Understudied Clinical Dimensions in Pediatric Obsessive
Adam B. Lewin•Nicole Caporino•Tanya K. Murphy•
Gary R. Geffken•Eric A. Storch
Published online: 20 July 2010
? Springer Science+Business Media, LLC 2010
of insight, avoidance, indecisiveness, overvalued responsibility, pervasive slowness, and
pathological doubting among youth with Obsessive-compulsive disorder (OCD) using the
ancillary items on the Children’s Yale-Brown Obsessive Compulsive Scale (CY-BOCS).
These factors are believed to be relevant to the clinical presentation of youth with OCD but
remain understudied. Eighty-nine youth with OCD were administered the CY-BOCS,
including six subsidiary items aimed at the constructs of interest in this research. Partic-
ipants also completed measures of OCD symptom clusters, depressive and anxious
symptoms, externalizing/internalizing behavioral problems, and functional impairment.
Associations between OCD symptom clusters and insight, avoidance, indecisiveness,
overvalued responsibility, pervasive slowness, and pathological doubting are presented.
Low insight, significant avoidance, indecisiveness, pervasive slowness and excessive sense
of responsibility were all related to elevations in functional impairment. Clinical
improvement in OCD severity was related to reductions in avoidance, doubting, and sense
of responsibility. The six ancillary items of the CY-BOCS appear to be a practical and
valid assessment of several constructs that are prognostically linked to cognitive-behav-
ioral therapy outcomes in youth with OCD. Implications for clinicians are discussed.
The present study aimed to assess the phenomenology and treatment sensitivity
Children’s Yale-Brown Obsessive Compulsive Scale (CY-BOCS) ? Children ?
Insight ? Cognitive-behavioral therapy (CBT)
Obsessive-compulsive disorder (OCD) ?
A. B. Lewin (&) ? N. Caporino ? T. K. Murphy ? E. A. Storch
Department of Pediatrics, Rothman Center for Neuropsychiatry, University of South Florida College
of Medicine, 800 Sixth Street South, Fourth Floor North, Box 7523, Saint Petersburg, FL 33701, USA
G. R. Geffken
Department of Psychiatry, University of Florida College of Medicine, Gainesville, FL, USA
Child Psychiatry Hum Dev (2010) 41:675–691
The presence and magnitude of the characteristic features of obsessive-compulsive dis-
order (OCD), namely obsessive thoughts and ritualistic behaviors, are typically used as the
basis for estimating syndrome severity. The Children’s Yale-Brown Obsessive Compulsive
Scale (CY-BOCS) , a clinician-administered semi-structured interview, is the most
commonly used measure of the presence and severity of obsessive-compulsive symptoms
among youth. Psychometric evaluations of the CY-BOCS have consistently demonstrated
the instrument’s validity and reliability [1–3], and treatment sensitivity across numerous
clinical trials [4–7]. More specifically, symptom severity, assessed using the CY-BOCS, is
based on patient endorsement of: time occupied by, interference and distress from, resis-
tance to, and control over obsessions and compulsions.
Based on clinical observations, the developers of the CY-BOCS and its parallel version
for adults (Y-BOCS; Yale Brown Obsessive Compulsive Inventory)  posed that the
following six clinical dimensions are also relevant in the characterization of OCD: insight,
avoidance, degree of indecisiveness, overvalued sense of responsibility, pervasive slow-
ness, and pathological doubting. Each of these dimensions (e.g., pathological doubting) has
been linked conceptually and anecdotally to one or more OCD symptom types (e.g.,
checking) and/or may be related to treatment outcomes. Although assessment of these
domains provides qualitatively rich information about the clinical presentation of pediatric
OCD, information regarding the nature or clinical correlates of these constructs is limited
in scope. The following is a brief review of each of these ‘‘ancillary’’ constructs assessed
via the CY-BOCS.
Insight into Obsessions and Compulsions
Insight refers to recognition of the senselessness of one’s obsessions and compulsions .
Poor insight has been associated with increased OCD symptom severity and comorbidity
[10–12]. Further, diminished insight may be related to early onset of symptoms and greater
duration of illness . A recent study found that youth with OCD who had poor insight
exhibited diminished intellectual functioning, greater depressive symptoms, more
impairments in adaptive functioning, and less perceived control over their environment
than youth with OCD who had adequate insight . Additionally, in adults, diminished
insight has been linked to more complex presentation of OCD, increased symptom
severity, greater likelihood of being prescribed atypical antipsychotics, higher likelihood of
schizophrenia spectrum/schizotypal symptoms, and worse prognosis . Finally, poor
insight has predicted poorer responses to both pharmacological and cognitive-behavioral
interventions for OCD in adults [15–20]. Moreover, while insight is a DSM-IV-TR 
diagnostic requirement for OCD in adults, youth with OCD can be diagnosed with the
qualifier of ‘‘with poor insight’’ (pg. 463). The CY-BOCS (item 11) offers a reliable
method for assessing insight in youth with OCD .
Avoidance of stimuli or situations eliciting anxiety is a hallmark characteristic of child-
hood and adult OCD , as well as other anxiety disorders . For example, harm
avoidance is common among adults with OCD , especially in comparison to controls
[25–27]. Avoidance, which some conceptualize as a compulsion in its own right, is often
the target of exposure/response prevention (E/RP) treatments [28, 29]. Like active rituals,
676 Child Psychiatry Hum Dev (2010) 41:675–691
avoidance may dispel anxiety in the short-term and is consequently maintained via neg-
ative reinforcement. However, avoidance maintains a child’s anxiety over time  and
disrupts the development of constructive strategies for mitigating fear . Further, high
levels of avoidance may be associated with severe functional impairment (e.g., school and
peer avoidance) [32, 33] and consequently marked accommodation [34, 35] and disability.
Although behavioral avoidance tasks [36, 37] and other observation-based assays of
avoidance may be ideal, there has been little application of such tasks to pediatric OCD;
thus, the CY-BOCS (item 12) offers an efficient alternative.
Degree of Indecisiveness
Indecisiveness, similar to avoidance, can manifest as a symptom of OCD. For example,
individuals have marked anxiety in situations requiring deliberation (often including
mundane, routine decision-making) . In non-clinical samples of adults, indecisiveness
has been highly associated with obsessive-compulsive tendencies [39, 40]. In adults 
and children  with OCD, indecisiveness has been most closely linked to hoarding.
Overall, this dimension remains understudied, especially in youth with OCD.
Overvalued Sense of Responsibility
Research suggests a central role of inflated responsibility among individuals with OCD
, especially among children and adolescents . An extension of this exaggerated
sense of responsibility is Thought-Action Fusion (TAF) [45, 46], a process by which
having an intrusive thought about a negative event is equated with wanting (or increasing
the likelihood) of that event occurring. For example, individuals with OCD are more likely
to believe a negative event will occur as a consequence of their negative thoughts  and
accordingly hold an erroneous sense of responsibility. These tendencies may distinguish
OCD from other anxiety disorders and are directly correlated with OCD symptom severity
[48, 49], although findings are mixed .
Pervasive Slowness/Disturbance of Inertia
Parents of youth with OCD frequently describe their child ‘‘getting stuck’’ or requiring
excessive amounts of time to complete simple, routine tasks. In severe cases of OCD,
pervasive obsessive slowness must be distinguished from catatonia, depressive psycho-
motor retardation, or bradykinesia. Slowness in patients with OCD may be due to a
hindrance in initiating goal-directed behavior as well as substantial consumption of neu-
rocognitive resources by suppressing obsessive thoughts and/or engaging in ritualistic
Clinically, obsessive doubt is commonplace among youth with OCD and often manifests as
uncertainty regarding the completion of school assignments, completing other activities, or
performing a task correctly. In more severe cases of pathological doubt, patients may
question their own perceptions, senses, or memory. Qualitative clinical experiences sug-
gest that children often attempt to mitigate anxiety associated with doubting obsessions via
excessive reassurance seeking, questioning, repeating or checking. Doubting is also
Child Psychiatry Hum Dev (2010) 41:675–691677
understudied in children, especially as it relates to treatment response. Added emphasis on
understanding internal symptoms such as obsessive doubt may be warranted given that
they are more difficult to assess (and treat using E/RP) than more overt rituals . Doubt
is believed to be a critical element in the development and presentation of OCD  and
has been shown to represent a relatively distinct domain in individuals with OCD .
In summary, insight, avoidance, degree of indecisiveness, overvalued sense of responsi-
bility, pervasive slowness, and pathological doubting are hypothesized to be relevant to the
phenomenology, clinical presentation, and treatment outcomes among youth with OCD.
Nevertheless, the majority of these domains remain understudied, especially in children
and adolescents. Accordingly, the present study provides the first empirical evaluation of
these constructs (as assessed via the CY-BOCS ancillary items), their clinical correlates,
and treatment sensitivity. Specifically, we will examine relations between these under-
studied clinical dimensions and: (a) OCD symptom dimensions (e.g., hoarding, checking,
washing); (b) comorbid symptomology (e.g., depression and anxiety); (c) school, familial,
daily living, and social impairment; and (d) treatment sensitivity [specifically, relations to
symptom improvement following cognitive-behavioral therapy (CBT)].
Participants were eighty-nine children and adolescents (37.5% females) with a primary
diagnosis of OCD and their parents who presented for clinical evaluation at a southeastern
United States university-based tertiary care child and adolescent psychiatry clinic spe-
cializing in OCD. Participants’ mean age was 12.6 years (SD = 2.8; range = 8–17 years).
The majority of participants were Caucasian (88%) followed by Hispanic American
(4.5%), other races/ethnicities (4.5%), and African American (2.3%). Fifty-nine partici-
pants met criteria for at least one additional diagnosis (34% met criteria for two or more
additional diagnoses). Twenty-eight percent of the participants had a comorbid non-OCD
anxiety disorder; 26% had a disruptive behavior disorder, 17% had a mood disorder, 13%
had a tic disorder, and 3% had trichotillomania.
All diagnoses [e.g., OCD and comorbid diagnoses, e.g., tic disorders, anxiety disorders,
mood disorders, Attention Deficit Hyperactivity Disorder (ADHD)] were made by a
licensed clinical psychologist or psychiatrist, according to criteria outlined in the DSM-IV-
TR (American Psychiatric Association ). The Anxiety Disorders Interview Schedule
for Children/Parents (ADIS-C/P)  was administered immediately prior to treatment in
order to confirm diagnoses. Other clinical information (e.g., from the CY-BOCS) was also
used as appropriate. Only youth for whom a primary diagnosis of OCD was made with
complete certainty were included. Among participants, 31% met criteria for an anxiety
disorder (17% with Generalized Anxiety Disorder), 27% met criteria for ADHD, 17% for a
mood disorder, 12% for a tic disorder, and 7% with Oppositional Defiant Disorder of
Disruptive Behavior Disorder Not Otherwise Specified (NOS).
Post-treatment data were collected for 57 participants. Treatment consisted of weekly
CBT with exposure and response prevention using conventional procedures for youth with
OCD [29, 56, 57]. Treatment data were not available for the remaining participants
678 Child Psychiatry Hum Dev (2010) 41:675–691
because these individuals did not seek treatment at our clinic for various reasons (e.g.,
distance from home, seeking a second opinion only, and insurance/financial limitations).
Demographic (age, gender, ethnicity) and clinical (comorbidity, OCD severity, ratings on
CY-BOCS ancillary items) variables did not differ from individuals on whom treatment
data were obtained.
Children’s Yale-Brown Obsessive Compulsive Scale
Considered the gold-standard for assessing symptom severity , the CY-BOCS Severity
Scale  consists of ten items measuring obsession and compulsion severity over a 1-week
interval. The CY-BOCS is a clinician-rated semi-structured interview (with both the parent
and child together) and takes 30–45 min. Separate Obsession and Compulsion Severity
Scores are derived by summing the applicable five-items (distress related to obsessions/
compulsions, frequency, interference, resistance, and symptom control); a Total Score is
derived by summing all severity items. CY-BOCS Severity scores range from 0 to 40 for
the Total severity; 0–20 on the Obsession and Compulsion severity. In addition to the
Severity Scale items, six supplemental items are included to assess: insight, avoidance,
indecisiveness, sense of responsibility, pervasive slowness, and pathological doubt. Scores
on these items range from 0 to 4 (0 = none, 1 = mild, 2 = moderate, 3 = severe,
4 = extreme). Although the six supplemental constructs are scored as single items, the
semi-structured nature of the CY-BOCS allowed the clinician to rate each item based on a
series of queries. For example, for the insight item, the rater may ask, ‘‘Do you think your
concerns or behaviors are unreasonable? What do you think would happen if you did not
perform the compulsion? Are you convinced something would really happen?’’ Ratings are
achieved similarly for the other five supplemental items. Follow-up queries are also per-
mitted. With the exception of items focused on internal rituals and covert obsessive
thoughts, parent ratings were emphasized in cases of parent-child disagreement, although
the clinician-rater was given discretion.
Finally, the CY-BOCS Symptom Checklist consists of 62 relatively common obsessions
and compulsions organized into seventeen distinct categories (e.g., contamination obses-
sions, washing/cleaning compulsions). Obsessions and compulsions are rated in a yes/no
fashion according to their current presence. The CY-BOCS has demonstrated excellent
psychometric properties, including internal consistency, test–retest stability, inter-rater
reliability, convergent and divergent validity [1, 2], and treatment sensitivity [4–7].
Cronbach’s alpha for the 10 severity items was acceptable at a = .81  based on the
present sample of youth.
Anxiety Disorders Interview Schedule for DSM-IV: Child and Parent Version 
The ADIS-C/P is a clinician-administered semi-structured diagnostic interview that
assesses major DSM-IV anxiety disorders and associated psychopathology (i.e., disruptive
behavior disorders, psychotic disorders, mood disorders and eating disorders) in school-
aged children and adolescents. Severity ratings are assigned using a scale that ranges from
0 to 8, with 4 indicating a clinically significant disorder. Inter-rater agreement, test–retest
reliability, and treatment sensitivity have been demonstrated [58, 60, 61]. The measure was
administered by trained clinicians.
Child Psychiatry Hum Dev (2010) 41:675–691 679
Obsessive-Compulsive Inventory—Child Version (OCI-CV)
The OCI-CV  is a 21-item self report measure of obsessive-compulsive symptoms.
Each item is rated on a 3-point Likert-type scale that yields symptom severity scores across
the following domains: washing, checking, ordering, obsessing, hoarding, neutralizing, and
doubting. Strong internal consistency and construct validity has been demonstrated .
The internal consistency of the OCI-CV in this study was acceptable (a = .84).
Child Obsessive Compulsive Impact Scale, Revised, Child and Parent Versions
The COIS-R-C/P  are child and parent report measures of the extent to which
obsessive-compulsive symptoms cause impairment across the domains of school activities,
social activities, home/family activities, and daily living skills. Respondents rate the extent
to which OCD interferes with the child’s functioning in each area using a 4-point scale
ranging from ‘‘not at all’’ to ‘‘very much.’’ The COIS-R has demonstrated good reliability
, construct validity , and treatment sensitivity . Estimates of the internal con-
sistency of the COIS-R-C/P were high (a = .89 and .92).
Child Behavior Checklist
The CBCL  consists of 113-items that measure how frequently a range of internalizing
and externalizing symptoms have occurred over the past 6 months. Items are rated on a
3-point scale, ranging from ‘‘not true (as far as you know)’’ to ‘‘very true or often true.’’
Eight subscales are embedded within the CBCL; as well, an Internalizing Problems
Composite score (based on Withdrawn, Somatic Complaints, and Anxious/Depressed
subscales), an Externalizing Problems Composite score (based on Delinquent Behavior,
and Aggressive Behavior subscales), and a Total Score are computed. Widely used, the
CBCL has demonstrated reliability and construct validity .
Multidimensional Anxiety Scale for Children (MASC)
The MASC  is a 39-item child-report measure of a range of anxiety symptoms.
Responses to all items are summed to derive a total score; four subscale scores measuring
physical symptoms, social anxiety, harm avoidance, and separation anxiety can also be
derived. Widely used, the MASC has demonstrated strong psychometric properties
[64–67]. For example, Rynn et al.  found strong convergence with other self-report
measures of anxiety symptoms; divergence with a measure of depressive symptoms; and
that the MASC subscales discriminated between anxious and depressed youth. Cronbach’s
a for the MASC total score was .72.
Children’s Depression Inventory (CDI)
The CDI  is a commonly used child-report measure of the presence and severity of 27
cognitive, affective, and behavioral symptoms of depression. For each item, children select
one of three statements that best indicates how they have been feeling over the past 2 weeks,
CDI has demonstrated good internal consistency, test–retest reliability, construct validity
[69–71], and treatment sensitivity . Cronbach’s a for the CDI total score was .74.
680Child Psychiatry Hum Dev (2010) 41:675–691
Board. The purpose of the study was explained and written parental consent and child assent
was obtained by the study investigator at the time of the child’s initial evaluation. Immedi-
ately after obtaining consent and assent, the CY-BOCS was administered to the child and
parent jointly in a private room. Interviewers (clinical psychologists, child/adolescent psy-
chiatrists, and postdoctoral fellows in clinical psychology) each had significant experience
sessions. Inter-rater reliability (obtained via clinician review of videotaped CY-BOCS
administrations) was high for a random subset (25%) of this sample [Intraclass correlation
coefficient (ICC) = .99] . Following the CY-BOCS administration, instructions were
treatment, an identical battery of measures was presented following the last therapy session.
Families were not provided with any tangible compensation for their participation in this
study. Total time of participation was approximately 45 min (excluding consent procedures
and administration of the structured diagnostic interview).
Internal consistency was assessed using coefficient alpha and inter-rater reliability via ICC.
Means and standard deviations werecalculated for each of the sixCY-BOCS ancillary items
(insight, avoidance, degree of indecisiveness, overvalued sense of responsibility, pervasive
age (using t-tests and Spearman’s rank order correlations). Spearman’s rank-order correla-
tions were used to examine associations between CY-BOCS ancillary domains and OCD
the ancillary items based on the presence/absence of OCD symptoms reported on the
CY-BOCS Symptom Checklist. Dimensional comparisons between CY-BOCS ancillary
items and theMASC,CDIand CBCL were completed using Spearman’scorrelations; t-tests
assessed via the COIS-R. Finally, a series of paired t-tests were used to examine pre- to post-
treatment changes in CY-BOCS ancillary items and correlations were used to determine
from post-treatment scores) were associated with changes in CY-BOCS severity scores.
the risk between types I and II errors.
Means and standard deviations are presented in Table 1. Also, the frequencies with which
each ancillary item was rated as mild or greater (i.e., mild, moderate, severe, or extreme)
Child Psychiatry Hum Dev (2010) 41:675–691681
and as severe or extreme are reported. The majority of the sample was rated at least mild
on each dimension except for inflated responsibility. Pervasive slowness was rated severe
or extreme relatively frequently (39%), followed by avoidance (23.5%). CY-BOCS
ancillary items did not differ as a function of gender. Insight was positively correlated with
age (younger participants reporting less insight; r =-.24, p\.01).
Briefly, psychometric properties of the ancillary CY-BOCS items were examined. Strong
consistency (a = .81) was acceptable for the CY-BOCS, inclusive of the ancillary items.
OCD Symptom Dimensions and CY-BOCS Ancillary Items
Table 2 displays correlations among CY-BOCS ancillary items and OCD symptom
dimension scores based on the OCI-CV. Avoidance was strongly associated with obsession
severity, compulsion severity, and total CY-BOCS scores. Indecisiveness and pervasive
slowness were each related to total CY-BOCS scores; the former was also related to
obsession severity while the latter was related to compulsion severity. With respect to
OCI-CV symptom dimensions, indecisiveness was directly associated with hoarding,
ordering, doubting, and neutralizing. Overvalued responsibility was related to checking,
ordering, doubting, and neutralizing symptoms. Pervasive slowness was positively corre-
lated with neutralizing and hoarding symptoms. Finally, pathological doubting was
robustly associated with endorsement of checking and doubting symptom clusters.
Associations among CY-BOCS ancillary items and comorbid clinical symptoms were
examined dimensionally (e.g., depressive, anxiety, internalizing and externalizing symp-
toms on the CDI, MASC and CBCL respectively; see Table 3) and categorically (based on
DSM-IV-TR diagnostic criteria).
Table 1 Means and standard
deviations for CY-BOCS severity
scores and responses to ancillary
CY-BOCS Children’s Yale-
Brown Obsessive Compulsive
CY-BOCSTotal samplePercent of the sample
Obsession 11.66 (2.91)––
Compulsion 12.51 (2.83)––
Insight1.07 (1.18) 54%18%
Avoidance1.37 (1.25) 65%23.5%
Indecisiveness1.20 (1.16) 58%16.5%
Sense of responsibility0.75 (1.00) 45%6%
Pervasive slowness 1.69 (1.37)68%39%
Pathological doubting1.14 (1.07) 61%12%
682 Child Psychiatry Hum Dev (2010) 41:675–691
Table 2 Correlations among CY-BOCS ancillary items and OCI-CV symptom dimension scores
Sense of responsibility
CY-BOCS Children’s Yale-Brown Obsessive Compulsive Scale, OCI-CV obsessive compulsive inventory, child version
* p\.05; ** p\.01; *** p\.001
Child Psychiatry Hum Dev (2010) 41:675–691683
Indecisiveness was positively associated with scores for anxiety symptoms (r = .47,
p\.01), depressive symptoms (r = .31; p\.05), and internalizing problems (r = .33,
p\.01). Similarly, youth meeting DSM-IV-TR criteria for a non-OCD anxiety disorder
t(85) = -2.0, p = .05 or a mood disorder (t = -2.1, p = .04) were rated has having
higher levels of indecisiveness. However, youth with ADHD were rated as having less
indecisiveness, t(84) = -2.2, p = .04.
Sense of responsibility was also related to anxiety symptoms (r = .41, p\.01) and
internalizing problems (r = .27, p\.05).
Pervasive Slowness and Avoidance
Pervasive slowness and avoidance related to the presence of internalizing problems
(r = .24 and r = .25, respectively; p\.05).
Pathological Doubt and Insight
Items assessing pathological doubting and insight were not significantly associated with
depressive symptoms, anxiety symptoms, or internalizing problems. However, patients
with a comorbid tic disorder diagnosis were rated as having less insight t(83) = -4.2,
p\.001. There were no other differences on the CY-BOCS ancillary items on the basis of
diagnostic comorbidity or symptom severity.
Functional Impairment and CY-BOCS Ancillary Items
CY-BOCS ancillary items were examined in relation to parent and child reports of
impairment in several domains of functioning: Daily Living, School, Family, and Social
(see Table 4). Insight was not related to parent- or child-reported functional impairment in
any domain. Avoidance was strongly and positively associated with parent-rated impair-
ment in family functioning (r = .44, p\.01) and functioning in social situations (r = .42,
p\.01); correlations with child ratings showed the same pattern (r = .30, p\.05 for
both domains). Indecisiveness was related to child-rated impairment in daily living
Table 3 Correlations among
CY-BOCS ancillary items and
anxiety symptoms, depressive
symptoms, internalizing prob-
lems, externalizing problems, and
CY-BOCS Children’s Yale-
Brown Obsessive Compulsive
* p\.05; ** p\.01
684Child Psychiatry Hum Dev (2010) 41:675–691
(r = .29, p\.05) and school performance (r = .28, p\.05) only. Sense of responsibility
was positively associated with child-rated impairment in family functioning (r = .25,
p\.05) and functioning in social situations (r = .23, p\.05). With the exception of
parent-rated impairment in social situations, pervasive slowness was related to all
impairment scores (coefficients range from r = .27 to r = .46; p\.05). Pathological
doubting was significantly associated with child-rated impairment in school functioning
only (r = .36, p\.01).
Treatment and CY-BOCS Ancillary Items
None of the scores on the CY-BOCS ancillary items, at pretreatment, were related to
CY-BOCS Severity change scores (pre-to-post treatment). However, a significant reduc-
tion in scores (from pre- to post-treatment) was found for all of the ancillary items: insight,
t(41) = 3.49, p\.01; avoidance, t(36) = 3.25, p\.01; indecisiveness, t(36) = 3.33,
p\.01; sense of responsibility, t(36) = 3.29, p\.01; pervasive slowness, t(36) = 4.97,
p\.01; and pathological doubting, t(36) = 4.31, p\.01.
Moreover, treatment-related reductions in the CY-BOCS severity score were associated
with reductions in avoidance (r = .40, p = .01), sense of responsibility (r = .47, p\.01),
and pathological doubting (r = .35, p\.05). Similar patterns were observed for reductions
in CY-BOCS obsessions and compulsions severity. Changes in insight, indecisiveness, or
pervasive slowness did not relate significantly to changes in CY-BOCS total severity,
CY-BOCS obsession severity, or CY-BOCS compulsion severity scores (Table 5).
Table 4 Correlations among CY-BOCS ancillary items and parent- and child-rated functional impairment
CY-BOCS ancillary items Child-rated impairmentParent-rated impairment
Insight-.03-.00-.03-.09-.01 .00 .01-.09
Avoidance .20.07.30*.30*.25* .22.44**.42**
Indecisiveness.29*.28* .23 .23 .12.15.12 .06
Sense of responsibility .09.20.25*.23* .05.15.13 .12
Pervasive slowness.46**.35**.30*.27*.52** .42**.30**.16
Pathological doubting.22 .36** .16.12 .18.20-.02-.01
CY-BOCS Children’s Yale-Brown Obsessive Compulsive Scale
* p\.05; ** p\.01
Table 5 Correlations between
change in CY-BOCS ancillary
items and change in symptom
CY-BOCS Children’s Yale-
Brown Obsessive Compulsive
* p\.05; ** p\.01
CY-BOCS ancillary itemsTotal
Insight .07.13 .01
Sense of responsibility .47**.45**.48**
Pathological doubting.35* .35*.34*
Child Psychiatry Hum Dev (2010) 41:675–691685
The purpose of this study was to provide a preliminary investigation of six constructs,
conceptualized to be clinically relevant in pediatric OCD, as they are assessed using the
CY-BOCS subsidiary items. Specifically, we examined clinical correlates and treatment
sensitivity of clinician-rated insight, avoidance, degree of indecisiveness, overvalued sense
of responsibility, pervasive slowness, and pathological doubting in a sample of 89 youth
Few correlates of insight were identified in the present sample. One exception—con-
sistent with previous findings—was that younger age was associated with reduced insight
. Interestingly, youth with a comorbid disorder had lower insight versus those without.
A possible explanation for this is OCD symptom variability among youth with comorbid
OCD and a tic disorder . For example, sensory-focused obsessions (i.e., ‘Tourettic
OCD’)  or ‘just right’ phenomena may be less likely to translate into clear insight that
obsessions and compulsions are unreasonable. Contrary to findings in adults [18, 19],
changes in insight were not predictive of changes in OCD symptom severity following
CBT, nor did insight relate to impairment or the presence of other comorbidity symptoms
(e.g., depression or anxiety). The reasons for this discrepancy are unclear. One possibility
is that the majority of youth were rated has having good or excellent insight, leading to a
restriction of range. Similarly, we may have lacked statistical power to detect a relationship
in present sample.
Avoidance was strongly related to the severity of both obsessions and compulsions and
was moderately associated with the presence of internalizing problems. More notably, the
presence of avoidance was consistently linked to pervasive functional impairments across
most domains, as assessed by both the child and parent. Such findings lend support to the
notion of avoidance serving in a similar manner as rituals in their impact on functioning;
pre-treatment assessments should attend to levels of avoidance to help determine treatment
targets. Although somewhat surprising, avoidance did not correlate with externalizing
behaviors (as rated by the parent on the CBCL). However, this finding suggests that
avoidance is specific to the OCD and is not a sign of oppositionality or defiance. Finally,
reductions in avoidance following CBT were strongly associated with changes in overall
OCD severity. These data combine to suggest that reducing OCD-related avoidance
behavior has significant consequences for mitigating functional impairment and for
facilitating clinical improvement.
Degree of indecisiveness was associated with obsessions but not compulsions. Increased
indecisiveness was linked to the degree of ordering, doubting, neutralizing, and hoarding
inherent in the aforementioned OCD symptom clusters (e.g., ‘‘should I save this item?’’ or
‘‘did I do this right?’’). Greater indecisiveness was also linked to the presence of anxiety and
is not surprising given that impulsivity is a hallmark of ADHD whereas problems with
decision making are commonly reported across mood and anxiety disorders. Moreover,
indecisiveness was associated with child-related impairment in school and daily living (e.g.,
problems deciding on answers on assignments), perhaps due to vacillating between answers
on examinations or struggling to make simple decisions posed by a parent or teacher.
Although an overvalued sense of responsibility was not linked to OCD severity,
responsibility was associated with checking, neutralizing, doubting, and ordering. It stands
to reason that among youth who blame themselves for matters beyond their control (and/or
experience high levels of TAF), checking, neutralizing, and doubting symptoms would be
686 Child Psychiatry Hum Dev (2010) 41:675–691
elevated in order to neutralize these fears. Not surprisingly, overvalued responsibility was
strongly related to anxiety and reductions in overvalued responsibility were strongly
correlated with improvements in overall OCD symptom severity. These findings are
consistent with the extant literature suggesting the robustness of TAF in anxiety disorders
and their sensitivity to treatment .
Pervasive slowness, often described as particularly frustrating to parents of youth with
OCD, was associated with increased severity of compulsions (but not obsessions). This
finding is also logical given that CY-BOCS assay of slowness focuses on behaviors and
activities, not cognitions. Individuals who hoard are more likely to endorse excessive
slowness, consistent with extant findings . Not surprisingly, the presence of excessive
slowness is linked to internalizing symptomatology and is the most robust correlate of
functional impairment, across domains and raters (parent and child). Getting ‘‘stuck’’ in
rituals may account for tardiness, missed assignments, problems completing tests, conflict
with family, and lack of understanding by peers. Whereas obsessions can be disguised,
slowness is pervasive and hard to overcome.
Pathological doubting was positively correlated with the level of checking or doubting
symptoms reported. Given that youth with OCD commonly utilize checking compulsions to
in doubting was also associated with clinical improvements (i.e., reductions in severity in
both obsessions and compulsions). This supports the use of cognitive-behavioral interven-
to rituals potentiated by doubting obsessions or (b) habituation—instructing the patient to
dwell on the worry without compensatory actions . In addition, thought-stopping,
restructuring and other cognitive approaches have utility, especially in adolescents [75, 76].
In summary, the six ancillary items of the CY-BOCS (which typically require less than
10 min to administer), provide rich information regarding clinical constructs that many
believe to be connected to, if not fundamental characteristics of, OCD. Although this is the
first empirical investigation of the supplemental items of the CY-BOCS, our data suggest a
pattern of symptoms that are prognostically linked to CBT. Specifically, reductions in
avoidance, pathological doubting, and over-responsibility are associated with clinical
improvement overall. It is possible that interventions targeting these constructs, e.g.,
experiential avoidance [77, 78], may facilitate response to treatment. Moreover, routine
assessment of these domains may assist clinicians in determining optimal components and
strategies for therapeutic approaches (e.g., balancing the order and amount of education,
behavioral, and cognitive techniques based on factors such as insight, avoidance, and
doubt). Finally, these data highlight associations between avoidance and impairment as
well as slowness and impairment. (To a lesser extent, indecision and doubt were each
associated with impairment as well.) These ‘ancillary’ domains might mediate the rela-
tionship between OCD severity and functional impairment, explaining why OCD symptom
severity is not perfectly correlated with impairment in youth [33, 79].
Limitations and Future Directions
One limitation of the present research is that each construct was assessed via a single item.
Fortunately, an increasing number of more comprehensive assessment instruments are
Child Psychiatry Hum Dev (2010) 41:675–691687
being validated for use with youth who have OCD [40, 80–82], e.g., the Brown Assessment
of Beliefs Scale, the Overvalued Ideas Scale, and the Thought Action Fusion Scale. Our
data suggest that the CY-BOCS ancillary items can be used as an initial ‘‘screening’’ to
determine whether further assessment is warranted. Additionally, our sample size limited
the ability for multivariate analysis of these data, especially with regard to diagnostic
comorbidity. Consequently, replication with a larger cohort of youth and extension to more
comprehensive rating scales may help improve our understanding regarding the contri-
bution of these constructs to OCD (and to treatment success). Further, due to the
exploratory nature of this research, correction for multiple comparisons was not employed.
Nevertheless, it is noteworthy that despite limited statistical power and reliance on single-
item inventories, the CY-BOCS ancillary items provide meaningful data on factors related
to symptom severity, comorbidity, symptom topography and most notably, treatment
outcome and functional impairment.
This study examined supplemental constructs assessed via the Children’s Yale-Brown
Obsessive Compulsive Scale (CY-BOCS): insight, avoidance, indecisiveness, overvalued
responsibility, pervasive slowness, and pathological doubting. Participants were 89 chil-
dren and adolescents with Obsessive-compulsive disorder (OCD) and their parents. The
majority of the supplemental constructs were related to multiple OCD symptom clusters.
Avoidance, indecisiveness, and pervasive slowness were each associated with the severity
of obsessions, compulsions, or overall OCD symptoms. With the exception of insight and
doubting, all of the constructs were related to comorbid internalizing but not externalizing
problems. Most notably, each construct was significantly associated with functional
impairment and decreases in avoidance, pathological doubting, and sense of responsibility
were positively associated with overall symptom reductions in cognitive-behavioral ther-
apy. Taken together, the findings suggest that routine assessment of these constructs using
ancillary items of the CY-BOCS could assist with treatment planning.
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