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Obsessive-Compulsive Disorder

Diagnosis and Management of Obsessive Compulsive Disorders in Children

Background. Obsessive compulsive disorder (OCD) is a common, chronic, and impairing psychiatric disorder that often begins in childhood or adolescence. Early identification and treatment of OCD is important to prevent a cascade of developmental disruptions lasting into adulthood. The 2012 American Academy of Child and Adolescent Psychiatry (AACAP) Practice Parameter recommends cognitive behavioral therapy that incorporates exposure and response prevention (ERP) as a first-line treatment for mild-to-moderate OCD in youth and recommends combined treatment with ERP (if feasible) and a selective serotonin reuptake inhibitor (SSRI) for some patients, particularly those with more severe symptoms. Clinical uncertainty exists regarding the optimal treatment strategies (and treatment combinations) that work best for specific populations and settings. In this report, we seek to evaluate the accuracy of brief assessment tools to identify OCD in symptomatic youth (Key Question [KQ] 1) and the effects and harms of treatment options for youth with OCD (KQ2).

Methods. We searched Medline®, Cochrane, Embase®, CINAHL®, and ClinicalTrials.gov from inception to May 15, 2024. After double screening, we extracted study data, assessed risk of bias, and conducted network and pairwise meta-analyses. We evaluated the strength of evidence (SoE) using standard methods. The protocol was registered in PROSPERO (registration number CRD42023461212).

Results. We found 117 studies (reported in 161 papers) that met inclusion criteria. Of these, 31 cross-sectional studies pertained to KQ1, diagnosis of OCD. For KQ 2, treatment of OCD, we included 71 randomized controlled trials, 2 nonrandomized comparative studies, and 13 single-arm studies that reported potential treatment effect modifiers. For KQ1, there is insufficient evidence regarding most brief assessment tools. Based on nine studies, the Child Behavior Checklist-Obsessive Compulsive subscale (CBCL-OCS) may have sufficiently high sensitivity and specificity to identify patients for specialist referral and diagnostic evaluation (moderate SoE). For KQ2, meta-analyses indicate that in-person ERP is more effective for OCD symptoms when compared to either waitlist (high SoE) or behavioral control (moderate SoE), and for remission when compared to waitlist (high SOE) or behavioral control (moderate SoE). ERP via telehealth is more effective than waitlist for OCD symptoms (high SoE) and remission (moderate SoE). SSRIs are more effective than placebo for OCD symptoms and global severity (high SoE). Clomipramine is probably more effective than placebo (moderate SoE). When used together, ERP and an SSRI are probably more effective than treatment with an SSRI alone for OCD symptoms (moderate SoE). ERP combined with an SSRI are as effective as ERP alone for OCD symptoms (high SoE). The side effects of SSRIs and clomipramine were inconsistently reported, precluding graded conclusions. Augmentation of ERP with D-cycloserine is as effective as ERP alone to reduce OCD symptoms (high SoE) or global severity (moderate SoE). The evidence was insufficient regarding potential effect modifiers.

Conclusion. The diagnosis of OCD relies on expert clinical evaluation, sometimes augmented by semi-structured interviews. The CBCL-OCS may be sufficiently accurate to indicate which youth should be further evaluated for OCD. ERP, delivered in-person or via telehealth, is an effective treatment for OCD in children and adolescents. ERP, alone or in combination with an SSRI, is probably more effective than treatment with an SSRI alone.

Keywords 
Obsessive-Compulsive Disorder cognitive behavioral therapy

Comparative efficacy, tolerability, and acceptability of pharmacological interventions for the treatment of children, adolescents, and young adults with Tourette's syndrome: a systematic review and network meta-analysis

Author/s: 
Farhat, L. C., Behling, E., Landeros-Weisenberger, A., Levine, J. L. S., Ferreira de Barros, P. M., Wang, Z., Bloch, M. H.

In clinical practice guidelines there is no consensus about the medications that should be initially offered to children and young people with Tourette's syndrome. To provide a rigorous evidence base that could help guide decision making and guideline development, we aimed to compare the efficacy, tolerability, and acceptability of pharmacological interventions for Tourette's syndrome.
Methods
For this systematic review and network meta-analysis, we searched the Cochrane Central Register of Controlled Trials, Embase, PsycINFO, PubMed, Web of Science, the WHO International Clinical Trials Registry Platform, and ClinicalTrials.gov, for published and unpublished studies from database inception to Nov 19, 2021. We included double-blind randomised controlled trials of any medication administered as a monotherapy for at least 1 week against another medication or placebo in children and adolescents (aged ≥4 years and ≤18 years), adults (>18 years), or both, diagnosed with Tourette's syndrome according to standardised criteria. We excluded studies that exclusively recruited participants with comorbid attention-deficit hyperactivity disorder or obsessive-compulsive disorder. The primary outcome was change in severity of tic symptoms (efficacy). Secondary outcomes were treatment discontinuations due to adverse events (tolerability) and for any reason (acceptability). Pharmacological interventions were examined considering medication categories and medications individually in separate analyses. Summary data were extracted and pooled with a random-effects network meta-analysis to calculate standardised mean differences for efficacy and odds ratios for tolerability and acceptability, with 95% CIs. The Confidence in Network Meta-Analysis (CINeMA) framework was used to assess the certainty of evidence. The protocol was pre-registered in PROSPERO (CRD42022296975).
Findings
Of the 12 088 records identified through the database search, 88 records representing 39 randomised controlled trials were included in the network meta-analysis; these 39 randomised controlled trials comprised 4578 participants (mean age 11·8 [SD 4·5] years; 3676 [80·8%] male participants) and evaluated 23 individual medications distributed across six medication categories. When considering medication categories, first-generation (standardised mean difference [SMD] –0·65 [95% CI –0·79 to –0·51]; low certainty of evidence) and second-generation (–0·71 [–0·88 to –0·54]; moderate certainty of evidence) antipsychotic drugs, as well as α-2 agonists (–0·21 [–0·39 to –0·03]; moderate certainty of evidence), were more efficacious than placebo. First-generation and second-generation antipsychotic drugs did not differ from each other (SMD 0·06 [95% CI –0·14 to 0·25]; low certainty of evidence). However, both first-generation (SMD 0·44 [95% CI 0·21 to 0·66]) and second-generation (0·49 [0·25 to 0·74]) antipsychotic drugs outperformed α-2 agonists, with moderate certainty of evidence. Similar findings were observed when individual medications were considered: aripiprazole (SMD –0·60 [95% CI –0·83 to –0·38]), haloperidol (–0·51 [–0·88 to –0·14]), olanzapine (–0·83 [–1·49 to –0·18]), pimozide (–0·48 [–0·84 to –0·12]), risperidone (–0·66 [–0·98 to –0·34]), and clonidine (–0·20 [–0·37 to –0·02]) all outperformed placebo, with moderate certainty of evidence. Antipsychotic medications did not differ from each other, but there was low to very low certainty of evidence for these comparisons. However, aripiprazole (SMD –0·40 [95% CI –0·69 to –0·12]) and risperidone (–0·46 [–0·82 to –0·11]) outperformed clonidine, with moderate certainty of evidence. Heterogeneity or inconsistency only emerged for a few comparisons. In terms of tolerability and acceptability, there were no relevant findings for any of the efficacious medication categories or individual medications against each other or placebo, but there was low to very low certainty of evidence associated with these comparisons.
Interpretation
Our analyses show that antipsychotic drugs are the most efficacious intervention for Tourette's syndrome, while α-2 agonists are also more efficacious than placebo and could be chosen by those who elect not to take antipsychotic drugs. Shared decision making about the degree of tic-related severity and distress or impairment, the trade-offs of efficacy and safety between antipsychotic drugs and α-2 agonists, and other highly relevant individual factors that could not be addressed in the present analysis, should guide the choice of medication for children and young people with Tourette's syndrome.

Keywords 
Antipsychotic Agents Obsessive-Compulsive Disorder Systematic Reviews as Topic Randomized Controlled Trials as Topic Tourette Syndrome
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