Obsessive-compulsive disorder in children and adolescents: Treatment guidelines

The prevalence of obsessive-compulsive disorder (OCD) is 2 to 3% in children and adolescents. A larger proportion have subthreshold symptoms. The initiation of symptoms may be insidious or more abrupt and children are reluctant to reveal symptoms. The most common obsessions are contamination fears and aggressive/sexual obsessions while the most common compulsions are repeating, ordering compulsions and washing rituals. Comorbid conditions include major depression, generalised anxiety, separation anxiety and tic disorders. A subgroup of children also have pervasive developmental disorder. Clinical management is based on careful information gathering, availability of the clinician to the family and illness education. Rating scales such as the Leyton Obsessional Inventory - Children's Version and the Children's Yale-Brown Obsessive-Compulsive Scale (CY-BOCS) are used to establish baseline symptoms. The CY-BOCS is used to assess severity on follow-up. Organic primary causes of OCD should be investigated. Cognitive-behavioural therapy is effective in adults and controlled trials are underway in children. Individual and family therapy are adjunct treatment modalities. Pharmacological interventions are based on the use of nonselective serotonin (5-hydroxytryptamine; 5-HT) reuptake inhibitors such as clomipramine or selective serotonin reuptake inhibitors (SSRIs) fluoxetine, fluvoxamine, paroxerine sertraline or citalopram. SSRIs are currently the agents of choice to treat paediatric OCD; although clomipramine is as effective as the SSRIs, adverse effects make it a less optimal first-line agent. There are no known efficacy differences between SSRIs. Fluoxetine and sertraline may cause more behavioural activation. Fluoxetine has a longer half-life, while fluvoxamine and sertraline have shorter half-lives. Controlled double-blind studies are available for clomipramine, flu voxamine (which has US Food and Drug Administration approval for use in OCD with children) and sertraline. Trials are underway for paroxetine and fluoxetine. Augmentation strategies are appropriate after a full trial with adequate length of treatment and maximum tolerated dosage with one or possibly two SSRIs of clomipramine. Tic-related OCD improves with antipsychotic augmentation. In adolescents, careful addition of an SSRI to clomipramine is an alternative strategy. Lithium and buspirone are not useful in augmentation, clonazepam is possibly beneficial. Attention should be paid to the cytochrome P450 metabolic pathway that affects the SSRIs when used with other drugs. Current experimental immune therapies in children with autoimmune OCD may provide additional treatment strategies. With adequate treatment most children with OCD will have a positive response, but long term treatment is indicated in most children with moderate to severe symptoms.