Pediatric Obsessive-Compulsive Disorder Treatment & Management

Updated: Nov 09, 2015
  • Author: James Robert Brasic, MD, MPH; Chief Editor: Caroly Pataki, MD  more...
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Treatment

Approach Considerations

Successful treatment of obsessive-compulsive disorder (OCD) involves the judicious use of SSRIs and structured psychotherapy designed to provide the patient with the skills to master the obsessive thoughts and accompanying compulsive behaviors. Both psychotherapy and pharmacotherapy are effective interventions for children with OCD. [18, 19] Management of infectious etiologies remains uncertain and may include strategies similar to those for Sydenham chorea.

Go to Pediatric Generalized Anxiety Disorder and Pediatric Panic Disorder for complete information on these topics.

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Antidepressant Therapy

SSRIs are greatly preferred over the other classes of antidepressants. Because the adverse effect profile of SSRIs is less prominent, improved compliance is promoted. SSRIs do not have the cardiac arrhythmia risk associated with tricyclic antidepressants. Arrhythmia risk is especially pertinent in overdose, and suicide risk must always be considered when treating a child or adolescent with mood disorder.

Physicians are advised to be aware of the following information and use appropriate caution when considering treatment with SSRIs in the pediatric population.

In December 2003, the UK Medicines and Healthcare Products Regulatory Agency (MHRA) issued an advisory that most SSRIs are not suitable for use by persons younger than 18 years for treatment of "depressive illness." After review, this agency decided that the risks to pediatric patients outweigh the benefits of treatment with SSRIs, except fluoxetine (Prozac), which appears to have a positive risk-benefit ratio in the treatment of depressive illness in patients younger than 18 years.

In 2004, the US Food and Drug Administration (FDA) issued a public health advisory regarding reports of suicidality in pediatric patients being treated with antidepressant medications for major depressive disorder. This advisory reported suicidality (both ideation and attempts) in clinical trials of various antidepressant drugs in pediatric patients. The FDA has asked that additional studies be performed, because suicidality occurred in treated and untreated patients with major depression and thus could not be definitively linked to drug treatment.

However, a study of more than 65,000 children and adults treated for depression between 1992 and 2002 by the Group Health Cooperative in Seattle found that suicide risk declined, rather than rose, with the use of antidepressants. This has been the largest study to date to address this issue.

Currently, evidence does not support an increased risk of suicide in obsessive-compulsive disorder (OCD) or other anxiety disorders treated with SSRIs. Clinicians are advised to use SSRIs when indicated while watching the child closely for suicidal ideation and advising parents to carefully assess the child for suicidal thoughts, plans, and actions.

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Psychotherapy

Cognitive behavioral therapy (CBT) routinely is described as the psychotherapeutic treatment of choice for adults, children, and adolescents who have been diagnosed with obsessive-compulsive disorder (OCD). Unlike psychodynamic or insight-oriented psychotherapy, CBT helps the child to understand the disorder and develop strategies to identify problem situations and resist giving in to the obsessive thoughts and compulsive behaviors. Treatment relies heavily on exposing the individual to the problem situations and then preventing the compulsive response. The resulting anxiety then is managed by training children to use strategies that help them to work with their anxiety in a more effective and less disruptive way. Involvement of the family in the administration of CBT facilitates the consistent utilization and practice of the procedure. [20, 19]

However, exposure to the anxiety-producing object is the key to success in treatment. Thus, for children who compulsively wash their hands because they feel that the hands are dirty or contaminated, the therapist may have them intentionally touch things that are dirty and then have patients wait several hours before washing their hands. This results in very high anxiety after the initial contamination, followed by a gradual reduction in anxiety over time, until hand washing is allowed some hours later. In pediatric patients, this exposure is presented gradually, under the patients' control, after patients have been taught other ways of managing their anxiety and fear.

Anxiety management techniques may include relaxation training, distraction, or imagery. Often, the OCD is personified as something that makes the child perform an action. Thus, children learn to assess situations and ask themselves if they really want to do something, as opposed to the perception that the OCD is making them do something. For school-aged children, the development of mastery and control is a critical issue in their overall psychologic growth; therefore, learning to overcome an irrational drive, such as one experienced with OCD, has a certain appeal to the children’s own sense of mastery.

With CBT, the initial goals are specific to 1 or 2 behaviors; however, as the patient becomes successful in coping with these situations, generalization usually occurs to other symptoms that have not been targeted. Usually, the patient reports an overall reduction in obsessive thoughts, general anxiety, and the need to perform certain actions.

While CBT requires a skilled therapist and 10-20 sessions to complete, its advantage is that once the skills are learned, the patient can use them in the future.

Therapists skilled in the administration of CBT may be located through the Anxiety Disorders Association of America, the Association for Behavioral and Cognitive Therapies, the Academy of Cognitive Therapy.

Relaxation therapy administered with the help of the family is also a promising technique for treatment of OCD. [20]

Exposure and response prevention therapy with extensive parental involvement demonstrates promise for preschool children with OCD as young as three years. [21]

Combination treatment

CBT and pharmacotherapy work well together clinically. Participation in 14 sessions of CBT over 12 weeks in addition to treatment with serotonin reuptake inhibitors provided significantly greater improvement in patients with OCD aged 7-17 years than either (1) treatment with serotonin reuptake inhibitors alone or (2) treatment with serotonin reuptake inhibitors and instruction in CBT. [22]

Psychodrama in conjunction with sertraline has been reported to relieve treatment-resistant OCD. [23]

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