Obsessive-compulsive disorder (OCD) is associated with substantial interference and chronicity in pediatric populations.1 Given that at least one-half of all cases of OCD begin before the age of 20 years,2 early and efficacious treatment could greatly reduce the high burden of OCD. Clinical guidelines for the treatment of pediatric OCD were published by the American Academy of Child and Adolescent Psychiatry in 2012.3 These provided a comprehensive overview of evidence-based treatments and a set of recommendations for best-practice treatment derived from empirical data and clinical consensus. In recent years, a number of meta-analyses and reviews have been published that address these recommendations, and in some cases, challenge them. This article provides an update on the evidence base for recommended pediatric OCD treatments and an overview of emerging directions for treatment research.
Recommended Treatments for Pediatric Obsessive-Compulsive Disorder
Cognitive-behavioral therapy (CBT) with exposure and response prevention (ERP) is the recommended first-line treatment for pediatric OCD.3 In addition to ERP, other core CBT components include psychoeducation, cognitive restructuring, behavioral experiments, and relapse prevention.4 Across published CBT studies, the median duration of treatment was 12 weekly sessions lasting 90 minutes each.4 Recent meta-analyses supported the efficacy of CBT, reporting large effect sizes (Hedges' g = 1.21–1.28) for OCD symptom reduction,4–6 response to treatment in 69.9% of cases, and remission of OCD diagnosis in 52.7% of cases.5
These meta-analyses indicated that studies with a higher proportion of participants with comorbid anxiety had greater treatment effects, suggesting that an anxiety-focused OCD presentation may respond particularly well to CBT.5,6 There was inconsistent evidence suggesting that greater efficacy may be associated with particular treatment protocols, with a higher number of therapeutic contact hours, or with increased levels of parental involvement in treatment.4,5,7 There was no evidence that treatment outcome varied according to the delivery format of CBT (ie, individual, family, or group), by participant age or gender, or by OCD severity, duration, or past treatment.4–6
Pharmacotherapy is recommended for use in combination with CBT in patients with more severe OCD presentations.3 However, pharmacotherapy alone may be indicated in a range of circumstances, such as when CBT is not available, when family conflict or other difficulties compromise treatment engagement, if OCD insight is poor, or when comorbid disorders like depression affect the ability to engage with CBT.3 The recommended first-line pharmacotherapy for OCD involves serotonin reuptake inhibitors (SRIs),3 specifically, the selective SRIs (SSRIs) sertraline, fluoxetine, and fluvoxamine.8 The minimum period of SRI treatment should be 10 weeks, and it is generally recommended to maintain successful medication for 6 to 12 months after a positive response.3,9
Meta-analyses of SRI-only treatment studies found, relative to placebo, a moderate effect size (g = 0.48–0.50) for OCD symptom reduction,5,6,8 response to treatment in 48.9% of cases, and remission of OCD diagnosis in 24.1% of cases.5 The meta-analyses found that clomipramine, an older tricyclic SRI, had a greater treatment effect than the SSRIs.7,8,10 However, clomipramine is associated with more frequent side effects including cardiac and seizure events;3,7 thus, it is not recommended for use as a first-line medication among affected youth. Greater treatment effects were associated with lower methodological quality of SRI studies in two meta-analyses,6,7 and with higher baseline OCD symptom severity in one meta-analysis.5 Across meta-analyses,5–7 SRI treatment outcome was not significantly associated with medication dosage or duration (contrary to findings in adults11), participant age or gender, or history of previous treatment.
A combination of CBT and pharmacotherapy is the recommended first-line treatment for moderate to severe OCD,3 but only four studies12–15 have examined combined treatment outcome in pediatric OCD. One meta-analysis found that combined treatment was not superior to CBT monotherapy but was superior to SRI monotherapy.8 However, another meta-analysis found that combined treatment was more efficacious than both CBT and SRI monotherapy when adjusting for the use of inactive control groups in CBT studies.7
Treatment of Young Children
Most of the pediatric treatment outcome studies involved children age 7 years or older. However, OCD can present in young children, and when it does it may involve atypical features that are difficult to differentiate from autism spectrum disorders, sensory problems, anxiety disorders, and behavioral difficulties.16 Despite these differences, when adapted to the developmental level of the young child, CBT can be a highly efficacious treatment for children as young as age 3 years.17 In fact, one meta-analysis found that the treatment effect size was actually larger in studies of youth age 3 to 8 years compared to those age 7 to 18 years,5 suggesting particularly robust effects for OCD intervention at an early age.
Although SRI studies have included participants as young as age 6 years, there is little information about the safety and efficacy of these medications in young children. Guidelines suggest that pharmacological treatment should not be given as a monotherapy to young children and should be used in combination with CBT only when symptoms are severe.18
Recommendations for First-Line Treatment
CBT and SSRIs are efficacious and appropriate choices for treating pediatric OCD; however, CBT has superior efficacy to SSRIs.5–8 There is no conclusive evidence that combined treatment is more effective than CBT monotherapy for moderate to severe OCD, or that the efficacy of CBT is lower in those with severe OCD.4–6 Current evidence supports the first-line use of CBT in the treatment of pediatric OCD, with SSRIs added according to clinical judgment of individual need. When CBT is not available, SSRI monotherapy is anticipated to have a moderate effect on OCD symptoms, with only a modest chance of leading to disorder remission. It is important to emphasize that the number of high-quality, randomized controlled trials of pediatric OCD treatments is still relatively small, and few studies involve combined treatments. Further research is greatly needed to evaluate the efficacy of combined treatments, predictors of the need for combined treatments, the impact of SSRI side effects on treatment, how to withdraw SSRI treatment while minimizing side effects and relapse, and the long-term outcomes of treatment.19,20
Interventions for Partial or Nonresponders to Treatment
A substantial number of young people with OCD either do not respond, or only respond partially, to first-line treatments.5 However, it is important to establish whether the individual received a sufficient “dose” of a first-line treatment before considering alternative treatments.20 If the individual has previously received psychotherapy, it is important to establish if CBT was delivered. If so, the number of hours of therapist-guided ERP should be assessed, as a lack of in-session exposure tasks is the most common reason for inadequate delivery of CBT.21 It should also be determined whether all planned sessions of CBT were attended, as a failure to complete a given program is associated with poorer outcome.6
If previous therapy was not CBT-based, or if previous CBT was inadequate, a full course of high-quality CBT should be provided. When a patient fails to respond to an adequate course of CBT, augmentation of therapy with an SSRI is recommended.3 Continued CBT should also be provided, as approximately 50% of youth who did not respond to a full course of CBT may improve with further CBT sessions.21,22
To be considered adequate, previous medication trials should involve a minimum of 10 weeks of the medication at the maximum recommended or maximum tolerable dose.3 If a medication trial was adequate but ineffective, switching to another SSRI is recommended. The factors associated with previous unsuccessful medication trials should be examined, as difficulties such as side effects, parental anxiety, or medication compliance can often be overcome.20 CBT should be delivered if possible, as this produces superior outcomes to SRI monotherapy.8
Augmentation of an SSRI with a non-SSRI medication should only be considered when an individual has not responded to two adequate SSRI trials and when CBT is ineffective or unavailable.3 Unfortunately, there is a lack of high-quality evidence to guide augmentation strategies in pediatric OCD.20 Even the efficacy of augmentation of SSRIs with clomipramine, the most common second-line medication strategy,3 has not been examined in pediatric OCD using a randomized controlled trial. There is an understandable reluctance to use medication-augmentation strategies in pediatric populations when limited information exists about safety and efficacy. The expert consensus is thus to exhaust every avenue to deliver CBT or SSRIs before considering such approaches, and to seek expert consultation if possible.20
Advances in Cognitive Behavioral Therapy
Improving Therapist Competencies
In routine clinical settings, many therapists do not use CBT when treating OCD, and many others deliver CBT inadequately.21 Thus, programs designed to increase a therapist's skills and confidence may hold promise in increasing the availability and quality of CBT. For example, in the United States, the International OCD Foundation offers 3-day intensive training courses for clinicians on the use of CBT for OCD. A recent study found that participants continued to use the skills over time, and increased the number of specialist referrals for OCD;23 therefore, access to quality care may be improved using programs that increase the core competencies of therapists treating OCD in routine clinical settings.
CBT typically involves 12 to 16 weekly sessions, delivered at a therapist's office. Attendance at regular therapy sessions can, therefore, place a substantial burden on families, often requiring time off work and school and disrupting family activities. To reduce this burden, intensive treatment protocols have been developed. These vary in the format of treatment, such as delivering therapy once daily for 3 weeks,24 twice daily for 5 days,25 or in two long sessions 1 week apart followed by three follow-up sessions.26 A meta-analysis found a large effect size for intensive CBT across six pediatric studies (g = 2.18).27 Intensive CBT thus constitutes an efficacious treatment that may be a more accessible and affordable option for some families.
Delivering CBT outside of traditional therapy settings can increase access to geographically isolated families and to families concerned about the stigma of seeking mental health treatment.28 Early forms of e-therapy involved delivering standard CBT programs via telephone or videoconferencing technology. A recent meta-analysis found that remotely delivered CBT produced large treatment effects across pediatric and adult samples (g = 1.64), comparable to the results of face-to-face CBT.28
Although delivering standard CBT remotely may overcome some access barriers for families, such programs are highly demanding of a therapist's time. Improving the overall availability of CBT may also be achieved by using programs that need less therapist time to implement or that can be delivered by therapists with less specialized training. Such “low-intensity” programs are available as books, computer programs, CD-ROMs, and websites.28 A meta-analysis found that low-intensity CBT programs in pediatric and adult samples produced large treatment effects when therapist support was provided (g = 1.36) and moderate effects for self-guided treatment (g = 0.58).28 Programs with asynchronous therapist support may also reduce scheduling difficulties around work and school schedules. Low-intensity interventions can be used alone in some circumstances, or used as the beginning of a “stepped care” treatment approach, as recommended by the National Institute of Clinical Excellence guidelines.29
Research on e-therapy for pediatric OCD is in its early stages, but there is clear potential for such programs to improve access to CBT by overcoming barriers related to stigma, availability, and cost.30 Further research is required to evaluate pediatric treatment outcomes, reduce treatment dropout, isolate the most active components of the programs, and determine the optimum balance between treatment outcomes and reduced therapist burden.28
Advances in Pharmacotherapy
Given the modest remission rates of pediatric OCD in current first-line pharmacotherapy trials,5 there is substantial interest in novel medications and augmentation approaches. Adult studies have explored the use of antipsychotics, glutamate-modulators, N-methyl-D-aspartate (NMDA) antagonists, benzodiazepines, serotonin-norepinephrine reuptake inhibitors, and SSRI supra-threshold dosing.20 However, there is little evidence about such approaches in pediatric samples;20 thus, decisions regarding second-line medications are primarily informed by clinical expertise using findings from adult studies.9
One novel approach that has been explored in pediatric samples is the augmentation of CBT with d-cycloserine (DCS), a widely used antibiotic with agonistic effects on the glutamatergic NMDA receptors.31 DCS is an example of a cognitive enhancer; it does not reduce OCD symptoms directly, rather it improves fear extinction resulting from exposure therapy.31 Despite promising outcomes in early studies,32 recent findings have been mixed,31 and the largest pediatric OCD study to date found no advantage of DCS over placebo in the augmentation of CBT.33 This may be related to ceiling effects with a highly efficacious treatment, fear reconsolidation in unsuccessful exposure sessions, SSRI interfering with fear extinction processes, or a lack of effect of DCS on non–fear-based OCD symptoms.33 Despite these mixed results, augmentation strategies that enhance the mechanisms of CBT are a promising direction for future research and should encourage further research into the mechanisms of CBT itself.
Another potential direction for OCD pharmacology involves the use of biomarkers to predict medication response.34 Biomarkers explored in pediatric OCD include the level of glutamate in the caudate nucleus; genetic variants in glutamate receptors; the volume of brain regions such as the amygdala, striatum, frontal, and cingulate regions; and functional imaging of response to cognitive tasks.34 Although there is insufficient evidence to support the use of biomarker information in clinical practice at present,34 the ability to predict or even improve response to pharmacological agents remains a promising direction for future research.
Meta-analyses published in recent years have extended the evidence base for the treatment of pediatric OCD. Overall, CBT with ERP has the strongest support as a first-line treatment, and due to its high efficacy should be provided wherever possible. Unfortunately, there are many barriers to families receiving high-quality CBT, including a shortage of experienced therapists, practical barriers including accessibility and cost, and stigma regarding therapy. Continuing efforts are needed to increase the dissemination of CBT, such as by providing training to increase CBT skills and confidence in therapists, and increasing the availability of CBT using e-therapy.
Pharmacotherapy is a moderately efficacious treatment for pediatric OCD, with good evidence for the use of SSRIs. However, research is greatly needed to improve SSRI treatment outcome and to explore the safety and efficacy of second-line pharmacotherapies and SSRI augmentation approaches. The outcomes of combined treatment approaches should also be further examined, as currently there is insufficient evidence to suggest that combined treatment is necessary for all moderate to severe pediatric OCD presentations.
Overall, there is good evidence for the use of CBT and SSRIs in the treatment of pediatric OCD. There are also a number of promising emerging treatments, including CBT adaptations and the use of cognitive enhancers during CBT. However, the number of high-quality treatment studies remains relatively small, and little is known about individual predictors of treatment outcome in youth with OCD. Further research is needed to address these gaps and to help guide selection of the optimum treatment for each individual. Improved dissemination of high-quality treatments for pediatric OCD is crucial to reduce the burden of this chronic and highly impairing disorder.
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