]) remains unknown. Understanding how EX/RP modulates network connectivity in adolescent versus adult patients with OCD may aid the identification of developmentally sensitive treatment targets that enhance cognitive control.
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Citation Excerpt :
Clinicians follow the Statistical Manual of Mental Disorders and International Classification of Disease and Diagnostic as the diagnostic criteria of OCD, but the existing diagnostic methods are too subjective. Moreover, OCD is often confused with other diseases, such as depression and anxiety (Fitzgerald et al., 2021). To solve this problem, we propose an objective diagnosis method of OCD based on neuroimaging.
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ReviewCognitive Control in Pediatric Obsessive-Compulsive and Anxiety Disorders: Brain-Behavioral Targets for Early Intervention

Abstract

Section snippets

Obsessive-Compulsive and Anxiety Symptoms: Relevance of Cognitive Control?

Cognitive Control: Definition, Development, and Focus on Relevant Subcomponents

Cognitive Control in Pediatric OCD and Anxiety Disorders: A Frame for Reviewing the Evidence

Obsessive-Compulsive Disorder

Opportunities for Clinical Translation

Conclusions

Acknowledgments and Disclosures

Clin Psychol Rev

J Am Acad Child Adolesc Psychiatry

Clin Psychol Rev

Behav Res Ther

J Behav Ther Exp Psychiatry

Pers Individ Dif

Cogn Psychol

Biol Psychiatry

Trends Cogn Sci

Trends Cogn Sci

Neuron

Trends Cogn Sci

Curr Opin Neurobiol

Dev Cogn Neurosci

Trends Cogn Sci

Handb Clin Neurol

Neuroimage

Dev Cogn Neurosci

Dev Cogn Neurosci

Dev Rev

J Am Acad Child Adolesc Psychiatry

Psychiatr Clin North Am

Neurosci Biobehav Rev

Dev Cogn Neurosci

J Anxiety Disord

Biol Psychiatry

Neurosci Lett

Psychiatry Res Neuroimaging

Biol Psychiatry

Eur Psychiatry

Biol Psychol

Brain Res Bull

Trends Cogn Sci

J Am Acad Child Adolesc Psychiatry

Biol Psychiatry

J Am Acad Child Adolesc Psychiatry

J Am Acad Child Adolesc Psychiatry

J Anxiety Disord

Int J Psychophysiol

Dev Cogn Neurosci

Diagnostic and Statistical Manual of Mental Disorders (DSM-5)

Avoidance learning: A review of theoretical models and recent developments

Front Behav Neurosci

Exposure Therapy for Anxiety: Principles and Practice

An integrative theory of prefrontal cortex function

Annu Rev Neurosci

Distinct brain networks for adaptive and stable task control in humans

Proc Natl Acad Sci U S A

The contribution of network organization and integration to the development of cognitive control

PLoS Biol

Wandering minds: The default network and stimulus-independent thought

Science

The human brain is intrinsically organized into dynamic, anticorrelated functional networks

Proc Natl Acad Sci U S A

Functional connectivity in the resting brain: A network analysis of the default mode hypothesis

Proc Natl Acad Sci U S A

A default mode of brain function

Proc Natl Acad Sci U S A

Review
Cognitive Control in Pediatric Obsessive-Compulsive and Anxiety Disorders: Brain-Behavioral Targets for Early Intervention