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08. Clinical Tips for Treating Pediatric OCD, Long-Term Follow-Up, and Treatment-Resistant OCD

Published on February 1, 2022 Expired on April 1, 2025

David R. Rosenberg, M.D.

Chair of the Department of Psychiatry & Behavioral Neuroscience - Wayne State University School of Medicine

Key Points

  • Forty percent of patients with OCD continue to suffer from full symptoms into adulthood.
  • One-third of OCD patients do not respond to any treatment.
  • Most patients respond partially.
  • Clomipramine can be used as an alternative treatment following 2 failed SSRI trials and augmentation with CBT.
  • Treatment recommendations encourage ERP augmentation of SSRIs and clomipramine use before augmentation with an antipsychotic.

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Slides and Transcript

Slide 1 of 12

Let’s turn to video 8, Clinical Tips for Treating Pediatric OCD, Long-Term Follow-up, and Treatment-Resistant OCD.
Clinical Tips for Treating Pediatric OCD, Long-Term Follow-Up, and Treatment-Resistant OCD Slide 1 of 12

Slide 2 of 12

So some tips for those of you who are in the trenches treating pediatric OCD. It’s vitally important to involve the family in the assessment and treatment options of pediatric OCD. The family can provide essential information regarding how children may involve other family members in compulsion, how symptoms impact everyday life, making everyone late for school because of morning rituals or limiting activities because of fear of contamination. It may also be very useful to externalize the problem by acknowledging how OCD makes children do things, talking about how OCD rather than the child makes everyone late for school to allow others to discuss symptoms without directly blaming the child.
References:
  • Geller, D. A., & March, J. (2012). Practice parameter for the assessment and treatment of children and adolescents with obsessive-compulsive disorder. Journal of the American Academy of Child & Adolescent Psychiatry, 51(1), 98-113.
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Slide 3 of 12

The long-term follow-up of pediatric OCD patients is significant. Forty percent of pediatric OCD patients continue to suffer from full OCD symptoms into adulthood. Sixty percent continue to suffer from subthreshold OCD symptoms.
References:
  • Micali, N., Heyman, I., Perez, M., Hilton, K., Nakatani, E., Turner, C., & Mataix-Cols, D. (2010). Long-term outcomes of obsessive–compulsive disorder: Follow-up of 142 children and adolescents. British Journal of Psychiatry, 197(2), 128-134.
  • Stewart, S. E., Geller, D. A., Jenike, M., Pauls, D., Shaw, D., Mullin, B., & Faraone, S. V. (2004). Long-term outcome of pediatric obsessive-compulsive disorder: A meta-analysis and qualitative review of the literature. Acta Psychiatrica Scandinavica, 110(1), 4-13.
Clinical Tips for Treating Pediatric OCD, Long-Term Follow-Up, and Treatment-Resistant OCD Slide 3 of 12

Slide 4 of 12

Anxiety and mood disorders are the most common comorbid conditions at follow-up. And earlier age of onset, increased duration of illness, and inpatient OCD treatment are associated with greater persistence of the disorder.
References:
  • Micali, N., Heyman, I., Perez, M., Hilton, K., Nakatani, E., Turner, C., & Mataix-Cols, D. (2010). Long-term outcomes of obsessive–compulsive disorder: Follow-up of 142 children and adolescents. British Journal of Psychiatry, 197(2), 128-134.
  • Stewart, S. E., Geller, D. A., Jenike, M., Pauls, D., Shaw, D., Mullin, B., & Faraone, S. V. (2004). Long-term outcome of pediatric obsessive-compulsive disorder: A meta-analysis and qualitative review of the literature. Acta Psychiatrica Scandinavica, 110(1), 4-13.
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Slide 5 of 12

The challenge is this. A third of patients don’t respond to any treatment and of those who do respond many respond only partially with continued functional impairment. Earlier onset may also be associated with decreased response.
References:
  • Bloch, M. H., & Storch, E. A. (2015). Assessment and management of treatment-refractory obsessive-compulsive disorder in children. Journal of the American Academy of Child & Adolescent Psychiatry, 54(4), 251-262.
  • Stewart, S. E., Geller, D. A., Jenike, M., Pauls, D., Shaw, D., Mullin, B., & Faraone, S. V. (2004). Long-term outcome of pediatric obsessive-compulsive disorder: A meta-analysis and qualitative review of the literature. Acta Psychiatrica Scandinavica, 110(1), 4-13.
Clinical Tips for Treating Pediatric OCD, Long-Term Follow-Up, and Treatment-Resistant OCD Slide 5 of 12

Slide 6 of 12

For treatment-resistant OCD, clomipramine may be used as an alternative following two failed SSRI trials and augmentation with cognitive behavioral therapy. Augmentation with clomipramine can significantly increase treatment response and there are studies that have shown this.
References:
  • Bloch, M. H., & Storch, E. A. (2015). Assessment and management of treatment-refractory obsessive-compulsive disorder in children. Journal of the American Academy of Child & Adolescent Psychiatry, 54(4), 251-262.
  • Geller, D. A., & March, J. (2012). Practice parameter for the assessment and treatment of children and adolescents with obsessive-compulsive disorder. Journal of the American Academy of Child & Adolescent Psychiatry, 51(1), 98-113.
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Slide 7 of 12

Clomipramine use requires detailed personal and family history of heart disease and seizures, physical examination, EKG at baseline and one to two weeks following dosage adjustment. Use serum levels of clomipramine and its non-serotonergic metabolite, desmethylclomipramine, to determine dose adjustments.
References:
  • Geller, D. A., & March, J. (2012). Practice parameter for the assessment and treatment of children and adolescents with obsessive-compulsive disorder. Journal of the American Academy of Child & Adolescent Psychiatry, 51(1), 98-113.
Clinical Tips for Treating Pediatric OCD, Long-Term Follow-Up, and Treatment-Resistant OCD Slide 7 of 12

Slide 8 of 12

Remember clomipramine is a tricyclic antidepressant and tricyclic antidepressants in children and adolescents have rarely been associated with significant cardiac arrhythmias and even sudden cardiac death.
References:
  • Geller, D. A., & March, J. (2012). Practice parameter for the assessment and treatment of children and adolescents with obsessive-compulsive disorder. Journal of the American Academy of Child & Adolescent Psychiatry, 51(1), 98-113.
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Slide 9 of 12

CBT, ERP augmentation of SSRI treatment, and a clomipramine trial should be completed before attempting treatment augmentation with an antipsychotic.
References:
  • Bloch, M. H., & Storch, E. A. (2015). Assessment and management of treatment-refractory obsessive-compulsive disorder in children. Journal of the American Academy of Child & Adolescent Psychiatry, 54(4), 251-262.
  • Geller, D. A., & March, J. (2012). Practice parameter for the assessment and treatment of children and adolescents with obsessive-compulsive disorder. Journal of the American Academy of Child & Adolescent Psychiatry, 51(1), 98-113.
Clinical Tips for Treating Pediatric OCD, Long-Term Follow-Up, and Treatment-Resistant OCD Slide 9 of 12

Slide 10 of 12

Key points are these. Forty percent of pediatric OCD patients continue to suffer from full OCD symptoms into adults while 60% continue to suffer from full or subthreshold OCD symptoms. One-third of OCD patients don’t respond to any treatment. And of those who do respond, most respond partially with continued functional impairment.
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Slide 11 of 12

Clomipramine can be used as an alternative treatment following two failed SSRI trials and augmentation with CBT.   Treatment recommendations encourage ERP augmentation of SSRI and clomipramine before augmentation with an antipsychotic.
Clinical Tips for Treating Pediatric OCD, Long-Term Follow-Up, and Treatment-Resistant OCD Slide 11 of 12

Slide 12 of 12

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Next Section

09. rTMS for Pediatric OCD

Earn credits for your learning!

No CMEs available

Certification expiration date: April 1, 2025

CME Information

Learning Objectives:

After completing this activity, the learner will be able to:

  1. Assess and recognize unique features of obsessive-compulsive disorder in children and adolescents.
  2. Differentiate pediatric OCD from other common diagnoses in children and adolescents.
  3. Identify the recommended treatments for pediatric OCD and prescribe them accordingly.

Original Release Date: 02/01/2022

Review and Re-release Date: 03/01/2024

Expiration Date: 04/01/2025

Expert: David Rosenberg, M.D.

Relevant Financial Disclosures:

None of the faculty, planners, and reviewers for this educational activity have relevant financial relationship(s) to disclose during the last 24 months with ineligible companies whose primary business is producing, marketing, selling, re-selling, or distributing healthcare products used by or on patients.

Contact Information: For questions regarding the content or access to this activity, contact us at support@psychopharmacologyinstitute.com

Instructions for Participation and Credit:

Participants must complete the activity online during the valid credit period that is noted above.

Follow these steps to earn CME credit:

  1. View the required educational content provided on this course page.
  2. Complete the Post Activity Evaluation for providing the necessary feedback for continuing accreditation purposes and for the development of future activities. NOTE: Completing the Post Activity Evaluation after the quiz is required to receive the earned credit.
  3. Download your certificate.

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This activity has been planned and implemented in accordance with the accreditation requirements and policies of the Accreditation Council for Continuing Medical Education through the joint providership of Medical Academy LLC and the Psychopharmacology Institute. Medical Academy is accredited by the ACCME to provide continuing medical education for physicians.

Credit Designation Statement

Medical Academy designates this enduring activity for a maximum of 1.00 AMA PRA Category 1 credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

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