INTRODUCTION — Obsessive-compulsive disorder (OCD) is a severe, prevalent, and most often chronically debilitating disorder characterized by repetitive, ritualistic, and distressing thoughts, ideas, and behaviors over which a person typically has very little if any control. Research suggests that as many as 50 percent of all cases have their onset in childhood and adolescence [1].
Treatments for OCD in children and adolescents include medications and psychotherapy. A combination of medication and psychotherapy may be useful in cases of more-severe, comorbid or treatment refractory illness.
This topic reviews the treatment of OCD in children and adolescents. The epidemiology, pathogenesis, clinical manifestations, course, assessment and diagnosis of OCD in children and adolescents are discussed separately. The epidemiology, pathogenesis, clinical manifestations, course, assessment, diagnosis, and treatment of OCD in adults are also discussed separately. Pediatric autoimmune neuropsychiatric disorder associated with group A streptococci (PANDAS) is also discussed separately.
●(See "Pharmacotherapy for obsessive-compulsive disorder in adults".)
●(See "Psychotherapy for obsessive-compulsive disorder in adults".)
●(See "PANDAS: Pediatric autoimmune neuropsychiatric disorder associated with group A streptococci".)
OVERVIEW — Effective treatments for obsessive-compulsive disorder (OCD) in children and adolescents include cognitive-behavioral therapy (CBT) and serotonergic reuptake inhibitors (SRIs) [2,3]. For mild to moderate cases of pediatric OCD, we suggest first-line treatment with CBT. An SRI can be used first-line in cases of patient and family preference or if CBT were not available. (See 'Comparing medication and CBT' below and 'Efficacy' below.)
For more severe presentations of pediatric OCD, we suggest first-line treatment with a combination of an SRI and CBT. The SRI may be needed to decrease the OCD and associated anxiety symptoms to a level where CBT can be effective [4]. In our clinical experience, concomitant use of CBT may allow for the use of a lower dose of an SRI than would otherwise be needed, potentially reducing medication side effects. (See 'Combining medication and CBT' below and 'Efficacy' below.)
Comorbid tic disorders can complicate diagnosis and treatment. Complex tics can be misdiagnosed as OCD. CBT alone, or in combination with SRI, is often the treatment of choice for OCD with co-occurring, complex tics.
Pediatric autoimmune neuropsychiatric disorder — Treatment of OCD symptoms and behaviors in children with a possible diagnosis of pediatric autoimmune neuropsychiatric disorder associated with group A streptococci (pediatric autoimmune neuropsychiatric disorder [PANDAS]) should be based on the recommendations described here for OCD, whether or not the patient has evidence of recent group A streptococci infection [5,6]. Treatment of psychiatric symptoms should not be delayed pending confirmation of PANDAS. Treatment of PANDAS is described in greater detail separately. (See "PANDAS: Pediatric autoimmune neuropsychiatric disorder associated with group A streptococci", section on 'Management'.)
COGNITIVE-BEHAVIORAL THERAPY — The psychotherapy of choice for pediatric obsessive-compulsive disorder (OCD) is cognitive-behavioral therapy (CBT). No other psychotherapies for OCD in youth have received comparable study nor have they demonstrated consistent efficacy in clinical trials.
Administration
In-person CBT — The basic approach and components of effective CBT programs for children with OCD are similar [7]. The framework and administration described here are from a widely used and well-studied program [8]. The program consists of 14 hour-long sessions over a 12-week period in sessions with the child and one or more family members [8]. These are supplemented by 10-minute phone sessions most weeks. The therapy is typically provided individually, but evidence supports its use in groups and with/without participating family members [9,10]. The clinical effects of CBT can decline over time; booster sessions may be provided in the months or years following treatment to prevent or reverse this decline.
Internet-delivered — Internet-delivered CBT may be as effective as face-to-face CBT for pediatric OCD. In most countries, children and adolescents with OCD have limited access to CBT provided by a specialist; internet-delivered treatment may help CBT to reach more individuals by breaking down the barriers to accessibility.
In a trial, 152 individuals with OCD were assigned to receive internet-delivered stepped-care CBT versus face-to-face CBT [11]. At six-month follow-up, improvements in children and adolescents using internet-delivered CBT were not statistically different from those using face-to-face CBT (mean difference 0.91 points on the 40-point Children’s Yale-Brown Obsessive Compulsive Scale [CY-BOCS]).
Components — CBT can be customized to the developmental limitations of the child and has been used to good result used in children as young as five years of age. Parents need to be critically involved when CBT is administered to pediatric OCD patients.
The program is delivered in five phases of treatment [8]:
●Psychoeducation
●Cognitive training
●Mapping OCD
●Graded exposure and response prevention
●Relapse prevention and generalization training
Efficacy — A systematic review and meta-analysis of nine randomized trials with 645 youth with OCD, age 4 to 18 years, compared treatment with CBT to a control condition [12]. Compared with the control group, patients who received CBT had a greater reduction in OCD symptom severity (mean difference = 6.81 points on the CY-BOCS, 95% CI 8.45-5.18). This finding is consistent with that of an earlier review [13].
Three trials with 146 patients compared CBT with selective serotonin reuptake inhibitors, finding no difference between the two interventions in the reduction of OCD symptom severity (mean difference = -0.75, 95% CI -3.79 to 2.29) [12].
As an example, a clinical trial randomly assigned 96 youth (age 10 to 18 years) to receive CBT (12 sessions), brief CBT (5 sessions and therapist-guided workbook) or a waitlisted control group [14]. Patients in both treatment groups experienced reduced OCD symptoms compared to the control group. No significant differences were seen in outcomes between treatment groups. Improvements were maintained at 17-week follow-up.
For patients with pediatric OCD who initially fail to respond to CBT treatment, additional CBT treatment may be effective for reducing symptoms. As an example, a clinical trial randomly assigned 54 youth (age 7 to 17 years) who failed to respond (posttreatment CY-BOCS ≥16) to an initial course of CBT (14 sessions of weekly individual exposure-based CBT) to receive either 10 additional CBT treatment sessions, or treatment with sertraline, over 16 weeks [15]. No significant differences were seen in outcomes between treatment groups. However, nearly half of patients in each treatment group (50 percent for CBT, 45.4 percent for sertraline) experienced reduced OCD symptoms.
Resources — The availability of therapists with experience providing CBT for pediatric OCD varies widely. Directories of therapists and other resources are available at the Anxiety and Depression Association of America and the International OCD Foundation. Many states in the United States have local Obsessive Compulsive Foundation branches.
A book recommended for education about pediatric OCD is “The Boy Who Couldn't Stop Washing” [16]. A well-regarded treatment manual for clinicians providing CBT is “OCD in Children and Adolescents: A Cognitive-Behavioral Treatment Manual” [17].
PHARMACOTHERAPY — Medications with demonstrated efficacy as monotherapy in children and adolescents with obsessive-compulsive disorder (OCD) include three selective serotonin reuptake inhibitors (SSRIs; fluoxetine, fluvoxamine, and sertraline) and a serotonergic, tricyclic antidepressant, clomipramine. When medication is used for pediatric OCD, we suggest one of the SSRIs as first-line choice of medications.
For treatment refractory pediatric OCD, we order medication trials as follows unless the individual circumstances of a specific case indicates otherwise.
●SSRI
●A second SSRI
●Augmentation of serotonergic reuptake inhibitor (SRI) with atypical antipsychotic
●Combination of SSRI and clomipramine
As an example, a reason to depart from the suggested algorithm might be if the patient’s history or family history included a robust clinical response to a specific medication.
SSRIs — Selective serotonin reuptake inhibitors (SSRIs) are the initial medication of choice for pediatric OCD due to their efficacy and generally well-tolerated side effect profile. SSRIs shown to be effective and safe in this population include fluoxetine, fluvoxamine, and sertraline.
Under most circumstances, an SSRI other than paroxetine, citalopram, or escitalopram is suggested for OCD in youth. Efficacy has not been established for citalopram or escitalopram. Paroxetine was found in a clinical trial to be efficacious in pediatric OCD [18], but showed a lack of efficacy compared with placebo in youth with depression, a commonly co-occurring condition in youth with OCD, and has not been approved for use in children by the US Food and Drug Administration (FDA). (See 'Efficacy' below and "Pediatric unipolar depression and pharmacotherapy: Choosing a medication", section on 'Other specific SSRIs' and "Obsessive-compulsive disorder in adults: Epidemiology, pathogenesis, clinical manifestations, course, and diagnosis", section on 'Comorbidities' and 'Suicidality' below.)
Use of paroxetine in a child with OCD could be considered if depression were not present and if there was a compelling reason (eg, for a patient with a first-degree relative who responded particularly well to paroxetine).
Efficacy — A 2003 meta-analysis of 12 short-term clinical trials with a total of 1044 children and adolescents with OCD found serotonergic antidepressants (SSRIs and clomipramine) to reduce OCD symptoms compared to placebo [19] An overall effect size for medication versus placebo was 0.46 (standardized mean difference; 95% CI 0.37-0.55), equivalent to approximately four points on the Children’s Yale-Brown Obsessive Compulsive Scale (CY-BOCS). Specific SSRIs tested in clinical trials of pediatric OCD, all with positive results, include sertraline [2,5], fluoxetine [20,21], fluvoxamine [22], and paroxetine [18].
As an example, a 12-week clinical trial randomly assigned 187 children and adolescents age 13 to 17 years to receive sertraline (up to 200 mg/day) or placebo [5]. Patients treated with sertraline showed greater improvement compared placebo-treated patients in the rate of response (42 versus 26 percent) and in reduction of OCD symptoms. Side effects to sertraline included insomnia, nausea, agitation, and tremor; 12 percent of sertraline-treated patients terminated treatment early due to side effects, compared with three percent on placebo.
Side effects — SSRIs are typically well tolerated by children and adolescents. Side effects are typically dose dependent; many are transient and dissipate over time [23-25]. The most common side effects include headache, abdominal pain, nausea, diarrhea, sleep changes, and jitteriness or agitation.
Suicidality — There is controversy about the relationship between SSRI use and suicidality in children. All antidepressants used in the United States have a boxed warning by the FDA about suicidality. There appears to be a slightly increased risk of suicidal thoughts and behaviors (but not completed suicide) among a small group of children and adolescents who are treated with antidepressant medications compared with placebo; however, the evidence is inadequate to conclusively establish this association, which is described in more detail separately. (See "Effect of antidepressants on suicide risk in children and adolescents".)
In a meta-analysis that included six clinical trials of antidepressants for pediatric OCD, the baseline risk of suicidal ideation/suicide attempts in youth with OCD was low, and increased by 0.5 percent (95% CI -1.2 to 2.2%) in youth treated with antidepressants compared to placebo [26]. Review of evidence on the association between SSRIs and suicidality has not found any one SSRI to have a stronger or weaker relationship to suicide than the others. (See "Effect of antidepressants on suicide risk in children and adolescents" and 'Efficacy' above.)
Antidepressant-induced mania — The role of antidepressants in inducing a patient’s switch in mood to mania is controversial. In a sample of 4786 patients age 5 to 29, younger children (age 10 to 14) had a higher risk of mania when treated with antidepressants compared to adolescents and young adults [27]. (See "Bipolar major depression in adults: Efficacy and adverse effects of antidepressants", section on 'Risk of switching to mania'.)
Longer-term outcomes — Our clinical experience and available research suggests that pediatric patients with OCD experience further improvement (on average approximately 30 percent) beyond the 12-week duration of clinical trials. An uncontrolled trial tested the continuation of sertraline (50 to 200 mg/day) for 52 weeks in 72 6- to 12-year-olds and 65 13- to 18-year-olds with OCD who already completed a 12-week clinical trial of sertraline and met the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders, Third Edition (DSM-III) criteria for OCD [28]. At the end of the study period, 55 percent of patients met criteria for full remission (CY-BOCS ≤8) and 31 percent met criteria for partial remission (CY-BOCS ≤15).
Comorbid conditions — In contrast to the other FDA-approved medications for pediatric OCD (fluvoxamine, sertraline, and clomipramine), fluoxetine is also FDA approved for major depressive disorder in children and adolescents [3]. Clinical trials have shown sertraline, fluvoxamine, and fluoxetine to be efficacious in the treatment of pediatric anxiety [29-31].
Administration — SSRIs are typically initiated at a low dose (eg, the equivalent of 25 mg of sertraline) for the first week and titrated up gradually (eg, every two to four weeks) to a therapeutic dose, which is then given a 12-week trial. If the clinical response is not adequate, subsequent gradual adjustments are made to maximize efficacy and minimize toxicity with additional trials of six to twelve weeks. As an example, the therapeutic dose of fluvoxamine ranges from 50 to 200 mg/day in pre-adolescent children and 50 to 300 mg/day in adolescents with OCD [3]. Fluvoxamine is typically started at 25 mg daily for one week and increased to 50 mg for an initial 12-week trial. Subsequent increases are made gradually at 50 mg increments. A table describes dosing for the SSRIs and other medications (table 1).
Dose ranges for fluoxetine are higher in pediatric OCD than in pediatric major depression (eg, 20 to 60 mg/day for OCD versus 10 to 20 mg/day for major depression). Improvement of OCD symptoms may occur more slowly with fluoxetine than with other SSRIs (eg, more than eight weeks on a therapeutic dose to manifest significant benefit).
Children and adolescents who are treated with antidepressants should be closely monitored by the clinician and family for suicidal thoughts/behaviors and symptoms of mania. When possible it is advised to see patients weekly during the first month, or no longer than every two weeks, and at least monthly thereafter. It should be noted that suicidal thoughts/behaviors and symptoms of mania are relatively rare adverse events. In contrast, sexual side effects are a not uncommon cause of discontinuation of antidepressants in adolescents.
Clomipramine — Clomipramine, a tricyclic antidepressant (TCA) that inhibits reuptake of serotonin and norepinephrine, is the only TCA with demonstrated effectiveness in pediatric OCD [32].
Efficacy — The 2003 meta-analysis [19] (described above) included five clinical trials of clomipramine compared to placebo or another TCA. These trials found the medication to be an effective treatment for pediatric OCD.
As an example, 60 children and adolescents with OCD were randomly assigned to receive clomipramine or placebo. After eight weeks, patients receiving clomipramine had a greater reduction of OCD symptoms compared to placebo (37 versus 8 percent). 35 to 68 percent of patients experienced dry mouth, somnolence, dizziness, and fatigue compared to 9 to 16 percent of the control group [33].
SRI antidepressants have been shown to be effective in a small trial of pediatric anxiety disorders. OCD, which is no longer classified as an anxiety disorder in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), was not included in the study [34].
Side effects — Anticholinergic side effects of clomipramine include sedation, dry mouth, constipation, urinary delay, and orthostatic hypotension [32]. Clomipramine can delay cardiac conduction and like other TCAs may be associated with the rare occurrence of sudden cardiac death in youth. (See "Tricyclic and tetracyclic drugs: Pharmacology, administration, and side effects", section on 'Clomipramine'.)
Clomipramine versus SSRIs — Although available research in children suggests that clomipramine is more efficacious than selective serotonin reuptake inhibitors (SSRIs) in pediatric OCD, SSRIs are the preferred treatment because they are better tolerated and safer than clomipramine. A meta-analysis of clinical trials of treatments for pediatric OCD patients found clomipramine to have greater efficacy than SSRIs [35]. However, it should be noted that there are no head-to-head trials comparing clomipramine with SSRIs in adult or pediatric OCD that demonstrates clomipramine to be superior to SSRI. It is also important to point out that in this meta-analysis the differences in effect size may be related to differences in underlying study populations, as children enrolled in later SSRI trials often failed to respond to similar medications. Head-to-head trials comparing clomipramine and SSRI in adults have not shown either drug to be superior for OCD [36-42]. (See 'Side effects' above and 'Side effects' above.)
Administration and monitoring — Prior to taking clomipramine, children/adolescents should be screened for cardiovascular illness and an electrocardiogram (ECG) should be obtained. A consult should be obtained from a cardiologist or primary care doctor prior to starting the medication if there is a history of cardiac illness, blood pressure or pulse abnormalities, or adverse ECG findings. A follow-up ECG along with blood pressure and pulse should be obtained in patients who are started on the medication, once they have achieved a stable, therapeutic dose, and following each subsequent increase in dose.
Clomipramine for pediatric OCD is typically started at 25 mg/day for one to two weeks (table 1). If the patient experiences an inadequate response, the dose can be increased at two-week intervals in increments of 25 mg/day to a maximum of 200 mg/day. Problematic side effects often limit dose escalation.
Clomipramine levels do not correlate with clomipramine dose, but may be helpful to assess for toxicity.
Medication augmentation
Atypical antipsychotics — Atypical antipsychotics can be used to augment SSRI or clomipramine in pediatric patients with OCD who have responded insufficiently to the medications individually. A case series of four youth with OCD who had not responded sufficiently to monotherapy found risperidone augmentation of an SRI to be associated with symptom improvement [43].
Compared to doses used to treat psychotic disorders, lower doses of atypical antipsychotics are suggested when augmenting SRIs in children and adolescents with OCD. As an example, risperidone can be initiated at 0.25 mg/day and increased weekly in 0.25 mg increments to a maximum of 1.5 to 2 mg/day. A one-month trial is often sufficient to determine effectiveness. In some cases, a longer time period may be necessary particularly if higher doses (eg, 1 to 2 mg/day are needed).
Youth treated with atypical antipsychotics are vulnerable to serious metabolic side effects. Children, especially pre-adolescents, are more sensitive to side effects than other patients, particularly to weight gain, diabetes, carbohydrate abnormalities [44].
A table provides a recommended schedule for monitoring metabolic effects of first and second-generation antipsychotics (table 2). More frequent measurements may be necessary for individual patients (eg, lipids and glucose in a patient with significant weight gain) or for patients on specific antipsychotics (eg, olanzapine, quetiapine, and clozapine, where there is clear evidence of an increased risk of insulin resistance) [45].
First-generation antipsychotic agents are typically not considered as first-line augmenting agents in youth with OCD because of their side effect profile and limited study in this population. That being said, first-generation medication, such as haloperidol, do have better metabolic side effect profiles than many of the atypical antipsychotic medications such as risperidone, olanzapine, etc.
SSRI and clomipramine — Uncontrolled studies of 13 youth with OCD have suggested that therapeutic effects of clomipramine may be improved and adverse effects reduced with the addition of a low dose of a selective serotonin reuptake inhibitor (SSRI; eg, 10 to 20 mg/day of fluoxetine) [46,47].
When using clomipramine, patients should avoid grapefruit and grapefruit juice, which can raise the mean plasma concentration of clomipramine [48].
Caution should be taken when adding an SSRI to clomipramine, as there is the possibility of serotonin syndrome, characterized by mental status changes (eg, agitation, hallucinations, delirium, and coma), autonomic instability (eg, tachycardia, labile blood pressure, dizziness, diaphoresis, flushing, hyperthermia), neuromuscular changes (eg, tremor, rigidity, myoclonus, hyperreflexia, incoordination), seizures, and/or gastrointestinal symptoms (eg, nausea, vomiting, diarrhea).
Other — Negative results have been in trials of other augmentation strategies in treatment of pediatric OCD:
●Lithium augmentation of SSRI and clomipramine [49,50]
●Buspirone augmentation of SSRIs [51]
●Thyroid-hormone augmentation of clomipramine [50]
Glutamate modulating drugs — Converging lines of evidence suggest that glutamate has an important role in the neurobiology of OCD [52]. Several glutamate-modulating agents have been used and/or tested in the treatment of OCD. Findings in pediatric OCD are described below. Experiences with these drugs in adult OCD are described separately. (See "Pharmacotherapy for obsessive-compulsive disorder in adults".)
●Riluzole – Despite promising preliminary results [53], a randomized trial of 51 subjects (7 to 17 years) with OCD did not find differences in outcome between groups treated with riluzole or placebo for 12 weeks [54].
●N-acetylcysteine (NAC) – Initial reports from a 12-week, double-blind, placebo-controlled randomized trial [55] and from several case studies [56-58] have noted that augmentation of SRI treatment with NAC, an antioxidant molecule that modulates glutamate transmission in the brain, successfully decreased OCD symptom severity in participants with treatment refractory OCD. However, the results from a 16-week, double-blind, placebo-controlled randomized trial [59] and an additional case study [60] were mixed. Evidence to support the use of NAC to augment more traditional OCD therapies remains limited at this time. Further larger controlled studies are needed to evaluate the effectiveness of NAC in the treatment of OCD, particularly given NAC’s well-tolerated side effect profile.
●Memantine – A case report described OCD symptom reduction in a pediatric patient associated with treatment with memantine, a noncompetitive NMDA receptor antagonist [61].
●D-cycloserine – A trial of 27 youth with OCD compared d-cycloserine to placebo, administered immediately after each of 10 cognitive-behavioral therapy sessions. Both groups improved and maintained their gains at one-year follow-up, but no significant advantage was seen between groups at any time point [62].
●Lamotrigine – There are no published reports of lamotrigine treatment of pediatric OCD, but cases of severe rash associated the medication have been reported, including Stevens-Johnson syndrome, toxic epidermal necrolysis and rash-related death. The rate of serious rash was greater in pediatric patients who received the medication [63]. (See "Stevens-Johnson syndrome and toxic epidermal necrolysis: Pathogenesis, clinical manifestations, and diagnosis".)
COMPARING MEDICATION AND CBT — A meta-analysis of 13 clinical trials in patients with pediatric obsessive-compulsive disorder (OCD) found that cognitive-behavioral therapy (CBT) was superior to wait-list and placebo therapy but not active treatments [13]. The CBT effect estimate was not significantly different when compared with serotonergic reuptake inhibitors (SRIs) alone or combined SRIs and CBT.
A 2004 head-to-head trial comparing an SRI to CBT in pediatric OCD similarly did not find a difference in the efficacy of the two treatments. In a 12-week trial, 112 patients age 7 to 17 years with OCD were randomly assigned to receive CBT alone, sertraline alone, combined CBT and sertraline, or a drug placebo [2]. Sertraline was dosed using a flexible strategy with an average dose of 170 mg/day (range 25 mg to 200 mg/day). Both sertraline alone and CBT alone reduced OCD symptoms compared to placebo; no difference in OCD reduction was seen between the two actively treated groups. There were significant site differences in outcomes, suggesting that patient adherence and quality of CBT may have an important effect on efficacy.
For tic-related OCD, a subgroup analysis of 17 children from the trial suggested that CBT may be more effective than selective serotonin reuptake inhibitor treatment [6].
COMBINING MEDICATION AND CBT — Combined treatment with cognitive-behavioral therapy (CBT) and a serotonergic reuptake inhibitor appears to be more effective than either treatment with CBT or a serotonergic reuptake inhibitor alone. Conflicting results have been found in trials; the larger, more adequately powered trial favored the combination of CBT and a selective serotonin reuptake inhibitor.
●In a previously described 2004 trial of 112 youth with obsessive-compulsive disorder (OCD), a greater proportion of patients receiving combined treatment experienced OCD symptom remission compared with patients receiving sertraline alone or placebo (53.6 versus 21.4 or 3.6 percent), but did not differ compared to CBT alone (53.6 versus 39.3 percent) [2].
●A trial comparing the efficacy of sequential sertraline and CBT to CBT with pill placebo over 18 weeks in 47 children and adolescents with OCD did not find a significant difference between the two approaches [64]. Patients were randomly assigned to one of three groups: sertraline and CBT from the start, CBT added after at least eight weeks of sertraline, CBT plus pill placebo. There were no significant differences in OCD symptom reduction among groups.
SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Obsessive-compulsive disorder and related disorders".)
SUMMARY AND RECOMMENDATIONS
●Initial treatment
•Mild to moderate cases – For mild to moderate cases of pediatric obsessive-compulsive disorder (OCD), we suggest first-line treatment with cognitive-behavioral therapy (CBT) rather than a medication or other psychotherapies (Grade 2C). (See 'Overview' above and 'Comparing medication and CBT' above and 'Combining medication and CBT' above.)
•Severe cases – For more severe presentations of pediatric OCD, we suggest first-line treatment with a combination of a selective serotonin reuptake inhibitor (SSRI) and CBT rather than either modality individually (Grade 2B). (See 'Overview' above and 'Efficacy' above and 'Efficacy' above and 'Combining medication and CBT' above.)
When medication is used to treat pediatric OCD, we suggest initial treatment with an SSRI rather than other medications due to their efficacy and generally well-tolerated side effect profile (Grade 2C). Although available research in children suggests that clomipramine is more efficacious than SSRIs in pediatric OCD, SSRIs are the preferred treatment because they are better tolerated and safer than clomipramine. (See 'SSRIs' above.)
•Pediatric autoimmune neuropsychiatric disorder associated with group A streptococci (PANDAS) – For pediatric patients with OCD symptoms and behaviors and a possible diagnosis of pediatric autoimmune neuropsychiatric disorder associated with group A streptococci (PANDAS), we suggest that treatment proceed based on the recommendations described here for OCD (Grade 2C). We do not delay treatment of psychiatric symptoms pending confirmation of PANDAS. (See 'Pediatric autoimmune neuropsychiatric disorder' above and "PANDAS: Pediatric autoimmune neuropsychiatric disorder associated with group A streptococci".)
●Suicidality – There is controversy about the relationship between SSRI use and suicidality in children. We monitor children or adolescents who are treated with SSRIs weekly during the first month, and at least monthly thereafter. (See 'Suicidality' above.)
●Subsequent treatment – For cases unresponsive to initial SSRI treatment, we generally conduct trials in the following order until a satisfactory clinical response is achieved, though patient and clinical factors in individual cases may influence the order in which we would use them. (See 'Pharmacotherapy' above.)
•A second SSRI
•Clomipramine (see 'Clomipramine' above)
•Augmentation of SRI with atypical antipsychotic (see 'Atypical antipsychotics' above)
•Combination of SSRI and clomipramine (see 'SSRI and clomipramine' above)
●Glutamate modulators – Evidence suggests that glutamate has an important role in the neurobiology of OCD. Glutamate modulating agents with limited support in the treatment of OCD in children or adolescents include riluzole, N-acetylcysteine, memantine, D-Cycloserine, and lamotrigine.
