Barrow, F

Clark, B

Heyman, I

Krebs, G

Nair, A

Wong, YL

UCL Discovery

LETTERSHas the ﬁrst-line managementof paediatric OCD improvedfollowing the introduction ofNICE guidelines?INTRODUCTIONObsessive–compulsive disorder (OCD) is adistressing and impairing condition thataffects between 0.25% and 4% of childrenand adolescents.1 In 2005, the NationalInstitute of Health and Care Excellence(NICE) introduced guidelines for the man-agement of paediatric OCD in the UK.2Based on robust evidence, NICE recom-mended cognitive behavioural therapy(CBT) and selective serotonin reuptakeinhibitors (SSRIs) as ﬁrst-line psychologicaland pharmacological treatments. However,the extent to which patients are able toaccess these evidence-based interventionsin routine clinical practice remains unclear.To assess the impact of these guidelines,we conducted an audit of the previoustreatment received by children with OCDreferred to the National and SpecialistPaediatric (N&S) OCD clinic at theMaudsley Hospital, London. We hypothe-sised that publication of NICE guidelines,in 2005, would increase the use of SSRIsand CBT in this group of patients.METHODSWe compared referrals received fromJanuary 2000 to January 2002 (T1 cohort,n=79) with those from January 2009 toJanuary 2011 (T2 cohort, n=143). Alldata were collected as part of the routinestandardised assessment carried out in theN&S OCD clinic. Table 1 shows the base-line demographic/clinical data collectedfor each cohort. Treatment data were cate-gorised into whether patients had ever pre-viously received CBT for OCD, an SSRImedication or a non-CBT-based psycho-therapy (eg, family therapy, counselling,psychodynamic therapy) or whether theyhad received either NICE-recommendedtreatment (SSRI or CBT).RESULTSTable 1 details our results. Comparing thetwo groups, the T2 cohort (after NICEguideline publication) were signiﬁcantlyolder (mean increase of 8.3 months, t(220)=−2.16, p=0.03) and reported more severeOCD symptoms (mean Children’sYale-Brown Obsessive Compulsive Scale(CY-BOCS) score increase of 4.58 points, t(220)=−6.03, p<0.001). There were nosigniﬁcant differences in gender, age atonset of OCD symptoms, or referral source.Contrary to our hypothesis, when com-paring patients in the T2 cohort with thosein the T1 cohort, we found a signiﬁcant22.3% decrease in the proportion whohad received either NICE-recommendedtreatments (SSRI or CBT) (χ2 (1, n=222)=10.18, p=0.001), with over half havingnot received either treatment. There was asigniﬁcant 23.0% decrease in the propor-tion who had received an SSRI (χ2(1, n=222)=23.87, p<0.001) and nosigniﬁcant increase in patients receivingCBT (χ2 (1, n=222)=0.66, p=0.418). Wealso found a signiﬁcant 13.1% increase inthe proportion of patients receivingnon-CBT psychotherapy (χ2 (1, n=222)=5.38, p=0.019).DISCUSSIONDespite the publication of NICE guidelinesin 2005, we found a striking decrease inSSRI use, no increase in the use of CBT,and an increase in non-CBT-based psy-chotherapies between our two cohorts.Shortage of CBT therapists in child ser-vices and concerns around the safety ofSSRIs in this population may explain someof our ﬁndings.3 4 Further work is urgentlyneeded to identify the barriers preventingyoung people with OCD from accessingevidence-based treatments.Akshay Nair,1 Yim Lun Wong,2 Faye Barrow,3Isobel Heyman,4,5 Bruce Clark,1Georgina Krebs1,61National Obsessive Compulsive Disorder Service,Michael Rutter Centre, Maudsley Hospital, London, UK2Coventry and Warwickshire NHS Partnership Trust,Coventry, UK3The Oxford Institute of Clinical Psychology Training,University of Oxford, Oxford, UK4Psychological Medicine Team, Department of Childand Adolescent Mental Health, Great Ormond StreetHospital for Children, London, UK5Institute of Child Health, University College London,London, UK6Social, Genetic and Developmental Psychiatry Centre,Institute of Psychiatry, Psychology and Neuroscience,King’s College London, London, UKCorrespondence to Dr Akshay Nair, NationalObsessive Compulsive Disorder Service, Michael RutterCentre, Maudsley Hospital, London SE5 8AZ, UK;akshay.nair@kcl.ac.ukContributors AN collected data in the T2 cohort,contributed to design of the audit, analysed data andwrote manuscript drafts. YLW collected data in the T1cohort. FB collated data at the time of assessment andmaintained the database. IH designed the datacollection and reviewed the manuscript. BC contributedto the design of the audit and reviewed themanuscript. GK contributed to the design of the audit,helped with data analysis and reviewed the manuscript.Funding AN and GK receive salary support from theNational Institute for Health Research (NIHR) MentalHealth Biomedical Research Centre at South Londonand Maudsley NHS Foundation Trust and King’s CollegeLondonCompeting interests None.Provenance and peer review Not commissioned;internally peer reviewed.Table 1 Characteristics of each cohortT1: 2000–2002 cohort(n=79)T2: 2009–2011 cohort(n=143)Clinical characteristicsFemale, % 41.8 46.9Age at assessment, mean(95% CI)13 years 10 months (9 years 5 months to17 years 3 months)14 years 7 months* (11 years to17 years 8 months)Age at onset, mean(95% CI)10 years 1 months (5 years to 14 years) 10 years 6 months (11 years to17 years 4 months)Baseline CY-BOCS, mean(95% CI)22 (12 to 32) 26 (18 to 35)***Referral source, %Child Psychiatry Services 69.6 73.4General practitioner 27.8 23.8Paediatricians 1.3 1.4Other 1.3 1.4Previous treatments, %CBT or SSRI 67.1 44.8**CBT 31.6 37.1SSRI 58.2 25.2***Non-CBT psychotherapy 11.4 24.5*Children’s Yale-Brown Obsessive Compulsive Scale (CY-BOCS) reliably measures OCD symptoms severity.*p<0.05, **p<0.01, ***p<0.001, significant difference between cohorts.CBT, cognitive behavioural therapy; OCD, obsessive–compulsive disorder; SSRI, selective serotonin reuptake inhibitor.Open AccessScan to access morefree content416 Arch Dis Child April 2015 Vol 100 No 4PostScriptgroup.bmj.com on April 20, 2015 - Published by http://adc.bmj.com/Downloaded from Open Access This is an Open Access articledistributed in accordance with the Creative CommonsAttribution Non Commercial (CC BY-NC 4.0) license,which permits others to distribute, remix, adapt, buildupon this work non-commercially, and license theirderivative works on different terms, provided theoriginal work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/To cite Nair A, Wong YL, Barrow F, et al. Arch DisChild 2015;100:416–417.Accepted 9 December 2014Published Online First 30 December 2014Arch Dis Child 2015;100:416–417.doi:10.1136/archdischild-2014-307900REFERENCES1 Krebs G, Heyman I. Obsessive-compulsive disorder inchildren and adolescents. Arch Dis Child 2014.Published Online First: 14 Nov 2014. doi:10.1136/archdischild-2014-3069342 NICE. Obsessive compulsive disorder (OCD) and bodydysmorphic disorder (BDD) (CG31). The NationalInstitute for Health and Care Excellence (NICE), 2005.3 Stallard P, Udwin O, Goddard M, et al. The availabilityof cognitive behaviour therapy within specialist childand adolescent mental health services (CAMHS):A national survey. Behav Cogn Psychother2007;35:501–5.4 Wijlaars LP, Nazareth I, Petersen I. Trends indepression and antidepressant prescribing in childrenand adolescents: a cohort study in The HealthImprovement Network (THIN). PLoS One 2012;7:e33181.PAWS for thoughtPaediatric Advanced Warning Scores(PAWS), or Paediatric Early Warning Scores(PEWS), are scales that are based on clinicalobservations intended to predict deterior-ation. There are a variety of tools in use inthe UK. Although standards for such toolshave been suggested,1 2 a systematic reviewhas made it clear that scores were lacking invalidity and reliability.3 The use of suchtools has increased over time and broa-dened to include sub-specialty locationswith a higher risk of acute deterioration.4We undertook a case-note review of theprevalence of raised PAWS (≥3; the triggerfor medical review) and clinician’sresponses to these in patients under thecare of paediatric haematology and oncol-ogy in the Leeds Children’s Hospital.A total of 140 patient observation pointswere randomly selected, stratiﬁed by timeperiod and date. PAWS and clinical detailswere recorded for each observation point,48 h before and after this point.Data were available on 103 of theobservation points, with 37 missingthrough difﬁculties obtaining the PAWScharts. Twenty-eight of 103 (27.2%) hada PAWS ≥3. In the 48 h before and afterthe time point, 63.1% and 61.8% of inpa-tients had a PAWS ≥3, respectively.Nine of the patients with raised PAWShad a nursing review documented, with amedical review requested in two patients.Another patient received a medical reviewwithout documented nursing review. Fourpatients with a low PAWS received amedical review due to other clinicalconcerns.Of the 28 patients with PAWS ≥3 at theindex time point, four had an adverse eventin the preceding 48 h and ﬁve had anadverse event in the following 48 h (includ-ing one patient who had an adverse eventin both time frames). Eleven of the 19recorded adverse events occurred inpatients with PAWS <3. One adverse eventnecessitated pediatric intensive care unitadmission, while the other events includednew bacteraemia, administration of ﬂuidboluses, acute renal impairment, acute righthemiplegia and medication error (seeﬁgure 1).We conclude that a raised PAWS does notnecessarily indicate signiﬁcant deterior-ation, noting that the majority of adverseevents occurred in patients without raisedPAWS. In this population, the sensitivityand speciﬁcity of a PAWS ≥3 was poor (sen-sitivity 0.56 (CI 0.21 to 0.86) and speciﬁ-city 0.76 (CI 0.66 to 0.84)), to detect afuture adverse event. We acknowledge thatour review was limited by reference only todocumented scores and reviews, and thatthe effects of the reviews apparently trig-gered by PAWS may have prevented otheradverse events. Further consideration needsto be taken to identify the appropriate earlydetection systems (both the scores andinterventional advice) for patients underthe care of paediatric haematology andoncology, as performing the recommendedinterventions is not feasible or efﬁcient withcurrent resources. Work is ongoing withinLeeds Children’s Hospital to develop sucha system—further evaluation will be per-formed following its implementation.Other subspecialties might also considerhow early warning score systems could beadjusted for their populations.Jessica Morgan,1,2 Elizabeth Day,1Robert Phillips1,21Department of Paediatric Haematology and Oncology,Leeds Teaching Hospitals Trust, Leeds, UK2Centre for Reviews and Dissemination, University ofYork, York, UKCorrespondence to Dr Jessica Morgan, Departmentof Paediatric Haematology and Oncology, LeedsTeaching Hospitals Trust, Leeds LS1 3EX, UK;jem539@york.ac.ukCompeting interests None.Provenance and peer review Not commissioned;externally peer reviewed.To cite Morgan J, Day E, Phillips R. Arch Dis Child2015;100:417.Accepted 31 January 2015Published Online First 20 February 2015Arch Dis Child 2015;100:417.doi:10.1136/archdischild-2014-307566REFERENCES1 Pearson GA, ed. Why children die: a pilot study 2006;England (South West, North East and West Midlands).Wales and Northern Ireland. 2008.2 NICE. CG50 Acutely ill patients in hospital. 2007. http://www.nice.org.uk/guidance/CG50/chapter/Key-priorities-for-implementation (accessed 10 Sep 2014).3 Chapman SM, Grocott MPW, Franck LS. Systematicreview of paediatric alert criteria for identifyinghospitalised children at risk of critical deterioration.Intensive Care Med 2010;36:600–11.4 Roland D, Oliver A, Edwards ED, et al. Use ofpaediatric early warning systems in Great Britain: hasthere been a change of practice in the last 7 years?Arch Dis Child 2014;99:26–9.Figure 1 Interaction between PaediatricAdvanced Warning Scores (PAWS) and adverseevents (AEs).Arch Dis Child April 2015 Vol 100 No 4 417PostScriptgroup.bmj.com on April 20, 2015 - Published by http://adc.bmj.com/Downloaded from NICE guidelines?OCD improved following the introduction of Has the first-line management of paediatricand Georgina KrebsAkshay Nair, Yim Lun Wong, Faye Barrow, Isobel Heyman, Bruce Clarkdoi: 10.1136/archdischild-2014-30790030, 20142015 100: 416-417 originally published online DecemberArch Dis Child  http://adc.bmj.com/content/100/4/416Updated information and services can be found at: These include:References #BIBLhttp://adc.bmj.com/content/100/4/416This article cites 2 articles, 0 of which you can access for free at: Open Accesshttp://creativecommons.org/licenses/by-nc/4.0/non-commercial. See: provided the original work is properly cited and the use isnon-commercially, and license their derivative works on different terms, permits others to distribute, remix, adapt, build upon this workCommons Attribution Non Commercial (CC BY-NC 4.0) license, which This is an Open Access article distributed in accordance with the CreativeserviceEmail alertingbox at the top right corner of the online article. Receive free email alerts when new articles cite this article. Sign up in theCollectionsTopic Articles on similar topics can be found in the following collections  (124)Open accessNoteshttp://group.bmj.com/group/rights-licensing/permissionsTo request permissions go to:http://journals.bmj.com/cgi/reprintformTo order reprints go to:http://group.bmj.com/subscribe/To subscribe to BMJ go to:group.bmj.com on April 20, 2015 - Published by http://adc.bmj.com/Downloaded from 

Has the first-line management of paediatric OCD improved following the introduction of NICE guidelines?

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Has the first-line management of paediatric OCD improved following the introduction of NICE guidelines?

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