The impact of pediatric obsessive-compulsive disorder on school attendance and school functioning: a case for supported education

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However, little is known about the characteristics of youth with OCD who struggle in school, whether these struggles interfere with treatment outcomes, and whether treatment improves school-related function. Among 385 youth with OCD at a specialist clinic (mean age [sd] = 13.7 [2.5]; 63.1% girls), 21.6% had partial or no school attendance at intake. Among those who received specialist treatment ( n = 322), outcomes were similar in those with no or partial attendance vs. those with full attendance, although the latter group needed fewer treatment sessions and were less likely to be on psychotropic medication. At post-treatment, 10.5% still had partial or no school attendance, and 22.8% of youths and 33.3% of parents reported significant school impairment, regardless of response status. Some youth with OCD may benefit from specific supported education and return to school strategies to complement regular evidence-based interventions. Obsessive-compulsive disorder functional impairment school function education treatment outcomes Figures Figure 1 Figure 2 INTRODUCTION Obsessive-compulsive disorder (OCD) is a relatively prevalent mental disorder which usually has an early age of onset ( 1 , 2 ). By definition, OCD is associated with substantial distress and impairment in several areas of functioning, including family life and social activities ( 1 ). The symptoms of OCD and associated comorbidities are also known to have a negative impact on school functioning ( 3 – 5 ), including difficulties concentrating during lessons, doing homework or even attending school. This impairment has the potential to severely affect long-term academic and professional opportunities of these young people ( 6 ). In the largest study to date examining educational attainment in OCD, Pérez Vigil et al. ( 6 ) used a Swedish nationwide cohort including over 15,000 individuals with OCD showed that the diagnosis was associated with significantly worse academic performance across the lifespan. Specifically, compared to unaffected individuals, people with OCD were 30–60% less likely to pass all core and additional school courses at the end of their compulsory education, 47–61% less likely to access upper secondary education, 43% less likely to finish upper secondary education, 72% less likely to start a university degree, 59% less likely to finish a university degree, and 52% to finish postgraduate education. The results were similar when people with OCD were compared to their unaffected siblings, indicating that the difficulties were not due to factors shared within the family, such as parental educational level or psychopathology. Additionally, the impact on academic performance was more notable in those individuals who had received their first OCD diagnosis in childhood ( 6 ). Although the evidence is currently scarce, some studies have described the extent to which some children with OCD may require additional school support, such as specific adaptations or special classes. In a small study including 30 youth with OCD recruited from a specialist clinic, 48% had received remedial help (i.e., instructional support or assistance in the classroom), 40% were in a special class, and 7% had repeated a grade ( 7 ). In another study, Abramovitch et al. ( 8 ) showed that 118 children and adolescents with OCD, compared to a sample of 142 controls without OCD, were significantly more likely to be in a special class (10% vs. 1%, respectively) and receive extra help in school (64% vs. 4%, respectively). Among those with OCD, symptom severity was associated with a higher likelihood of receiving these school adaptations. However, school adaptations usually require for the pupils to attend school. To our knowledge, there are no published data on the extent of school attendance (i.e., school days missed) in young people with OCD. Other important questions that have not been empirically addressed are 1) whether children with poor school attendance benefit from treatment as much as other children fully engaged in school, and 2) whether school attendance and school impairment improve after the successful treatment of OCD. The first question is important because we do not know if these children with poor school function require additional treatment. The second question is clinically relevant because if evidence-based treatments for OCD are not sufficient to improve school functioning, this would justify the need for additional, more targeted interventions that focus on this specific area ( 9 ). The aims of this study were three-fold. First, we aimed to describe the school attendance and school impairment of a sample of 385 treatment-seeking children and adolescents diagnosed with OCD in a specialist obsessive-compulsive and related disorders clinic. Second, we aimed to compare the sociodemographic and clinical characteristics of youth with OCD with full school attendance vs. those with partial or no school attendance. And third, for the subgroup of individuals undertaking treatment at the clinic, we examined whether their level of school attendance was associated with their treatment outcomes, and whether the level of school attendance and school impairment improved after receiving treatment. METHODS Settings and procedures All participants had been referred to the specialist OCD and Related Disorders Clinic for Children and Adolescents in Stockholm, Sweden. The clinic accepts referrals from the Stockholm region, and occasionally other parts of Sweden and the Nordic countries. Upon referral to the clinic, all families are invited to participate in research and for their routinely collected clinical data to be used for research purposes. The study was approved by the Stockholm Regional Ethical Review Board. All participants and their families (parents or legal guardians) provided informed consent to participate. Participants in the study had a diagnosis of OCD according to the diagnostic criteria in the Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5) ( 1 ). The diagnosis was established in the routine initial clinical assessment at the clinic. Assessments are about 3 hours long and are conducted by experienced clinical psychologists. The assessments include a general battery of questions about development, sociodemographic and clinical characteristics, semi-structured clinical interviews to establish the primary diagnosis and associated comorbidities, and a series of general and disorder-specific clinician-administered, self-reported, and parent-reported measures (see Measures section). The information collected during the initial assessments is then discussed in a multidisciplinary team meeting, including clinical psychologists and child and adolescent psychiatrists, who collaboratively decide on the diagnosis and treatment plan (or alternative plan of action; e.g., referral to another service). Measures All measures were collected at baseline and, for those undertaking treatment at the clinic, also at post-treatment. Exceptions were the diagnostic semi-structured interviews (see section below) and the two questions about school adaptations, which were only done at baseline, but not at post-treatment, and the Clinical Global Impression-Improvement (CGI-I) and the classification of participants into treatment responders and remitters, that were only done at post-treatment for those that had been on treatment. Semi-structured interviews The diagnosis of OCD, as well as other obsessive-compulsive-related comorbidities, was formally evaluated with a semi-structured interview based on the Structured Clinical Interview for DSM-IV (SCID-I) (34) adapted by our research group to align with the more recent DSM-5 criteria for obsessive-compulsive and related disorders. The presence of other psychiatric comorbidities was assessed with the standardized diagnostic interview Mini International Neuropsychiatric Interview for Children and Adolescents (MINI-KID) (35). Clinician-rated measures The Children’s Yale-Brown Obsessive Compulsive Scale (CY-BOCS) is a clinician-rated, semi-structured interview which is used to assess the severity of the OCD symptoms ( 10 ). It consists of five severity items for both obsessions and compulsions, with a total OCD severity score ranging from 0 to 40. The CY-BOCS has shown good reliability as well as good convergent and discriminant validity ( 11 ). We used the empirically established benchmarks by Cervin et al. ( 12 ) to classify the individuals into different levels of symptom severity according to their baseline CY-BOCS score. The Clinical Global Impression-Severity (CGI-S) is a one-item clinician rating of symptom severity. It is rated on a seven-point scale ranging from 1 (no symptoms) to 7 (extremely severe symptoms) ( 13 ). The CGI-I is a one-item clinician rating of symptom severity change from the baseline assessment. This scale ranges from 1 (very much improved) to 7 (very much worse) ( 14 ). Treatment response was defined as a ≥ 35% reduction on the CY-BOCS from baseline to post-treatment plus a CGI-I score of 1 or 2, while remission was defined as a total score of ≤ 12 at post-treatment plus a CGI-S rating of 1 or 2 ( 15 ). The Children’s Global Assessment Scale (CGAS) is a clinician-rated measure of global functioning that comprises one item (ranging from 1 to 100; higher scores indicate better functioning). The CGAS has shown high reliability as well as discriminant and concurrent validity ( 16 ). Self- and parent-rated measures The OCI-CV is a self-reported measure of OCD symptom severity in children and adolescents. Both the total score and the subscales of the OCI-CV have good internal consistency and test-retest reliability, as well as good convergent and discriminant validity ( 17 ). Family accommodation of the OCD symptoms was measured with the Family Accommodation Scale – Self-rated (FAS-SR). The FAS-SR is a 19-item parent-reported measure that assesses the degree to which parents accommodate their child’s OCD symptoms. The FAS-SR has shown excellent internal consistency, strong agreement with the FAS – Interviewer Rated, and expected convergence with criterion measures ( 18 ). Self-reported depressive symptoms were assessed by the Short Mood and Feeling Questionnaire, child version (SMFQ-C) and its parent reported version (SMFQ-P). The scales consist of 13 items and have shown good psychometric properties, including satisfying to good internal consistency, good convergent, concurrent, and criterion validity, and sensitivity to change ( 19 – 21 ). The self-reported Work and Social Adjustment Scale–Youth (WSAS-Y) and Parent (WSAS-P) versions were used to assess functional impairment in five areas (i.e., school/work, daily situations, social activities, leisure activities, and relationships) as a result of the participants’ OCD symptoms. Items range from 0 (‘not at all’) to 8 (‘severely impaired’), with total scores ranging from 0 to 40. The instruments have demonstrated excellent psychometric properties, with high internal consistency, good convergent and divergent validity, and sensitivity to change ( 22 ). In the current paper, we used scores ≥ 4 in the school/work item as the cut-off to represent significant school impairment. School-related questions The battery of questions administered at baseline included 3 items related to school impairment. The first question enquired about the estimated school attendance in the last month, and responses were grouped in 5 intervals of 20% (i.e., 0–20%, 21–40%, 41–60%, 61–80%, and 81–100% attendance). For the purpose of the present study, the interval 81–100% attendance was coded as full school attendance (i.e., attendance of at least 4 days a week during the past month), while the remaining intervals were grouped together and coded as partial or no school attendance (i.e., missing school more than one day a week during the past month). The other questions focused on school support and adaptations: “does the child have any school support measures or is he/she in an adapted class? If so, what measures” and “ does the child have any learning difficulties, for example, does he/she need any support in school? If so, what support.” Treatment The treatment received at the clinic was multimodal, consisting of cognitive-behavior therapy (CBT) and medication, when deemed necessary by the clinical team. The CBT treatment followed a manualized protocol delivered in 14–16 sessions ( 23 , 24 ). Usually, sessions lasted one hour and were conducted weekly. Some cases could also be offered intensive (e.g., several hours per day) clinic-based or home-based sessions (for homebound patients), based on the therapists’ judgement and the families’ preferences. Sessions were delivered by clinical psychologists with extensive experience in treating pediatric OCD or clinical psychologists in training under close supervision. The CBT treatment included varying degrees of parental/carer involvement, depending on the case formulation. Initial sessions were devoted to psychoeducation about OCD, mid-treatment sessions were primarily focused on graded exposure with response prevention (both therapist-assisted in vivo ERP and as between-session assignments), and the final sessions included strategies for relapse prevention and maintenance of gains. Participants could also receive pharmacological treatment for their OCD and other comorbid symptoms/disorders, which was prescribed (or modified after the initial assessment or during treatment) by experienced child and adolescent psychiatrists at the clinic, according to treatment guidelines ( 25 ) and clinical judgement. Statistical analyses Means and standard deviations, or frequencies and percentages, were used to describe the characteristics of the sample. Student’s t tests or Chi-square tests, as appropriate, were used to examine group differences. For those who undertook treatment at the clinic and had repeated outcome measures, mixed-effects regression models with maximum likelihood estimation of parameters were implemented. All models included fixed effects of time (baseline and post-treatment), school attendance status (partial or no attendance and full attendance), and the interaction time × school attendance status. A random intercept was also added to account for the variances between and within participants. Alpha levels (two-tailed) were set to p < .05. All analyses were performed using Stata 15.1 (StataCorp LLC). RESULTS Participants From November 2019 to November 2024, 428 individuals were assessed at the clinic who had OCD as the main diagnosis requiring treatment and had provided written consent for their data to be used for research purposes. Of these, 43 records were excluded due to being returning patients (i.e., they had done more than one initial assessment at the clinic) ( n = 18) or because they had missing information on school attendance at the baseline assessment, as this was the main outcome in this study ( n = 25). Hence, the final study sample included 385 participants. The sample consisted of young people with a mean age of 13.7 years (SD, 2.5; range, 7–17) who were mainly girls ( n = 243; 63.1%). Most participants ( n = 202; 52.5%) were on the moderate range of OCD symptom severity. More than half ( n = 193; 50.8%) had at least one additional psychiatric disorder. The most common comorbidities were attention-deficit/hyperactivity disorder (ADHD), autism spectrum disorder (ASD), anxiety disorders, and depression. Baseline characteristics of the full sample are presented in Table 1 . Table 1 Baseline characteristics of the total study sample, and by school attendance status. Variable (available n ) Total study sample (n = 385) Full school attendance (n = 302) Partial or no school attendance (n = 83) Statistics t / ꭓ 2 p Age at initial assessment (385), mean (sd) 13.74 2.53 13.69 2.63 13.92 2.17 -0.72 0.470 Self-reported age of OCD onset (361), mean (sd) 10.99 2.68 10.92 2.78 11.25 2.49 -0.93 0.352 Gender (385), n (%) a 6.73 0.035* Girl 243 63.12 186 61.59 57 68.67 Boy 137 35.58 114 37.75 23 27.71 Other 5 1.30 2 0.66 3 3.61 Comorbid mental disorders (380), n (%) 193 50.79 134 44.97 59 71.95 18.73 < 0.001*** Autism spectrum disorder 72 18.95 46 15.44 26 31.71 11.09 0.001** ADHD 96 25.26 68 22.82 28 34.15 4.37 0.037* Depression 36 9.47 23 7.72 13 15.85 4.96 0.026* Anxiety disorders b 37 9.74 27 9.06 10 12.20 0.72 0.396 Other 45 11.84 37 12.42 8 9.76 0.44 0.509 On medication at intake (380), n (%) 189 49.74 132 44.30 57 69.51 16.36 < 0.001*** Antidepressants 123 32.37 86 28.86 37 45.12 7.77 0.005** Antipsychotics 22 5.79 11 3.69 11 13.41 11.15 0.001** ADHD medication 46 12.11 34 11.41 12 14.63 0.63 0.428 Other medication 109 28.68 69 23.15 40 48.78 20.64 < 0.001*** Support in school (358), n (%) 118 32.96 82 29.18 36 46.75 8.45 0.004** Learning difficulties (358), n (%) 106 29.61 79 28.11 27 35.06 1.40 0.237 CY-BOCS (385), mean (sd) 22.48 4.19 21.80 3.79 24.94 4.68 -6.33 < 0.001*** Subclinical, n (%) 6 1.56 5 1.66 1 1.20 0.09 0.769 Mild, n (%) 155 40.26 137 45.36 18 21.69 15.18 < 0.001*** Moderate, n (%) 202 52.47 155 51.32 47 56.63 0.73 0.392 Severe, n (%) 22 5.71 5 1.66 17 20.48 42.83 < 0.001*** CGI-S (383), mean (sd) 4.32 0.78 4.23 0.65 4.65 1.09 -4.37 < 0.001*** CGAS (384), mean (sd) 51.40 5.80 52.58 4.86 47.10 6.84 8.28 < 0.001*** OCI-CV (322), mean (sd) 19.09 8.06 18.74 8.07 20.43 18.50 -1.53 0.127 FAS-SR (349), mean (sd) 24.93 17.75 22.51 16.78 33.79 18.48 -5.04 < 0.001*** SMFQ-C (326), mean (sd) 10.29 6.20 9.42 5.89 13.64 6.24 -5.17 < 0.001*** SMFQ-P (357), mean (sd) 10.51 5.97 9.75 5.80 13.33 5.75 -4.78 < 0.001*** WSAS-Y (328), mean (sd) 17.19 8.70 15.86 7.95 22.28 9.59 -5.67 < 0.001*** School or work 4.18 2.36 3.65 2.17 6.24 1.92 -8.98 < 0.001*** Everyday functioning 3.81 2.55 3.60 2.41 4.62 2.91 -2.96 0.003** Social activities 3.44 2.42 3.15 2.27 4.53 2.67 -4.30 < 0.001*** Spare time 2.60 2.36 2.59 2.36 2.65 2.39 -0.18 0.856 Family activities 3.16 2.39 2.88 2.21 4.25 2.74 -4.32 < 0.001*** WSAS-P (357), mean (sd) 19.94 9.12 18.40 8.59 25.62 8.82 -6.46 < 0.001*** School or work 4.83 2.24 4.34 2.12 6.67 1.64 -8.92 < 0.001*** Everyday functioning 4.22 2.56 4.00 2.51 5.07 2.55 -3.28 0.001** Social activities 4.38 2.47 4.04 2.40 5.63 2.31 -5.16 < 0.001*** Spare time 2.55 2.34 2.36 2.25 3.28 2.54 -3.07 0.002** Family activities 3.94 2.51 3.66 2.47 4.97 2.37 -4.14 < 0.001*** * p < 0.05; ** p < 0.01; *** p < 0.001. School attendance, school impairment, and school adaptations Among the 385 individuals in the sample, 302 (78.4%) were classified as having full school attendance, while 83 (21.6%) were classified as having partial or no school attendance. Among these, 5.7% ( n = 22) of participants had minimal school attendance (i.e. attendance of one day or less a week during the last month). Those with partial or no school attendance were significantly more likely to be girls, have more psychiatric comorbidities, including neurodevelopmental disorders (i.e., ASD and ADHD) and depression, and be on psychotropic medication. They also had significantly more severe scores on clinician-rated symptom severity (CY-BOCS and CGI-S) – but not self-rated severity (OCI-CV), more family accommodation (FAS-SR), depression (SMFQ-C and SMFQ-P), and worse functioning (CGAS, WSAS-Y, and WSAS-P). As expected, the largest between-group difference within the WSAS scales was in the school/work item (Table 1 ). According to their scores on the WSAS-Y and WSAS-P, 196 of the youth (59.8%) and 261 of the parents (73.1%) reported significant school impairment (i.e., scores ≥ 4). Among participants with full school attendance, these numbers were 136 (52.3%) for the youth (WSAS-Y) and 190 (67.6%) for the parents (WSAS-P). The respective numbers for those with partial or no school attendance were 60 (88.2%) and 71 (93.4%). The differences by school attendance status were statistically significant for both the young people (ꭓ 2 =28.93, p < 0.001) and the parents (ꭓ 2 =20.26, p < 0.001) (Fig. 2 ). A total of 118 (33.0%) individuals reported to have school adaptations or receive support in school. Adaptations were significantly more frequent in the group that reported partial or no school attendance, compared to the group with full attendance ( n = 36 [46.8%] vs. n = 82 [29.2%], respectively; ꭓ 2 =8.45, p = 0.004). Adaptations in the whole group included attending special class or school (n = 32; 27.1%), adaptations related to their comorbid neurodevelopmental disorders (e.g., ADHD or ASD) (n = 29; 24.6%), having an extra person in school for support (n = 17; 14.4%), having shorter school days (n = 11; 9.3%), and other or unspecified adaptations (n = 29; 24.6%), including for example a special placement in the classroom, regular meetings with the school counsellor or school psychologist, special food, and other adaptations related to the OCD symptoms (e.g., being able to leave the classroom to wash hands). Another 106 (29.6%) of the total sample reported having learning difficulties (e.g., issues with concentration, difficulties with reading, difficulties with math-related tasks) that required school support. These were similarly distributed between the youth with full school attendance and youth with partial or no school attendance ( n = 79 [28.1%] vs. n = 27 [35.1%], respectively; ꭓ 2 =1.40, p = 0.237). Effect of school attendance on OCD treatment outcomes Of the initial sample of 385 participants, 322 (83.6%) received treatment for OCD at the clinic and had post-treatment data available. Characteristics of this subgroup were very similar to those in the group without available post-treatment data, aside from a slight difference in OCD symptom severity at the intake, showing slightly lower CY-BOCS scores in those with no available post-treatment data compared to those with available data (means [SD] = 21.4 [4.4] vs. 22.7 [4.1]; t-test=-2.22, p = 0.027) ( Supplementary Table 1 ). Raw means and standard deviations for all study outcomes are presented in Supplementary Table 2 . The means and standard errors from the mixed-effect regression models are reported in Table 2 . The models showed a significant main effect of time on all treatment outcomes, denoting a reduction of OCD-related and comorbid symptoms (CY-BOCS, CGI-S, OCI-CV, FAS-SR, SMFQ-C, SMFQ-P) and an improvement in functioning (CGAS, WSAS-Y, WSAS-P), regardless of school attendance. There were also significant main effects of group in all measures (except for the CGAS), reflecting the higher baseline scores of the individuals in the partial or no school attendance group at baseline. The interaction time × school attendance status reached significance for the CY-BOCS, the FAS-SR, the SMFQ-C, the SMFQ-P, the WSAS-Y, and the WSAS-P (Table 2 ). These results indicate that, although those with partial or no school attendance started with higher baseline scores, both groups improved to a similar degree by the end of the treatment. This is illustrated in Fig. 1 , which graphically represents the baseline and post-treatment CY-BOCS scores in both groups. Table 2 Results from the mixed-effect regression models in the subsample of individuals with obsessive-compulsive disorder with post-treatment data (n = 322). Variable Full school attendance (n = 258) Partial or no school attendance (n = 64) Main effect of time Main effect of group Time x group interaction effects Measure Mean SE Mean SE Coefficient (CI) Coefficient (CI) Coefficient (CI) CY-BOCS -11.57 (-12.26 – -10.88)*** 3.14 (2.02–4.25)*** -2.20 (-3.73 – -0.68)** Baseline 21.80 0.26 24.94 0.50 Post-treatment 10.24 0.28 11.17 0.57 CGI-S -1.67 (-1.80 – -1.53)*** 0.42 (0.20–0.63)*** -0.09 (-0.39–0.21) Baseline 4.23 0.05 4.65 0.10 Post-treatment 2.56 0.05 2.89 0.11 CGAS 7.13 (6.23–8.03)*** -5.49 (-7.13 – -3.84)*** 0.03 (-1.96–2.02) Baseline 52.58 0.39 47.10 0.74 Post-treatment 59.72 0.41 54.26 0.82 OCI-CV -7.20 (-8.44 – -5.97)*** 1.68 (-0.39–3.75) -1.73 (-4.34–0.88) Baseline 18.75 0.48 20.43 0.94 Post-treatment 11.55 0.62 11.50 1.15 FAS-SR -14.94 (-17.36 – -12.53)*** 11.15 (7.38–14.93)*** -8.34 (-13.54 – -3.14)** Baseline 22.57 0.89 33.73 1.71 Post-treatment 7.63 1.11 10.44 2.13 SMFQ-C -2.50 (-3.34 – -1.66)*** 4.12 (2.53–5.70)*** -2.27 (-4.07 – -0.47)* Baseline 9.42 0.37 13.54 0.72 Post-treatment 6.92 0.45 8.77 0.86 SMFQ-P -4.23 (4.99 – -3.48)*** 3.54 (2.17–4.91)*** -1.98 (3.60–0.35)* Baseline 9.75 0.32 13.29 0.62 Post-treatment 5.52 0.39 7.08 0.74 WSAS-Y -7.27 (-8.74 – -5.81)*** 6.41 (4.32–8.50)*** -5.25 (-8.38 – -2.13)** Baseline 15.86 0.49 22.28 0.95 Post-treatment 8.59 0.65 9.75 1.20 WSAS-P -8.08 (-9.43 – -6.74)*** 7.24 (5.15–9.33)*** -4.03 (-6.94–1.12)** Baseline 18.41 0.49 25.65 0.95 Post-treatment 10.32 0.60 13.54 1.16 * p < 0.05; ** p < 0.01; *** p < 0.001. In line with the results from the models, there were no statistically significant between-group differences in the proportion of participants classified as treatment responders and remitters at post-treatment, when comparing those with full attendance and those with partial or no attendance (responders: n = 186 [73.2%] vs. n = 49 [76.6%], respectively; ꭓ 2 =0.29, p = 0.587; remitters: n = 108 [42.4%] vs. n = 21 [32.8%], respectively; ꭓ 2 =1.93, p = 0.164). Importantly, individuals with partial or no school attendance had received significantly more CBT sessions than those with full school attendance (19.2 vs. 14.9 sessions, respectively; t-test=-3.80, p < 0.001) and they were also more likely to be on psychotropic medication at post-treatment ( n = 51 [79.7%] vs. n = 124 [48.6%]; ꭓ 2 =19.93, p < 0.001). Effect of OCD treatment on school attendance and school impairment Of 385 participants with data on school attendance at baseline, 276 (71.7%) had available data on school attendance at post-treatment. The number of youth with partial or no school attendance decreased from 83/385 (21.6%) at baseline to 29/276 (10.5%) at post-treatment. Among those with partial or no school attendance at baseline with available data at post-treatment, almost 40% still reported to have partial or no school attendance at the end of the treatment (n = 18/47, 38.3%). Among youth with full school attendance at baseline, the vast majority ( n = 218/229, 95.2%) still had full school attendance at the end of treatment. The proportion of individuals with partial or no school attendance at post-treatment was similar among treatment responders and non-responders ( n = 22, 10.7% vs. n = 6, 8.6%, respectively; ꭓ 2 =2.27, p = 0.606). The same was true for remitters and non-remitters ( n = 9, 7.8% and n = 19, 12.0%; ꭓ 2 =1.29, p = 0.256). This suggests that school attendance status and response or remission status were somewhat independent outcomes. Additionally, the school/work items in the WSAS-Y and the WSAS-P were examined. Results showed that school impairment (i.e., scores ≥ 4) decreased throughout the course of the treatment, as reported by both the youth with OCD and the parents. However, of those with available data, a total of 45 (22.8%) youth (WSAS-Y) and 76 (33.3%) parents (WSAS-P) still presented with significant school impairment at the end of the treatment. Ten (52.6%) youth and 11 (55.0%) parents with partial or no school attendance at post-treatment still reported school impairment at this timepoint, compared to 24 (17.5%) youth and 50 (29.8%) parents among those with full school attendance at the end of treatment (ꭓ 2 =12.07, p = 0.001 and ꭓ 2 =5.19, p = 0.023; respectively) (Fig. 2 ). DISCUSSION This study included 385 children and adolescents diagnosed with OCD attending a specialist obsessive-compulsive and related disorders clinic. Around 22% of the sample was not attending school or had partial school attendance at intake. This is a considerable proportion, considering that the mean age of the sample was around 13–14 years, which are years of compulsory education in Sweden (up to approximately age 16). In line with previous, smaller studies in children and adolescents with OCD ( 7 , 8 ), our figures also showed that around one third of the children and adolescents needed school adaptations and support. These adaptations were present in about 30% of those with full school attendance and 47% of children with poor attendance, indicating that even those fully engaged in school required extra support. The adaptations were several, varying from having shorter school days to attending a special class. This highlights that different children with OCD and associated comorbidities will have different needs (in form and degree) and that it is important to evaluate each particular case and provide individualized solutions. Youth with poor school attendance were more likely to be girls, had more psychiatric comorbidities, were more likely to be on medication already at intake, and presented with more severe clinical symptomatology and general impairment. About 60%, according to the young people, or 73%, according to the parental report, were classified as having significant school impairment. As expected, this was a lot more pronounced in youth with poor school attendance, compared to those with full attendance. Hence, most individuals in our large sample, regardless of the informant or the degree of engagement in school, presented with significant school impairment, mirroring previous reports on pediatric OCD samples ( 3 – 5 ). Although we did not have data on school performance, we can hypothesize that the reported school-related functional impairment is likely to translate into lower grades, as we have previously reported in OCD ( 6 ). Hence, it is important to consider this impairment when treating OCD to ensure that youths with OCD fulfill their educational potential and are able to develop academic and professional careers of their choice. One positive result from our study was that school struggles did not necessarily interfere with OCD treatment outcomes. The proportion of treatment responders and remitters was similar in youths with limited vs full school attendance. However, it is important to note that children and adolescents with limited school attendance received more CBT sessions and more medication, which may suggest that they were either more complex to begin with or that they required a higher dose of treatment to achieve comparable results. Also, it is likely that some of the time in the sessions was spent motivating the youth to attend school and talking about the school difficulties with both the youth and the parents. Interestingly, although the multimodal treatment was overall successful at improving symptom severity (about three fourths of participants were classified as treatment responders, regardless of their school attendance at baseline) and the proportion of youth with full school attendance increased from baseline to post-treatment, almost 40% of those that reported partial or no school attendance at baseline still were not able to go back to full-time schooling by the end of the treatment. Moreover, a significant proportion of both parents and children still reported significant impairment scores in the school domain at this timepoint. Previous studies have suggested that, although CBT is a powerful treatment, reduction in symptom severity is not necessarily associated with improvements in other life domains ( 9 ). Hence, it seems that a more holistic intervention approach including a specific focus on supporting these youth in school may be required ( 9 ). Indeed, interventions specifically targeting the educational needs of students with psychiatric disorders have shown a positive impact on the academic functioning of these populations ( 26 ). However, there is limited evidence for these interventions given that empirical studies are few and of moderate quality ( 26 ). Hence, methodologically sound studies on supported education and return to school strategies for youth with OCD who struggle in school are warranted. Strengths and limitations The study included a large and well-characterized sample of children and adolescents with OCD consecutively referred to a specialist clinic, with no exclusion criteria. We used validated, gold standard instruments and collected information on a wide range of clinically relevant aspects. However, the study should also be interpreted in light of some limitations. First, in youth that had reduce their schedule or had shorter school days as a form of school adaptation, parents and clinicians often regarded their attendance as full, as this adaptation had been previously agreed with the school. Hence, it might be that, at least for some of the individuals in the sample, the school attendance was overestimated. Second, we did not have a control group. Therefore, we cannot conclude that the described school-related functional impairment is associated with the diagnosis of OCD or the concurrent psychiatric disorders in the sample. Similarly, we cannot conclude that the observed clinical improvements were due to the multimodal treatment. Third, the data used in the study were collected over a period of around five years, which may have resulted in some heterogeneity in the data collection and data loss in different parts of the process. Finally, our results may not generalize to non-specialist clinics. Nonetheless, it is important to note that the sample encompassed all levels of OCD symptom severity, with over 40% being classified as having mild OCD. In the same way, results may not generalize to other countries with different educational systems. For example, the Swedish school system allows for adaptations, even in mainstream schools, which may translate into better attendance or better performance compared to more rigid contexts. Conclusions School-related functional impairment is common in children and adolescents with OCD. About 22% of our well-characterized sample of almost 400 youth with OCD presented with partial or no school attendance at intake. Despite substantial improvement of OCD symptom severity and associated features with treatment, a significant proportion of youth still had poor school attendance and reported significant school impairment after treatment. Children and adolescents with OCD who struggle at school may benefit from specific supported education and return to school strategies to completement regular evidence-based interventions focused on symptom reduction. Declarations Competing Interests L.F.C. receives royalties for contributing articles to UpToDate and Wolters Kluwer Health and personal fees for editorial work from Elsevier, all outside the submitted work. D.M.C. receives royalties for contributing articles to UpToDate and Wolters Kluwer Health, occasional payments from funding agencies as an external grant reviewer, and is part owner of Scandinavian E-Health, AB, all outside the submitted work. All other authors report no competing interests. Author Contribution L.F.C., D.R., and D.M.C. conceived and designed the study. L.F.C. wrote the original draft. D.R. performed the analyses. All authors contributed intellectually and approved the final version of the manuscript. Data Availability Patient data supporting this study cannot be made publicly available due to ethical and legal restrictions. References American Psychiatric Association (2013) The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5). American Psychiatric Association Ruscio AM, Stein DJ, Chiu WT, Kessler RC (2010) The epidemiology of obsessive-compulsive disorder in the National Comorbidity Survey Replication. Mol Psychiatry. ; 15(1): 53–63. https://doi.org/110.1038/mp.2008.94 du Plessis LJ, Lochner C, Louw D, Hendricks G, Bowles S, Fischer M et al (2022) A comprehensive view of functional impairment in children and adolescents with obsessive-compulsive disorder adds value. Early Interv Psychiatry 16(9):994–1001. https://doi.org/10.1111/eip.13241 Piacentini J, Bergman RL, Keller M, McCracken J (2003) Functional impairment in children and adolescents with obsessive-compulsive disorder. J Child Adolesc Psychopharmacol 13(Suppl 1):S61–S69. https://doi.org/10.1089/104454603322126359 Valderhaug R, Ivarsson T (2005) Functional impairment in clinical samples of Norwegian and Swedish children and adolescents with obsessive-compulsive disorder. Eur Child Adolesc Psychiatry 14(3):164–173. https://doi.org/10.1007/s00787-005-0456-9 Pérez-Vigil A, Fernández de la Cruz L, Brander G, Isomura K, Jangmo A, Feldman I et al (2018) Association of obsessive-compulsive disorder with objective indicators of educational attainment: A nationwide register-based sibling control study. JAMA Psychiatry 75(1):47–55. https://doi.org/10.1001/jamapsychiatry.2017.3523 Geller DA, Biederman J, Griffin S, Jones J, Lefkowitz TR (1996) Comorbidity of juvenile obsessive-compulsive disorder with disruptive behavior disorders. J Am Acad Child Adolesc Psychiatry 35(12):1637–1646. https://doi.org/10.1097/00004583-199612000-00016 Abramovitch A, Duncan B, Schuyler M, Geller DA (2024) The psychosocial and educational burden of obsessive-compulsive disorder in youth. J Affect Disord 367:678–685. https://doi.org/10.1016/j.jad.2024.09.022 Mataix-Cols D, Fernández de la Cruz L, Rück C (2020) When improving symptoms is not enough - Is it time for next-generation interventions for obsessive-compulsive disorder? JAMA Psychiatry 77(1):9–10. https://doi.org/10.1001/jamapsychiatry.2019.2335 Scahill L, Riddle MA, McSwiggin-Hardin M, Ort SI, King RA, Goodman WK et al (1997) Children's Yale-Brown Obsessive Compulsive Scale: Reliability and validity. J Am Acad Child Adolesc Psychiatry 36(6):844–852. https://doi.org/10.1097/00004583-199706000-00023 Gallant J, Storch EA, Merlo LJ, Ricketts ED, Geffken GR, Goodman WK et al (2008) Convergent and discriminant validity of the Children's Yale-Brown Obsessive Compulsive Scale-Symptom Checklist. J Anxiety Disord 22(8):1369–1376. https://doi.org/10.1016/j.janxdis.2008.01.017 Cervin M, Consortium OCDSB, Mataix-Cols D (2022) Empirical severity benchmarks for obsessive-compulsive disorder across the lifespan. World Psychiatry 21(2):315–316. https://doi.org/10.1002/wps.20984 Busner J, Targum SD (2007) The clinical global impressions scale: Applying a research tool in clinical practice. Psychiatry (Edgmont) 4(7):28–37 National Institute of Mental Health (1976) ECDEU assessment manual for psychopharmacology. US Department of Health Administation, National Institute of Mental Health, Psychopharmacology Research Branch, Division of Extramural Research Programs, Rockville, Md. Mataix-Cols D, Fernández de la Cruz L, Nordsletten AE, Lenhard F, Isomura K, Simpson HB (2016) Towards an international expert consensus for defining treatment response, remission, recovery and relapse in obsessive-compulsive disorder. World Psychiatry 15(1):80–81. https://doi.org/10.1002/wps.20299 Shaffer D, Gould MS, Brasic J, Ambrosini P, Fisher P, Bird H et al (1983) A children's global assessment scale (CGAS). Arch Gen Psychiatry 40(11):1228–1231. https://doi.org/10.1001/archpsyc.1983.01790100074010 Foa EB, Coles M, Huppert JD, Pasupuleti RV, Franklin ME, March J (2010) Development and validation of a child version of the obsessive compulsive inventory. Behav Therapy 41(1):121–132. https://doi.org/10.1016/j.beth.2009.02.001 Pinto A, Van Noppen B, Calvocoressi L (2013) Development and preliminary psychometric evaluation of a self-rated version of the Family Accommodation Scale for Obsessive-Compulsive Disorder. J Obsessive Compuls Relat Disord 2(4):457–465. https://doi.org/10.1016/j.jocrd.2012.06.001 Burleson Daviss W, Birmaher B, Melhem NA, Axelson DA, Michaels SM, Brent DA (2006) Criterion validity of the Mood and Feelings Questionnaire for depressive episodes in clinic and non-clinic subjects. J Child Psychol Psychiatry 47(9):927–934. https://doi.org/10.1111/j.1469-7610.2006.01646.x Rhew IC, Simpson K, Tracy M, Lymp J, McCauley E, Tsuang D et al (2010) Criterion validity of the Short Mood and Feelings Questionnaire and one- and two-item depression screens in young adolescents. Child Adolesc Psychiatry Ment Health 4(1):8. https://doi.org/10.1186/1753-2000-4-8 Thabrew H, Stasiak K, Bavin L-M, Frampton C, Merry S (2018) Validation of the Mood and Feelings Questionnaire (MFQ) and Short Mood and Feelings Questionnaire (SMFQ) in New Zealand help-seeking adolescents. Int J Methods Psychiatr Res 27(3):e1610. https://doi.org/10.1002/mpr.1610 Jassi A, Lenhard F, Krebs G, Gumpert M, Jolstedt M, Andrén P et al (2020) The Work and Social Adjustment Scale, Youth and Parent Versions: Psychometric Evaluation of a Brief Measure of Functional Impairment in Young People. Child Psychiatry Hum Dev 51(3):453–460. https://doi.org/10.1007/s10578-020-00956-z Turner CM, Mataix-Cols D, Lovell K, Krebs G, Lang K, Byford S et al (2014) Telephone cognitive-behavioral therapy for adolescents with obsessive-compulsive disorder: a randomized controlled non-inferiority trial. J Am Acad Child Adolesc Psychiatry 53(12):1298–307e2. https://doi.org/10.1016/j.jaac.2014.09.012 Mataix-Cols D, Turner C, Monzani B, Isomura K, Murphy C, Krebs G et al (2014) Cognitive-behavioural therapy with post-session D-cycloserine augmentation for paediatric obsessive-compulsive disorder: pilot randomised controlled trial. Br J Psychiatry 204(1):77–78. https://doi.org/10.1192/bjp.bp.113.126284 Barn- och ungdomspsykiatri [Child and Adolescent Mental Health Services] Region Stockholm (2021) Instruktion för barn- och ungdomspsykiatrisk läkemedelsbehandling [Instructions for pharmacological treatment in child and adolescent psychiatry]. Barn- och ungdomspsykiatri [Child and Adolescent Mental Health Services] Region Stockholm Hofstra J, van der Velde J, Farkas M, Korevaar L, Buttner S (2023) Supported education for students with psychiatric disabilities: A systematic review of effectiveness studies from 2009 to 2021. Psychiatr Rehabil J 46(3):173–184. https://doi.org/10.1037/prj0000528 Additional Declarations Competing interest reported. L.F.C. receives royalties for contributing articles to UpToDate and Wolters Kluwer Health and personal fees for editorial work from Elsevier, all outside the submitted work. D.M.C. receives royalties for contributing articles to UpToDate and Wolters Kluwer Health, occasional payments from funding agencies as an external grant reviewer, and is part owner of Scandinavian E-Health, AB, all outside the submitted work. All other authors report no competing interests. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-5720873","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":396913715,"identity":"e0750f3d-78d3-4f66-8e1b-1c3a9d509ffc","order_by":0,"name":"Lorena Fernández de la Cruz","email":"data:image/png;base64,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","orcid":"","institution":"Centre for Psychiatry Research, Department of Clinical Neuroscience, Karolinska Institutet","correspondingAuthor":true,"prefix":"","firstName":"Lorena","middleName":"Fernández de la","lastName":"Cruz","suffix":""},{"id":396913716,"identity":"3bbdd34c-e00e-41bd-93ed-a2652b3027ee","order_by":1,"name":"Daniel Rautio","email":"","orcid":"","institution":"Centre for Psychiatry Research, Department of Clinical Neuroscience, Karolinska Institutet","correspondingAuthor":false,"prefix":"","firstName":"Daniel","middleName":"","lastName":"Rautio","suffix":""},{"id":396913717,"identity":"51e56fb0-4fcd-4e32-8982-7fcd4790e00f","order_by":2,"name":"Frida Wickberg","email":"","orcid":"","institution":"Stockholm Health Care Services, Region Stockholm","correspondingAuthor":false,"prefix":"","firstName":"Frida","middleName":"","lastName":"Wickberg","suffix":""},{"id":396913718,"identity":"06f36472-6146-46a8-845d-9be599ceaede","order_by":3,"name":"Cecilia Gordan","email":"","orcid":"","institution":"Stockholm Health Care Services, Region Stockholm","correspondingAuthor":false,"prefix":"","firstName":"Cecilia","middleName":"","lastName":"Gordan","suffix":""},{"id":396913719,"identity":"70ee3ae7-e53f-42cc-8e4d-27c206a5c51a","order_by":4,"name":"Maria Silverberg-Mörse","email":"","orcid":"","institution":"Stockholm Health Care Services, Region Stockholm","correspondingAuthor":false,"prefix":"","firstName":"Maria","middleName":"","lastName":"Silverberg-Mörse","suffix":""},{"id":396913720,"identity":"492a37a5-9b3a-421a-a575-c400d99caec8","order_by":5,"name":"David Mataix-Cols","email":"","orcid":"","institution":"Centre for Psychiatry Research, Department of Clinical Neuroscience, Karolinska Institutet","correspondingAuthor":false,"prefix":"","firstName":"David","middleName":"","lastName":"Mataix-Cols","suffix":""}],"badges":[],"createdAt":"2024-12-27 10:23:19","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-5720873/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-5720873/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1007/s10578-025-01846-y","type":"published","date":"2025-05-09T15:57:00+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":73080998,"identity":"a7319e20-9f49-464e-9168-75e2136a9f1a","added_by":"auto","created_at":"2025-01-06 14:12:21","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":27985,"visible":true,"origin":"","legend":"\u003cp\u003eGraphical representation of the Children’s Yale-Brown Obsessive Compulsive Scale (CY-BOCS) across the two assessment points. Error bars indicate 95% confidence intervals.\u003c/p\u003e","description":"","filename":"1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-5720873/v1/ae2fde4e47006928df059582.jpg"},{"id":73079664,"identity":"66411fcf-eba2-4084-b281-d2886ce9caf1","added_by":"auto","created_at":"2025-01-06 14:04:21","extension":"jpg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":159961,"visible":true,"origin":"","legend":"\u003cp\u003ePercentage of participants classified as having significant school impairment (scores ≥4 in the school/work item of the Work and Social Adjustment Scale, Youth and Parent versions) at baseline and at post-treatment, according to their school attendance status.\u003c/p\u003e","description":"","filename":"2.jpg","url":"https://assets-eu.researchsquare.com/files/rs-5720873/v1/b70cb93c20847b98b13477d0.jpg"},{"id":82537431,"identity":"0e891b52-aab2-44f4-a67b-a2b287366eb0","added_by":"auto","created_at":"2025-05-12 16:05:54","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1681652,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-5720873/v1/0613b3a5-2eeb-464f-afbd-2f3c72a296f8.pdf"},{"id":73079350,"identity":"14921c62-584a-4be1-810b-cd2b3994b5a7","added_by":"auto","created_at":"2025-01-06 13:56:21","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":24826,"visible":true,"origin":"","legend":"","description":"","filename":"SUPPLEMENTARYTABLES.docx","url":"https://assets-eu.researchsquare.com/files/rs-5720873/v1/cdb5789608b96bf272ebb629.docx"}],"financialInterests":"Competing interest reported. L.F.C. receives royalties for contributing articles to UpToDate and Wolters Kluwer Health and personal fees for editorial work from Elsevier, all outside the submitted work. D.M.C. receives royalties for contributing articles to UpToDate and Wolters Kluwer Health, occasional payments from funding agencies as an external grant reviewer, and is part owner of Scandinavian E-Health, AB, all outside the submitted work. All other authors report no competing interests.","formattedTitle":"The impact of pediatric obsessive-compulsive disorder on school attendance and school functioning: a case for supported education","fulltext":[{"header":"INTRODUCTION","content":"\u003cp\u003eObsessive-compulsive disorder (OCD) is a relatively prevalent mental disorder which usually has an early age of onset (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e). By definition, OCD is associated with substantial distress and impairment in several areas of functioning, including family life and social activities (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e). The symptoms of OCD and associated comorbidities are also known to have a negative impact on school functioning (\u003cspan additionalcitationids=\"CR4\" citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e), including difficulties concentrating during lessons, doing homework or even attending school. This impairment has the potential to severely affect long-term academic and professional opportunities of these young people (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e). In the largest study to date examining educational attainment in OCD, P\u0026eacute;rez Vigil et al. (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e) used a Swedish nationwide cohort including over 15,000 individuals with OCD showed that the diagnosis was associated with significantly worse academic performance across the lifespan. Specifically, compared to unaffected individuals, people with OCD were 30\u0026ndash;60% less likely to pass all core and additional school courses at the end of their compulsory education, 47\u0026ndash;61% less likely to access upper secondary education, 43% less likely to finish upper secondary education, 72% less likely to start a university degree, 59% less likely to finish a university degree, and 52% to finish postgraduate education. The results were similar when people with OCD were compared to their unaffected siblings, indicating that the difficulties were not due to factors shared within the family, such as parental educational level or psychopathology. Additionally, the impact on academic performance was more notable in those individuals who had received their first OCD diagnosis in childhood (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eAlthough the evidence is currently scarce, some studies have described the extent to which some children with OCD may require additional school support, such as specific adaptations or special classes. In a small study including 30 youth with OCD recruited from a specialist clinic, 48% had received remedial help (i.e., instructional support or assistance in the classroom), 40% were in a special class, and 7% had repeated a grade (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e). In another study, Abramovitch et al. (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e) showed that 118 children and adolescents with OCD, compared to a sample of 142 controls without OCD, were significantly more likely to be in a special class (10% vs. 1%, respectively) and receive extra help in school (64% vs. 4%, respectively). Among those with OCD, symptom severity was associated with a higher likelihood of receiving these school adaptations. However, school adaptations usually require for the pupils to attend school. To our knowledge, there are no published data on the extent of school attendance (i.e., school days missed) in young people with OCD.\u003c/p\u003e \u003cp\u003eOther important questions that have not been empirically addressed are 1) whether children with poor school attendance benefit from treatment as much as other children fully engaged in school, and 2) whether school attendance and school impairment improve after the successful treatment of OCD. The first question is important because we do not know if these children with poor school function require additional treatment. The second question is clinically relevant because if evidence-based treatments for OCD are not sufficient to improve school functioning, this would justify the need for additional, more targeted interventions that focus on this specific area (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe aims of this study were three-fold. First, we aimed to describe the school attendance and school impairment of a sample of 385 treatment-seeking children and adolescents diagnosed with OCD in a specialist obsessive-compulsive and related disorders clinic. Second, we aimed to compare the sociodemographic and clinical characteristics of youth with OCD with full school attendance vs. those with partial or no school attendance. And third, for the subgroup of individuals undertaking treatment at the clinic, we examined whether their level of school attendance was associated with their treatment outcomes, and whether the level of school attendance and school impairment improved after receiving treatment.\u003c/p\u003e"},{"header":"METHODS","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eSettings and procedures\u003c/h2\u003e \u003cp\u003eAll participants had been referred to the specialist OCD and Related Disorders Clinic for Children and Adolescents in Stockholm, Sweden. The clinic accepts referrals from the Stockholm region, and occasionally other parts of Sweden and the Nordic countries. Upon referral to the clinic, all families are invited to participate in research and for their routinely collected clinical data to be used for research purposes. The study was approved by the Stockholm Regional Ethical Review Board. All participants and their families (parents or legal guardians) provided informed consent to participate.\u003c/p\u003e \u003cp\u003eParticipants in the study had a diagnosis of OCD according to the diagnostic criteria in the Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5) (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e). The diagnosis was established in the routine initial clinical assessment at the clinic. Assessments are about 3 hours long and are conducted by experienced clinical psychologists. The assessments include a general battery of questions about development, sociodemographic and clinical characteristics, semi-structured clinical interviews to establish the primary diagnosis and associated comorbidities, and a series of general and disorder-specific clinician-administered, self-reported, and parent-reported measures (see Measures section). The information collected during the initial assessments is then discussed in a multidisciplinary team meeting, including clinical psychologists and child and adolescent psychiatrists, who collaboratively decide on the diagnosis and treatment plan (or alternative plan of action; e.g., referral to another service).\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eMeasures\u003c/h3\u003e\n\u003cp\u003eAll measures were collected at baseline and, for those undertaking treatment at the clinic, also at post-treatment. Exceptions were the diagnostic semi-structured interviews (see section below) and the two questions about school adaptations, which were only done at baseline, but not at post-treatment, and the Clinical Global Impression-Improvement (CGI-I) and the classification of participants into treatment responders and remitters, that were only done at post-treatment for those that had been on treatment.\u003c/p\u003e\n\u003ch3\u003eSemi-structured interviews\u003c/h3\u003e\n\u003cp\u003eThe diagnosis of OCD, as well as other obsessive-compulsive-related comorbidities, was formally evaluated with a semi-structured interview based on the Structured Clinical Interview for DSM-IV (SCID-I) (34) adapted by our research group to align with the more recent DSM-5 criteria for obsessive-compulsive and related disorders. The presence of other psychiatric comorbidities was assessed with the standardized diagnostic interview Mini International Neuropsychiatric Interview for Children and Adolescents (MINI-KID) (35).\u003c/p\u003e\n\u003ch3\u003eClinician-rated measures\u003c/h3\u003e\n\u003cp\u003eThe Children\u0026rsquo;s Yale-Brown Obsessive Compulsive Scale (CY-BOCS) is a clinician-rated, semi-structured interview which is used to assess the severity of the OCD symptoms (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e). It consists of five severity items for both obsessions and compulsions, with a total OCD severity score ranging from 0 to 40. The CY-BOCS has shown good reliability as well as good convergent and discriminant validity (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e). We used the empirically established benchmarks by Cervin et al. (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e) to classify the individuals into different levels of symptom severity according to their baseline CY-BOCS score.\u003c/p\u003e \u003cp\u003eThe Clinical Global Impression-Severity (CGI-S) is a one-item clinician rating of symptom severity. It is rated on a seven-point scale ranging from 1 (no symptoms) to 7 (extremely severe symptoms) (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e). The CGI-I is a one-item clinician rating of symptom severity change from the baseline assessment. This scale ranges from 1 (very much improved) to 7 (very much worse) (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eTreatment response was defined as a\u0026thinsp;\u0026ge;\u0026thinsp;35% reduction on the CY-BOCS from baseline to post-treatment plus a CGI-I score of 1 or 2, while remission was defined as a total score of \u0026le;\u0026thinsp;12 at post-treatment plus a CGI-S rating of 1 or 2 (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe Children\u0026rsquo;s Global Assessment Scale (CGAS) is a clinician-rated measure of global functioning that comprises one item (ranging from 1 to 100; higher scores indicate better functioning). The CGAS has shown high reliability as well as discriminant and concurrent validity (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e).\u003c/p\u003e\n\u003ch3\u003eSelf- and parent-rated measures\u003c/h3\u003e\n\u003cp\u003eThe OCI-CV is a self-reported measure of OCD symptom severity in children and adolescents. Both the total score and the subscales of the OCI-CV have good internal consistency and test-retest reliability, as well as good convergent and discriminant validity (\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eFamily accommodation of the OCD symptoms was measured with the Family Accommodation Scale \u0026ndash; Self-rated (FAS-SR). The FAS-SR is a 19-item parent-reported measure that assesses the degree to which parents accommodate their child\u0026rsquo;s OCD symptoms. The FAS-SR has shown excellent internal consistency, strong agreement with the FAS \u0026ndash; Interviewer Rated, and expected convergence with criterion measures (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eSelf-reported depressive symptoms were assessed by the Short Mood and Feeling Questionnaire, child version (SMFQ-C) and its parent reported version (SMFQ-P). The scales consist of 13 items and have shown good psychometric properties, including satisfying to good internal consistency, good convergent, concurrent, and criterion validity, and sensitivity to change (\u003cspan additionalcitationids=\"CR20\" citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe self-reported Work and Social Adjustment Scale\u0026ndash;Youth (WSAS-Y) and Parent (WSAS-P) versions were used to assess functional impairment in five areas (i.e., school/work, daily situations, social activities, leisure activities, and relationships) as a result of the participants\u0026rsquo; OCD symptoms. Items range from 0 (\u0026lsquo;not at all\u0026rsquo;) to 8 (\u0026lsquo;severely impaired\u0026rsquo;), with total scores ranging from 0 to 40. The instruments have demonstrated excellent psychometric properties, with high internal consistency, good convergent and divergent validity, and sensitivity to change (\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e). In the current paper, we used scores\u0026thinsp;\u0026ge;\u0026thinsp;4 in the school/work item as the cut-off to represent significant school impairment.\u003c/p\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eSchool-related questions\u003c/h2\u003e \u003cp\u003eThe battery of questions administered at baseline included 3 items related to school impairment. The first question enquired about the estimated school attendance in the last month, and responses were grouped in 5 intervals of 20% (i.e., 0\u0026ndash;20%, 21\u0026ndash;40%, 41\u0026ndash;60%, 61\u0026ndash;80%, and 81\u0026ndash;100% attendance). For the purpose of the present study, the interval 81\u0026ndash;100% attendance was coded as \u003cem\u003efull school attendance\u003c/em\u003e (i.e., attendance of at least 4 days a week during the past month), while the remaining intervals were grouped together and coded as \u003cem\u003epartial or no school attendance\u003c/em\u003e (i.e., missing school more than one day a week during the past month). The other questions focused on school support and adaptations: \u003cem\u003e\u0026ldquo;does the child have any school support measures or is he/she in an adapted class? If so, what measures\u0026rdquo;\u003c/em\u003e and \u0026ldquo;\u003cem\u003edoes the child have any learning difficulties, for example, does he/she need any support in school? If so, what support.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eTreatment\u003c/h3\u003e\n\u003cp\u003eThe treatment received at the clinic was multimodal, consisting of cognitive-behavior therapy (CBT) and medication, when deemed necessary by the clinical team. The CBT treatment followed a manualized protocol delivered in 14\u0026ndash;16 sessions (\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e). Usually, sessions lasted one hour and were conducted weekly. Some cases could also be offered intensive (e.g., several hours per day) clinic-based or home-based sessions (for homebound patients), based on the therapists\u0026rsquo; judgement and the families\u0026rsquo; preferences. Sessions were delivered by clinical psychologists with extensive experience in treating pediatric OCD or clinical psychologists in training under close supervision. The CBT treatment included varying degrees of parental/carer involvement, depending on the case formulation. Initial sessions were devoted to psychoeducation about OCD, mid-treatment sessions were primarily focused on graded exposure with response prevention (both therapist-assisted \u003cem\u003ein vivo\u003c/em\u003e ERP and as between-session assignments), and the final sessions included strategies for relapse prevention and maintenance of gains.\u003c/p\u003e \u003cp\u003eParticipants could also receive pharmacological treatment for their OCD and other comorbid symptoms/disorders, which was prescribed (or modified after the initial assessment or during treatment) by experienced child and adolescent psychiatrists at the clinic, according to treatment guidelines (\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e) and clinical judgement.\u003c/p\u003e\n\u003ch3\u003eStatistical analyses\u003c/h3\u003e\n\u003cp\u003eMeans and standard deviations, or frequencies and percentages, were used to describe the characteristics of the sample. Student\u0026rsquo;s t tests or Chi-square tests, as appropriate, were used to examine group differences. For those who undertook treatment at the clinic and had repeated outcome measures, mixed-effects regression models with maximum likelihood estimation of parameters were implemented. All models included fixed effects of time (baseline and post-treatment), school attendance status (partial or no attendance and full attendance), and the interaction time \u0026times; school attendance status. A random intercept was also added to account for the variances between and within participants. Alpha levels (two-tailed) were set to \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;.05. All analyses were performed using Stata 15.1 (StataCorp LLC).\u003c/p\u003e"},{"header":"RESULTS","content":"\u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eParticipants\u003c/h2\u003e \u003cp\u003eFrom November 2019 to November 2024, 428 individuals were assessed at the clinic who had OCD as the main diagnosis requiring treatment and had provided written consent for their data to be used for research purposes. Of these, 43 records were excluded due to being returning patients (i.e., they had done more than one initial assessment at the clinic) (\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;18) or because they had missing information on school attendance at the baseline assessment, as this was the main outcome in this study (\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;25). Hence, the final study sample included 385 participants.\u003c/p\u003e \u003cp\u003eThe sample consisted of young people with a mean age of 13.7 years (SD, 2.5; range, 7\u0026ndash;17) who were mainly girls (\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;243; 63.1%). Most participants (\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;202; 52.5%) were on the moderate range of OCD symptom severity. More than half (\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;193; 50.8%) had at least one additional psychiatric disorder. The most common comorbidities were attention-deficit/hyperactivity disorder (ADHD), autism spectrum disorder (ASD), anxiety disorders, and depression. Baseline characteristics of the full sample are presented in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eBaseline characteristics of the total study sample, and by school attendance status.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"9\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c9\" colnum=\"9\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eVariable (available \u003cem\u003en\u003c/em\u003e)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" morerows=\"1\" nameend=\"c3\" namest=\"c2\" rowspan=\"2\"\u003e \u003cp\u003eTotal study sample\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;385)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" morerows=\"1\" nameend=\"c5\" namest=\"c4\" rowspan=\"2\"\u003e \u003cp\u003eFull school attendance\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;302)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" morerows=\"1\" nameend=\"c7\" namest=\"c6\" rowspan=\"2\"\u003e \u003cp\u003ePartial or no school attendance\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;83)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c9\" namest=\"c8\"\u003e \u003cp\u003eStatistics\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c8\"\u003e \u003cp\u003et / ꭓ\u003csup\u003e2\u003c/sup\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c9\"\u003e \u003cp\u003ep\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAge at initial assessment\u003c/b\u003e (385), \u003cem\u003emean (sd)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e13.74\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2.53\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e13.69\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e2.63\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e13.92\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e2.17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e-0.72\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e0.470\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eSelf-reported age of OCD onset\u003c/b\u003e (361), \u003cem\u003emean (sd)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e10.99\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2.68\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e10.92\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e2.78\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e11.25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e2.49\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e-0.93\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e0.352\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eGender\u003c/b\u003e (385), \u003cem\u003en (%)\u003c/em\u003e\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e6.73\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e0.035*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGirl\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e243\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e63.12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e186\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e61.59\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e57\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e68.67\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBoy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e137\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e35.58\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e114\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e37.75\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e23\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e27.71\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOther\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1.30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.66\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e3.61\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eComorbid mental disorders\u003c/b\u003e (380), \u003cem\u003en (%)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e193\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e50.79\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e134\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e44.97\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e59\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e71.95\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e18.73\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001***\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAutism spectrum disorder\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e72\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e18.95\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e46\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e15.44\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e26\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e31.71\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e11.09\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e0.001**\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eADHD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e96\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e25.26\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e68\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e22.82\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e28\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e34.15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e4.37\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e0.037*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDepression\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e36\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e9.47\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e23\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e7.72\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e15.85\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e4.96\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e0.026*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAnxiety disorders\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e37\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e9.74\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e27\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e9.06\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e12.20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e0.72\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e0.396\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOther\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e45\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e11.84\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e37\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e12.42\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e9.76\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e0.44\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e0.509\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eOn medication at intake\u003c/b\u003e (380), \u003cem\u003en (%)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e189\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e49.74\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e132\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e44.30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e57\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e69.51\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e16.36\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001***\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAntidepressants\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e123\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e32.37\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e86\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e28.86\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e37\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e45.12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e7.77\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e0.005**\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAntipsychotics\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e22\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e5.79\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e3.69\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e13.41\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e11.15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e0.001**\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eADHD medication\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e46\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e12.11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e34\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e11.41\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e14.63\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e0.63\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e0.428\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOther medication\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e109\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e28.68\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e69\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e23.15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e40\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e48.78\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e20.64\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001***\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eSupport in school\u003c/b\u003e (358), \u003cem\u003en (%)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e118\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e32.96\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e82\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e29.18\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e36\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e46.75\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e8.45\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e0.004**\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eLearning difficulties\u003c/b\u003e (358), \u003cem\u003en (%)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e106\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e29.61\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e79\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e28.11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e27\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e35.06\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e1.40\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e0.237\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eCY-BOCS\u003c/b\u003e (385), \u003cem\u003emean (sd)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e22.48\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e4.19\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e21.80\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e3.79\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e24.94\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e4.68\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e-6.33\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001***\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSubclinical, \u003cem\u003en (%)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1.56\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e1.66\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e1.20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e0.09\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e0.769\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMild, \u003cem\u003en (%)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e155\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e40.26\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e137\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e45.36\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e18\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e21.69\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e15.18\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001***\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eModerate, \u003cem\u003en (%)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e202\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e52.47\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e155\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e51.32\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e47\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e56.63\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e0.73\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e0.392\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSevere, \u003cem\u003en (%)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e22\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e5.71\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e1.66\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e20.48\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e42.83\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001***\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eCGI-S\u003c/b\u003e (383), \u003cem\u003emean (sd)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4.32\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.78\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4.23\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.65\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e4.65\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e1.09\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e-4.37\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001***\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eCGAS\u003c/b\u003e (384), \u003cem\u003emean (sd)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e51.40\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e5.80\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e52.58\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e4.86\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e47.10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e6.84\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e8.28\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001***\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eOCI-CV\u003c/b\u003e (322), \u003cem\u003emean (sd)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e19.09\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e8.06\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e18.74\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e8.07\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e20.43\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e18.50\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e-1.53\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e0.127\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eFAS-SR\u003c/b\u003e (349), \u003cem\u003emean (sd)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e24.93\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e17.75\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e22.51\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e16.78\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e33.79\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e18.48\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e-5.04\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001***\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eSMFQ-C\u003c/b\u003e (326), \u003cem\u003emean (sd)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e10.29\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e6.20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e9.42\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e5.89\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e13.64\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e6.24\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e-5.17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001***\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eSMFQ-P\u003c/b\u003e (357), \u003cem\u003emean (sd)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e10.51\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e5.97\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e9.75\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e5.80\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e13.33\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e5.75\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e-4.78\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001***\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eWSAS-Y\u003c/b\u003e (328), \u003cem\u003emean (sd)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e17.19\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e8.70\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e15.86\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e7.95\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e22.28\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e9.59\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e-5.67\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001***\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSchool or work\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4.18\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2.36\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3.65\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e2.17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e6.24\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e1.92\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e-8.98\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001***\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEveryday functioning\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3.81\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2.55\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3.60\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e2.41\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e4.62\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e2.91\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e-2.96\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e0.003**\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSocial activities\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3.44\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2.42\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3.15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e2.27\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e4.53\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e2.67\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e-4.30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001***\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSpare time\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2.60\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2.36\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2.59\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e2.36\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e2.65\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e2.39\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e-0.18\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e0.856\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFamily activities\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3.16\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2.39\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2.88\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e2.21\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e4.25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e2.74\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e-4.32\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001***\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eWSAS-P\u003c/b\u003e (357), \u003cem\u003emean (sd)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e19.94\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e9.12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e18.40\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e8.59\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e25.62\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e8.82\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e-6.46\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001***\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSchool or work\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4.83\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2.24\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4.34\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e2.12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e6.67\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e1.64\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e-8.92\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001***\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEveryday functioning\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4.22\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2.56\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e2.51\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e5.07\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e2.55\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e-3.28\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e0.001**\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSocial activities\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4.38\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2.47\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4.04\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e2.40\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e5.63\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e2.31\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e-5.16\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001***\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSpare time\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2.55\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2.34\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2.36\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e2.25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e3.28\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e2.54\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e-3.07\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e0.002**\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFamily activities\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3.94\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2.51\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3.66\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e2.47\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e4.97\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e2.37\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e-4.14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001***\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"9\"\u003e* \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05; ** \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.01; \u003cem\u003e*** p\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003eSchool attendance, school impairment, and school adaptations\u003c/h2\u003e \u003cp\u003eAmong the 385 individuals in the sample, 302 (78.4%) were classified as having full school attendance, while 83 (21.6%) were classified as having partial or no school attendance. Among these, 5.7% (\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;22) of participants had minimal school attendance (i.e. attendance of one day or less a week during the last month).\u003c/p\u003e \u003cp\u003eThose with partial or no school attendance were significantly more likely to be girls, have more psychiatric comorbidities, including neurodevelopmental disorders (i.e., ASD and ADHD) and depression, and be on psychotropic medication. They also had significantly more severe scores on clinician-rated symptom severity (CY-BOCS and CGI-S) \u0026ndash; but not self-rated severity (OCI-CV), more family accommodation (FAS-SR), depression (SMFQ-C and SMFQ-P), and worse functioning (CGAS, WSAS-Y, and WSAS-P). As expected, the largest between-group difference within the WSAS scales was in the school/work item (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eAccording to their scores on the WSAS-Y and WSAS-P, 196 of the youth (59.8%) and 261 of the parents (73.1%) reported significant school impairment (i.e., scores\u0026thinsp;\u0026ge;\u0026thinsp;4). Among participants with full school attendance, these numbers were 136 (52.3%) for the youth (WSAS-Y) and 190 (67.6%) for the parents (WSAS-P). The respective numbers for those with partial or no school attendance were 60 (88.2%) and 71 (93.4%). The differences by school attendance status were statistically significant for both the young people (ꭓ\u003csup\u003e2\u003c/sup\u003e=28.93, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001) and the parents (ꭓ\u003csup\u003e2\u003c/sup\u003e=20.26, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001) (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eA total of 118 (33.0%) individuals reported to have school adaptations or receive support in school. Adaptations were significantly more frequent in the group that reported partial or no school attendance, compared to the group with full attendance (\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;36 [46.8%] vs. \u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;82 [29.2%], respectively; ꭓ\u003csup\u003e2\u003c/sup\u003e=8.45, p\u0026thinsp;=\u0026thinsp;0.004). Adaptations in the whole group included attending special class or school (n\u0026thinsp;=\u0026thinsp;32; 27.1%), adaptations related to their comorbid neurodevelopmental disorders (e.g., ADHD or ASD) (n\u0026thinsp;=\u0026thinsp;29; 24.6%), having an extra person in school for support (n\u0026thinsp;=\u0026thinsp;17; 14.4%), having shorter school days (n\u0026thinsp;=\u0026thinsp;11; 9.3%), and other or unspecified adaptations (n\u0026thinsp;=\u0026thinsp;29; 24.6%), including for example a special placement in the classroom, regular meetings with the school counsellor or school psychologist, special food, and other adaptations related to the OCD symptoms (e.g., being able to leave the classroom to wash hands).\u003c/p\u003e \u003cp\u003eAnother 106 (29.6%) of the total sample reported having learning difficulties (e.g., issues with concentration, difficulties with reading, difficulties with math-related tasks) that required school support. These were similarly distributed between the youth with full school attendance and youth with partial or no school attendance (\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;79 [28.1%] vs. \u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;27 [35.1%], respectively; ꭓ\u003csup\u003e2\u003c/sup\u003e=1.40, p\u0026thinsp;=\u0026thinsp;0.237).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003eEffect of school attendance on OCD treatment outcomes\u003c/h2\u003e \u003cp\u003eOf the initial sample of 385 participants, 322 (83.6%) received treatment for OCD at the clinic and had post-treatment data available. Characteristics of this subgroup were very similar to those in the group without available post-treatment data, aside from a slight difference in OCD symptom severity at the intake, showing slightly lower CY-BOCS scores in those with no available post-treatment data compared to those with available data (means [SD]\u0026thinsp;=\u0026thinsp;21.4 [4.4] vs. 22.7 [4.1]; t-test=-2.22, p\u0026thinsp;=\u0026thinsp;0.027) (\u003cb\u003eSupplementary Table\u0026nbsp;1\u003c/b\u003e).\u003c/p\u003e \u003cp\u003eRaw means and standard deviations for all study outcomes are presented in \u003cb\u003eSupplementary Table\u0026nbsp;2\u003c/b\u003e. The means and standard errors from the mixed-effect regression models are reported in Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e. The models showed a significant main effect of time on all treatment outcomes, denoting a reduction of OCD-related and comorbid symptoms (CY-BOCS, CGI-S, OCI-CV, FAS-SR, SMFQ-C, SMFQ-P) and an improvement in functioning (CGAS, WSAS-Y, WSAS-P), regardless of school attendance. There were also significant main effects of group in all measures (except for the CGAS), reflecting the higher baseline scores of the individuals in the partial or no school attendance group at baseline. The interaction time \u0026times; school attendance status reached significance for the CY-BOCS, the FAS-SR, the SMFQ-C, the SMFQ-P, the WSAS-Y, and the WSAS-P (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). These results indicate that, although those with partial or no school attendance started with higher baseline scores, both groups improved to a similar degree by the end of the treatment. This is illustrated in Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e1\u003c/span\u003e, which graphically represents the baseline and post-treatment CY-BOCS scores in both groups.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eResults from the mixed-effect regression models in the subsample of individuals with obsessive-compulsive disorder with post-treatment data (n\u0026thinsp;=\u0026thinsp;322).\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"8\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\"\u0026minus;\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariable\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003eFull school attendance\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;258)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003ePartial or no school attendance\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;64)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eMain effect of time\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003eMain effect of group\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c8\"\u003e \u003cp\u003eTime x group interaction effects\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMeasure\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMean\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eSE\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eMean\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eSE\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eCoefficient (CI)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003eCoefficient (CI)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c8\"\u003e \u003cp\u003eCoefficient (CI)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eCY-BOCS\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e-11.57 (-12.26 \u0026ndash; -10.88)***\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e3.14 (2.02\u0026ndash;4.25)***\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026minus;\" colname=\"c8\"\u003e \u003cp\u003e-2.20 (-3.73 \u0026ndash; -0.68)**\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBaseline\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e21.80\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.26\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e24.94\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.50\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePost-treatment\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e10.24\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.28\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e11.17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.57\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eCGI-S\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e-1.67 (-1.80 \u0026ndash; -1.53)***\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.42 (0.20\u0026ndash;0.63)***\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026minus;\" colname=\"c8\"\u003e \u003cp\u003e-0.09 (-0.39\u0026ndash;0.21)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBaseline\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e4.23\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.05\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e4.65\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePost-treatment\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2.56\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.05\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e2.89\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eCGAS\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e7.13 (6.23\u0026ndash;8.03)***\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e-5.49 (-7.13 \u0026ndash; -3.84)***\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026minus;\" colname=\"c8\"\u003e \u003cp\u003e0.03 (-1.96\u0026ndash;2.02)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBaseline\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e52.58\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.39\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e47.10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.74\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePost-treatment\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e59.72\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.41\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e54.26\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.82\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eOCI-CV\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e-7.20 (-8.44 \u0026ndash; -5.97)***\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e1.68 (-0.39\u0026ndash;3.75)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026minus;\" colname=\"c8\"\u003e \u003cp\u003e-1.73 (-4.34\u0026ndash;0.88)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBaseline\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e18.75\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.48\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e20.43\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.94\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePost-treatment\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e11.55\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.62\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e11.50\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e1.15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eFAS-SR\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e-14.94 (-17.36 \u0026ndash; -12.53)***\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e11.15 (7.38\u0026ndash;14.93)***\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026minus;\" colname=\"c8\"\u003e \u003cp\u003e-8.34 (-13.54 \u0026ndash; -3.14)**\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBaseline\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e22.57\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.89\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e33.73\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e1.71\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePost-treatment\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e7.63\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1.11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e10.44\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e2.13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eSMFQ-C\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e-2.50 (-3.34 \u0026ndash; -1.66)***\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e4.12 (2.53\u0026ndash;5.70)***\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026minus;\" colname=\"c8\"\u003e \u003cp\u003e-2.27 (-4.07 \u0026ndash; -0.47)*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBaseline\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e9.42\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.37\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e13.54\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.72\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePost-treatment\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e6.92\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.45\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e8.77\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.86\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eSMFQ-P\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e-4.23 (4.99 \u0026ndash; -3.48)***\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e3.54 (2.17\u0026ndash;4.91)***\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e-1.98 (3.60\u0026ndash;0.35)*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBaseline\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e9.75\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.32\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e13.29\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.62\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePost-treatment\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e5.52\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.39\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e7.08\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.74\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eWSAS-Y\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e-7.27 (-8.74 \u0026ndash; -5.81)***\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e6.41 (4.32\u0026ndash;8.50)***\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026minus;\" colname=\"c8\"\u003e \u003cp\u003e-5.25 (-8.38 \u0026ndash; -2.13)**\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBaseline\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e15.86\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.49\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e22.28\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.95\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePost-treatment\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e8.59\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.65\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e9.75\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e1.20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eWSAS-P\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e-8.08 (-9.43 \u0026ndash; -6.74)***\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e7.24 (5.15\u0026ndash;9.33)***\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026minus;\" colname=\"c8\"\u003e \u003cp\u003e-4.03 (-6.94\u0026ndash;1.12)**\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBaseline\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e18.41\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.49\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e25.65\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.95\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePost-treatment\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e10.32\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.60\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e13.54\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e1.16\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"8\"\u003e* \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05; ** \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.01; \u003cem\u003e*** p\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eIn line with the results from the models, there were no statistically significant between-group differences in the proportion of participants classified as treatment responders and remitters at post-treatment, when comparing those with full attendance and those with partial or no attendance (responders: \u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;186 [73.2%] vs. \u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;49 [76.6%], respectively; ꭓ\u003csup\u003e2\u003c/sup\u003e=0.29, p\u0026thinsp;=\u0026thinsp;0.587; remitters: \u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;108 [42.4%] vs. \u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;21 [32.8%], respectively; ꭓ\u003csup\u003e2\u003c/sup\u003e=1.93, p\u0026thinsp;=\u0026thinsp;0.164).\u003c/p\u003e \u003cp\u003eImportantly, individuals with partial or no school attendance had received significantly more CBT sessions than those with full school attendance (19.2 vs. 14.9 sessions, respectively; t-test=-3.80, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001) and they were also more likely to be on psychotropic medication at post-treatment (\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;51 [79.7%] vs. \u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;124 [48.6%]; ꭓ\u003csup\u003e2\u003c/sup\u003e=19.93, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec15\" class=\"Section2\"\u003e \u003ch2\u003eEffect of OCD treatment on school attendance and school impairment\u003c/h2\u003e \u003cp\u003eOf 385 participants with data on school attendance at baseline, 276 (71.7%) had available data on school attendance at post-treatment. The number of youth with partial or no school attendance decreased from 83/385 (21.6%) at baseline to 29/276 (10.5%) at post-treatment. Among those with partial or no school attendance at baseline with available data at post-treatment, almost 40% still reported to have partial or no school attendance at the end of the treatment \u003cem\u003e(n\u003c/em\u003e\u0026thinsp;=\u0026thinsp;18/47, 38.3%). Among youth with full school attendance at baseline, the vast majority (\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;218/229, 95.2%) still had full school attendance at the end of treatment.\u003c/p\u003e \u003cp\u003eThe proportion of individuals with partial or no school attendance at post-treatment was similar among treatment responders and non-responders (\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;22, 10.7% vs. \u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;6, 8.6%, respectively; ꭓ\u003csup\u003e2\u003c/sup\u003e=2.27, p\u0026thinsp;=\u0026thinsp;0.606). The same was true for remitters and non-remitters (\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;9, 7.8% and \u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;19, 12.0%; ꭓ\u003csup\u003e2\u003c/sup\u003e=1.29, p\u0026thinsp;=\u0026thinsp;0.256). This suggests that school attendance status and response or remission status were somewhat independent outcomes.\u003c/p\u003e \u003cp\u003eAdditionally, the school/work items in the WSAS-Y and the WSAS-P were examined. Results showed that school impairment (i.e., scores\u0026thinsp;\u0026ge;\u0026thinsp;4) decreased throughout the course of the treatment, as reported by both the youth with OCD and the parents. However, of those with available data, a total of 45 (22.8%) youth (WSAS-Y) and 76 (33.3%) parents (WSAS-P) still presented with significant school impairment at the end of the treatment. Ten (52.6%) youth and 11 (55.0%) parents with partial or no school attendance at post-treatment still reported school impairment at this timepoint, compared to 24 (17.5%) youth and 50 (29.8%) parents among those with full school attendance at the end of treatment (ꭓ\u003csup\u003e2\u003c/sup\u003e=12.07, p\u0026thinsp;=\u0026thinsp;0.001 and ꭓ\u003csup\u003e2\u003c/sup\u003e=5.19, p\u0026thinsp;=\u0026thinsp;0.023; respectively) (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003c/div\u003e"},{"header":"DISCUSSION","content":"\u003cp\u003eThis study included 385 children and adolescents diagnosed with OCD attending a specialist obsessive-compulsive and related disorders clinic. Around 22% of the sample was not attending school or had partial school attendance at intake. This is a considerable proportion, considering that the mean age of the sample was around 13\u0026ndash;14 years, which are years of compulsory education in Sweden (up to approximately age 16). In line with previous, smaller studies in children and adolescents with OCD (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e), our figures also showed that around one third of the children and adolescents needed school adaptations and support. These adaptations were present in about 30% of those with full school attendance and 47% of children with poor attendance, indicating that even those fully engaged in school required extra support. The adaptations were several, varying from having shorter school days to attending a special class. This highlights that different children with OCD and associated comorbidities will have different needs (in form and degree) and that it is important to evaluate each particular case and provide individualized solutions.\u003c/p\u003e \u003cp\u003eYouth with poor school attendance were more likely to be girls, had more psychiatric comorbidities, were more likely to be on medication already at intake, and presented with more severe clinical symptomatology and general impairment. About 60%, according to the young people, or 73%, according to the parental report, were classified as having significant school impairment. As expected, this was a lot more pronounced in youth with poor school attendance, compared to those with full attendance. Hence, most individuals in our large sample, regardless of the informant or the degree of engagement in school, presented with significant school impairment, mirroring previous reports on pediatric OCD samples (\u003cspan additionalcitationids=\"CR4\" citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eAlthough we did not have data on school performance, we can hypothesize that the reported school-related functional impairment is likely to translate into lower grades, as we have previously reported in OCD (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e). Hence, it is important to consider this impairment when treating OCD to ensure that youths with OCD fulfill their educational potential and are able to develop academic and professional careers of their choice.\u003c/p\u003e \u003cp\u003eOne positive result from our study was that school struggles did not necessarily interfere with OCD treatment outcomes. The proportion of treatment responders and remitters was similar in youths with limited vs full school attendance. However, it is important to note that children and adolescents with limited school attendance received more CBT sessions and more medication, which may suggest that they were either more complex to begin with or that they required a higher dose of treatment to achieve comparable results. Also, it is likely that some of the time in the sessions was spent motivating the youth to attend school and talking about the school difficulties with both the youth and the parents.\u003c/p\u003e \u003cp\u003eInterestingly, although the multimodal treatment was overall successful at improving symptom severity (about three fourths of participants were classified as treatment responders, regardless of their school attendance at baseline) and the proportion of youth with full school attendance increased from baseline to post-treatment, almost 40% of those that reported partial or no school attendance at baseline still were not able to go back to full-time schooling by the end of the treatment. Moreover, a significant proportion of both parents and children still reported significant impairment scores in the school domain at this timepoint. Previous studies have suggested that, although CBT is a powerful treatment, reduction in symptom severity is not necessarily associated with improvements in other life domains (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e). Hence, it seems that a more holistic intervention approach including a specific focus on supporting these youth in school may be required (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e). Indeed, interventions specifically targeting the educational needs of students with psychiatric disorders have shown a positive impact on the academic functioning of these populations (\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e). However, there is limited evidence for these interventions given that empirical studies are few and of moderate quality (\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e). Hence, methodologically sound studies on supported education and return to school strategies for youth with OCD who struggle in school are warranted.\u003c/p\u003e \u003cdiv id=\"Sec17\" class=\"Section2\"\u003e \u003ch2\u003eStrengths and limitations\u003c/h2\u003e \u003cp\u003eThe study included a large and well-characterized sample of children and adolescents with OCD consecutively referred to a specialist clinic, with no exclusion criteria. We used validated, gold standard instruments and collected information on a wide range of clinically relevant aspects. However, the study should also be interpreted in light of some limitations. First, in youth that had reduce their schedule or had shorter school days as a form of school adaptation, parents and clinicians often regarded their attendance as full, as this adaptation had been previously agreed with the school. Hence, it might be that, at least for some of the individuals in the sample, the school attendance was overestimated. Second, we did not have a control group. Therefore, we cannot conclude that the described school-related functional impairment is associated with the diagnosis of OCD or the concurrent psychiatric disorders in the sample. Similarly, we cannot conclude that the observed clinical improvements were due to the multimodal treatment. Third, the data used in the study were collected over a period of around five years, which may have resulted in some heterogeneity in the data collection and data loss in different parts of the process. Finally, our results may not generalize to non-specialist clinics. Nonetheless, it is important to note that the sample encompassed all levels of OCD symptom severity, with over 40% being classified as having mild OCD. In the same way, results may not generalize to other countries with different educational systems. For example, the Swedish school system allows for adaptations, even in mainstream schools, which may translate into better attendance or better performance compared to more rigid contexts.\u003c/p\u003e \u003c/div\u003e"},{"header":"Conclusions","content":"\u003cp\u003eSchool-related functional impairment is common in children and adolescents with OCD. About 22% of our well-characterized sample of almost 400 youth with OCD presented with partial or no school attendance at intake. Despite substantial improvement of OCD symptom severity and associated features with treatment, a significant proportion of youth still had poor school attendance and reported significant school impairment after treatment. Children and adolescents with OCD who struggle at school may benefit from specific supported education and return to school strategies to completement regular evidence-based interventions focused on symptom reduction.\u003c/p\u003e"},{"header":"Declarations","content":"\u003ch2\u003eCompeting Interests\u003c/h2\u003e\n\u003cp\u003eL.F.C. receives royalties for contributing articles to UpToDate and Wolters Kluwer Health and personal fees for editorial work from Elsevier, all outside the submitted work. D.M.C. receives royalties for contributing articles to UpToDate and Wolters Kluwer Health, occasional payments from funding agencies as an external grant reviewer, and is part owner of Scandinavian E-Health, AB, all outside the submitted work. All other authors report no competing interests.\u003c/p\u003e\n\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\n\u003cp\u003eL.F.C., D.R., and D.M.C. conceived and designed the study. L.F.C. wrote the original draft. D.R. performed the analyses. All authors contributed intellectually and approved the final version of the manuscript.\u003c/p\u003e\n\u003ch2\u003eData Availability\u003c/h2\u003e\n\u003cp\u003ePatient data supporting this study cannot be made publicly available due to ethical and legal restrictions.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eAmerican Psychiatric Association (2013) The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5). American Psychiatric Association\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRuscio AM, Stein DJ, Chiu WT, Kessler RC (2010) The epidemiology of obsessive-compulsive disorder in the National Comorbidity Survey Replication. 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Psychiatr Rehabil J 46(3):173\u0026ndash;184. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1037/prj0000528\u003c/span\u003e\u003cspan address=\"10.1037/prj0000528\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"child-psychiatry-and-human-development","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"chud","sideBox":"Learn more about [Child Psychiatry \u0026 Human Development](http://link.springer.com/journal/10578)","snPcode":"10578","submissionUrl":"https://submission.nature.com/new-submission/10578/3","title":"Child Psychiatry \u0026 Human Development","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"Obsessive-compulsive disorder, functional impairment, school function, education, treatment outcomes","lastPublishedDoi":"10.21203/rs.3.rs-5720873/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-5720873/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eSchool-related functional impairment is common in children and adolescents with obsessive-compulsive disorder (OCD). However, little is known about the characteristics of youth with OCD who struggle in school, whether these struggles interfere with treatment outcomes, and whether treatment improves school-related function. Among 385 youth with OCD at a specialist clinic (mean age [sd]\u0026thinsp;=\u0026thinsp;13.7 [2.5]; 63.1% girls), 21.6% had partial or no school attendance at intake. Among those who received specialist treatment (\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;322), outcomes were similar in those with no or partial attendance vs. those with full attendance, although the latter group needed fewer treatment sessions and were less likely to be on psychotropic medication. At post-treatment, 10.5% still had partial or no school attendance, and 22.8% of youths and 33.3% of parents reported significant school impairment, regardless of response status. Some youth with OCD may benefit from specific supported education and return to school strategies to complement regular evidence-based interventions.\u003c/p\u003e","manuscriptTitle":"The impact of pediatric obsessive-compulsive disorder on school attendance and school functioning: a case for supported education","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-01-06 13:40:16","doi":"10.21203/rs.3.rs-5720873/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-02-12T16:14:13+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-01-30T23:03:40+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-01-15T01:04:45+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"107538808143980509649106089561580439552","date":"2025-01-02T17:08:29+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"1136236478363797754506106608817601416","date":"2025-01-02T16:56:10+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"307990026760897449646863726844644347360","date":"2025-01-02T16:24:55+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-01-02T14:59:59+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-12-31T13:56:46+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-12-28T09:51:11+00:00","index":"","fulltext":""},{"type":"submitted","content":"Child Psychiatry \u0026 Human Development","date":"2024-12-27T10:18:57+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"child-psychiatry-and-human-development","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"chud","sideBox":"Learn more about [Child Psychiatry \u0026 Human Development](http://link.springer.com/journal/10578)","snPcode":"10578","submissionUrl":"https://submission.nature.com/new-submission/10578/3","title":"Child Psychiatry \u0026 Human Development","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"45334fd9-3d6b-4736-8d39-9c14b629489c","owner":[],"postedDate":"January 6th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2025-05-12T15:58:59+00:00","versionOfRecord":{"articleIdentity":"rs-5720873","link":"https://doi.org/10.1007/s10578-025-01846-y","journal":{"identity":"child-psychiatry-and-human-development","isVorOnly":false,"title":"Child Psychiatry \u0026 Human Development"},"publishedOn":"2025-05-09 15:57:00","publishedOnDateReadable":"May 9th, 2025"},"versionCreatedAt":"2025-01-06 13:40:16","video":"","vorDoi":"10.1007/s10578-025-01846-y","vorDoiUrl":"https://doi.org/10.1007/s10578-025-01846-y","workflowStages":[]},"version":"v1","identity":"rs-5720873","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-5720873","identity":"rs-5720873","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}