In her book, amen, amen, amen: Memoir of a Girl Who Couldn’t Stop Praying (Among Other Things), Abby Sher describes the onset and course of obsessive compulsive disorder from a child’s perspective. From the time of her father’s death, she finds herself compelled to make the world safe by kissing things, saying things, and collecting things over and over. Indeed, her world depends on it. It is a poignant reminder of how much the disorder fits into a child’s magical thinking.

For our own patients, we can take a less magical approach. Cognitive behavior therapy (CBT) is the mainstay of OCD treatment and has been shown to be more effective and more durable than medication, but it can be insufficient (O’Kearney RT et al, Behavioural and cognitive behavioural therapy for obsessive compulsive disorder in children and adolescents. Cochrane Review, The Cochrane Library 2010, Issue 1). For example a meta-analysis by Watson et al demonstrated an effect size of 0.48 for medication and 1.45 for CBT (Watson HJ and Rees CS , J Child Psychol Psychiatry 2008;49(5):489–498). Marrs Garcia et al found that for children with family histories of OCD, the effectiveness of CBT drops significantly.

The accompanying table goes through possible pharmacological treatment and augmentation strategies for treatment-resistant OCD (Marrs Garcia A et al, J Am Acad Child Adolesc Psychiatry 2010;49(10):1024–1033). First begin with CBT, exposure and response therapy in particular, but consider medication if 1) the child has a family history of OCD; 2) traditional “by the book” CBT is not readily available; 3) the child’s anxiety is so high that he or she is unable to attempt to learn any CBT skills.

Practically, that might mean that when a child describes his or her anxiety as a seven or greater on a scale of one to 10, with 10 being the worst. More formally, consider medication if the Yale Brown Obsessive Compulsive Scale (CYBOCS) is greater than 23 (Mancuso E et al, J Child Adolesc Psychopharmacol 2010;20(4):299–308).

Medications Used to Treat OCD
The medication first used is usually an SSRI. Fluvoxamine (Luvox), fluoxetine (Prozac), sertraline (Zoloft) have FDA approval for OCD in children, although there is data to support citalopram (Celexa) and paroxetine (Paxil), as well. Although there is some variation among SSRIs, the average effect size is 0.48 with no significant differences between them (Mancuso ibid). There is evidence that sometimes higher doses of SSRIs are needed to treat OCD, at least in adults (Bloch MH et al, Mol Psychiatry 2010; 15(8): 850–855).

The tricyclic antidepressant clomipramine (Anafranil), which is also FDA approved for OCD, has been demonstrated to be superior to SSRIs, with an effect size of 0.85, but is less tolerable to patients and has associated cardiac risks including fatal arrhythmias. Other mixed agents such as venlafaxine (Effexor) may be effective; however, as discussed in previous editions of CCPR, these are not without risk: venlafaxine appears to confer a higher risk of suicidality as well as an uncomfortable withdrawal syndrome.

In treatment resistant cases of OCD, augmentation may be needed. However, be sure it’s treatment resistance you are dealing with. Before adding something, try at least two different trials of a serotonergic agent at maximum dose for at least 10 weeks, in combination with adequately delivered CBT.

There is also some evidence for concurrent clomipramine and an SSRI. However, there is a drug-drug interaction that may enhance toxicity as well as effectiveness by inhibiting metabolism of clomipramine. Therefore, serum levels and EKG effects should be followed (Mancuso ibid).

Augmenting agents are many but evidence, particularly in children, is lacking. Clonazepam (Klonopin) may lead to memory and learning difficulties and behavioral disinhibition in children. It is best used as a short term augmentation if possible, perhaps for those difficult first weeks until the SSRI takes effect.

Antipsychotic agents have the most evidence to support their use, and, while hardly overwhelming in their effect, they may provide just the thing to push a stubborn case along. They appear more beneficial in children with comorbid tic disorders, mood dysregulation, or behavior disorders. (For a review, see Bloch et al, Mol Psychiatry 2006;11(7):622–632.)

Mixed amphetamine (Adderall) and dextroamphetamine (Dexedrine, Vyvanse) is used by some practitioners as an augmenting agent, and given the research that links OCD with ADHD and dopaminergic abnormalities, it’s apparent why. The effect appears to be idiosyncratic, however, with some children having a fairly prompt effect, and some experiencing a worsening of symptoms (Mancuso op.cit). There is evidence to link hoarding behavior with ADHD rather than OCD, so these patients may be more likely to respond (Sheppard B et al, Depress Anxiety 2010;27(7):667–674).

D-cycloserine is another agent that may help, with a few studies to support its use. (For example, see Storch EA et al, Biol Psychiatry 2010;68(11):1073–1076.) Inositol, St. John’s Wort, gabapentin (Neurontin), caffeine, sumatriptan (Imitrex), pindolol (Visken), opiates, Nacetyl cysteine, and the glutamate antagonists memantine (Namenda) and riluzole (Rilutek) are other agents that have been tried, by and large with more hope than data (Mancuso op.cit).

Treatment recommendations are to continue treatment for six to 12 months after symptoms remit, then gradually taper by 25% every month or two. Relapse is common, however, and long term maintenance therapy is recommended after two to four episodes of relapse (Mancuso ibid).