Pediatric obsessive-compulsive disorder is a chronic and impairing condition that often persists into adulthood. This review refreshes the state of support for psychosocial treatments and the predictors or moderators that relate to their efficacy and evaluates how the literature has improved since the last update in 2014. A secondary goal is to propose an additional framework for the categorization of studies based on central research questions rather than treatment format. Psychosocial treatment studies conducted since the last review are described and evaluated according to methodological rigor and evidence-based classification using the Journal of Clinical Child and Adolescent Psychology evidence-based treatment evaluation criteria. Findings again converge in support of cognitive-behavioral therapy (CBT) as an effective and appropriate first-line treatment for youth with obsessive-compulsive disorder. Family-focused CBT is now well-established. A number of other treatments including CBT+ D-Cycloserine, CBT+ Sertraline, CBT+ positive family interaction therapy, and technology-based CBT are now probably efficacious. Demographic, clinical, and family factors are consistent predictors of CBT outcome with conflicting findings for neurocognitive predictors. The field has advanced significantly since the last review, but there is still room for improvement. Some of the conclusions that can be drawn may be limited by our evaluation criteria. Future directions are proposed to advance treatment outcome research beyond a focus on which treatments work to exploring factors that account for how and why they work.

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Despite increased empirical support for, and consensus recognition of, the values of responsive treatment personalization in the delivery of evidence-based mental health care for youth, the literature has actually offered very little structured guidance with which to inform the actual practice of treatment flexibility. The present paper offers aworking heuristic framework for navigating the necessary deliberations that must be at the center of individual therapist efforts to thoughtfully tailor evidence-based practices. Our guiding Strategic Flexibility Model is organized around five critical questions/deliberations, which we collectively refer to as "the Who, What, When, Where, and Why of Strategic Flexibility." Specifically, our model has the therapist thoughtfully consider: (1) who warrants treatment flexibility?; (2) what treatment components merit flexibility, and what modifications can be applied?; (3) when in treatment is flexibility warranted?; (4) where (i. e., in what settings) is flexibility needed, and where (in what settings) can flexibility by applied?; and (5) why (i.e., to what end) should flexibility be applied under specific circumstances? Strategic Flexibility is conceptualized as an active and dynamic process of careful consideration, hypothesis generation, hypothesis testing, and course correction, as needed. Within our model, it is haphazard clinical "off-roading"-not protocol non-adherence, per say-that is of primary concern. Specific examples are offered throughout, and recommendations for future efforts on this front are discussed.