Two categories of beliefs have been found to be important to the development and maintenance of adult and pediatric obsessive-compulsive disorder (OCD): cognitive beliefs and metacognitive beliefs. Cognitive beliefs refer to general or social beliefs, and noteworthy beliefs relevant to OCD symptoms include exaggerated personal responsibility, intolerance of uncertainty, and perfectionism. Metacognitive beliefs refer to beliefs about thought itself, and metacognitive beliefs relevant to OCD symptoms include positive and negative beliefs about worry (i.e., perceived benefits and consequences of worry, respectively), cognitive confidence (i.e., faith in one’s memory and attention), beliefs that thoughts need to be controlled, and cognitive self-consciousness (i.e., tendency to focus attention on thought processes).
Researchers, having found age differences in OCD symptom presentation, have been interested in examining age differences in the clinical importance of cognitive and metacognitive beliefs to OCD. Children as young as 5 display metacognitive understanding, which continues to develop as they grow older. Children and adolescents can exhibit compulsions without well-defined obsessions, and they may have difficulty identifying or articulating obsessions underlying compulsions, suggesting beliefs are not as relevant to their symptoms and may become more salient (or at least more recognizable) over time as a function of age. Research examining the relationship between age and cognitive and metacognitive beliefs in pediatric OCD is limited and has yielded mixed results.
The current study added to existing literature by simultaneously examining the relations between these beliefs to OCD symptoms in both children and adolescents with OCD, and the moderating effect age may have on the relations between these two factors. Clinician-rated measures of OCD, in addition to self-report measures, were used to further expand upon the literature. We hypothesized there would be moderate positive relationships between cognitive and metacognitive beliefs and pediatric OCD symptom severity, and that age would positively moderate the relationship between these beliefs and OCD symptom severity. As a secondary aim, we compared differences in beliefs between children and adolescents with OCD. Hypotheses were tested in a sample of children and adolescents between the ages of 7-17 with a primary diagnosis of OCD (n = 142).
Results indicated the cognitive and metacognitive beliefs were positively related to self-rated but not clinician-rated OCD symptoms. Age did not moderate the relationship between these beliefs and OCD symptom severity. Interestingly, we found that adolescents endorsed significantly higher levels of cognitive and metacognitive beliefs compared to children. Despite significant age differences found in cognitive and metacognitive beliefs, the importance of these beliefs may be moderated by the symptom presentation of OCD, irrespective of age. Youth with OCD can have symptoms that relate to fears (e.g., fears of contamination) and those unrelated to fears (e.g., ordering/ symmetry concerns), and it is possible that other factors (e.g., “not-just-right” feelings) may be more important than beliefs to the maintenance of OCD symptoms unrelated to fears.
Overall, the current study suggests cognitive and metacognitive beliefs are clinically important to children and adolescents OCD cases alike, and highlights the importance of assessing for these beliefs in order to inform treatment approaches. Using cognitive interventions, including these designed to specifically modify metacognitive beliefs (MCT), are indicated in pediatric patients, is well advised to reinforce learning from exposure and response prevention (ERP). Understanding the relevance of beliefs to OCD symptoms in pediatric patients will help clinicians use ERP to directly challenge beliefs and maximize learning, resulting in more clinically meaningful treatment.
Read the full paper: Rizvi, M., Smilansky, H., Porth, R., Myers, N., Geller, D., Small, B. J., McGuire, J. F., Wilhelm, S., & Storch, E. A. (2020). The moderating effect of age on the associations of cognitive and metacognitive beliefs with pediatric OCD symptoms. Cognitive Behaviour Therapy. doi: 10.1080/16506073.2020.1819866.
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