W11 Pediatric Clinical Reference Tool

Child

Adolescent

(Ok to type “same as child” if appropriate)

Notable differences from adults

(if applicable)

Description of the Disorder in Pediatric Populations

According to Geller & March (2012), OCD symptoms in children are difficult to differentiate, especially in young children. In children, OCD can manifest itself as compulsions with no definite obsessions and rituals (Geller & March, 2012). Interestingly, childrens’ obsessions often focus on a worry of a devastating family tragedy, such as the death of a parent (Geller & March, 2012).

It is important for providers to rule out disorders that may mimic presentation of OCD in adolescents such as anxiety, ADHD, Autism, Depression and Tourette’s (Fenske & Petersen, 2015). These disorders can also often be comorbid (Geller,et al., 2021). Often, presentations of OCD are written off as being symptoms of other disorders (OCD Clinical Practice Review Task Force, 2015).

Both children and adolescents may not realize their behaviors, thoughts, are “excessive” in ways an adult might (Krebs & Heyman, 2014). It can be challenging to differentiate OCD from rituals that emerge during adolescent growth and development, and certain “taboo” obsessions, such as sexual obsessions, may not be shared with family or teachers (Krebs & Heyman, 2014).

Traits such as “perfectionism” are often reinforced by parents, teachers, and coaches at this stage, making symptom recognition challenging (Geller et al., 2021).

New onset in children often occurs before puberty, and in the adult population new onset typically occurs in the early 20s (Geller et al., 2021). Adults are less likely to have family become involved in their rituals when compared with children (Geller et al., 2021).

Adults are also less likely to reach remission of symptoms when compared to children (Geller et al., 2021).

Presence of a comorbid mood disorder is common (OCD Clinical Practice Review Task Force, 2015).

Treatment Recommendations

(Expand Boxes as Needed) (Place as asterisk next to treatments that are FDA approved)

There are many different practice guidelines for the treatment of OCD. However, first-line treatments always consist of psychotherapy. Therapies such as cognitive-behavioral therapy and exposure and response prevention are important first-line considerations (OCD Clinical Practice Review Task Force, 2015). Geller & March (2021) go so far as to say the use of CBT in childrens’ OCD is the greatest progress in the previous decade. Next, for moderate to severe OCD, medication is indicated as an additive to CBT. For preadolescent children, the FDA has approved Clomipramine*, fluoxetine*, sertraline* and fluvoxamine* (Gellar & March, 2012). Studies (sponsored by the pharmacology industry) have showed efficacy with the use of SSRIs versus placebo in children with OCD symptoms (Gellar & March, 2012).

As with children, it is important to incorporate family and the school in the treatment plan that may include CBT and pharmacotherapy (SSRI’s) (OCD Clinical Practice Review Task Force, 2015).

Adolescents have a lower rate of adverse effects when taking sertraline compared to children (Garland et al., 2016).

Treatment includes a combination of SSRI’s and CBT (Geller et al., 2021). FDA approved SSRI’s for adults include Fluoxetine 20-80 mg*

Fluvoxamine 50-300 mg*

Paroxetine 20-60 mg* and

Sertraline 50-200 mg* (OCD Clinical Practice Review Task Force, 2015).

Non FDA approved medications for adults with OCD include Escitalopram 10-20mg ad

Citalopram 20-40 mg (OCD Clinical Practice Review Task Force, 2015).

Safety Issues (Include any medications/treatments that are contraindicated in pediatric populations or have warnings.)

In 2004, the FDA issued a “black-box” warning on SSRIs stating there is an increased risk of suicidal thinking in children taking this medication (OCD Clinical Practice Review Task Force, 2015). Prescribers need also to be aware of the possible changes in behavior associated with SSRI use in young children. Geller & March (2012) state that prepubescent children who take SSRIs were at high risk to display mania symptoms. In particular, clomipramine warrants a cardiac evaluation prior to and during use (Gellar & March, 2012). If an EKG shows an elongated PR, QRS or QT interval, there is a risk of ventricular arrhythmias associated with clomipramine (Gellar & March, 2012).

Adolescents have a lower rate of adverse effects when taking sertraline compared to children (Garland et al., 2016). While there is a black box warning for use of SSRI’s in adolescents, research shows benefit typically outweighs risk (Garland et al., 2016).

While typically safe and well tolerated, risk for cardiac side effects also exists in the adult population, although rare (Stahl, 2021).

Studies do not show increased risk of suicidality with use of SSRI’s beyond age 24 (Stahl, 2021).