Practice parameters for the assessment and treatment of children and adolescents with obsessive-compulsive disorder. AACAP

Impact of Cytochrome P450 Genetic Variation on Patient-Reported Symptom Improvement and Side Effects Among Children and Adolescents Treated with Fluoxetine

Background: Clinical practice guidelines recommend the use of fluoxetine, a selective serotonin reuptake inhibitor (SSRI), as a first-line pharmacotherapy for major depressive disorder (MDD) and obsessive compulsive disorder (OCD) in children and adolescents. However, response and tolerability to fluoxetine varies from child to child, which may in part, be a result of interindividual differences in fluoxetine metabolism. In this study, we examined whether genotype-predicted activity scores of cytochrome P450 enzymes were associated with patient-reported symptom improvement and side effects in children and adolescents treated with fluoxetine. Methods: Ninety children and adolescents aged 7-18 with a MDD or OCD diagnosis and a history of fluoxetine treatment were recruited from Western Canada. For each participant, fluoxetine dose and duration information were collected, as well as questions about adherence, side effects, and symptom improvement. DNA was extracted from a saliva sample and genotyped for CYP2D6, CYP2C19, CYP2C9, CYP3A4, and CYP3A5. Logistic regression models were fitted to assess the impact of activity scores on symptom improvement and side effects. Results: Increased CYP2D6 activity score was significantly associated with reduced odds of symptom improvement (odds ratio [OR] = 0.46, 95% confidence interval [CI] = 0.23-0.91, p = 0.028) as well as a trend association with reduced side effects (OR = 0.49, 95% CI = 0.22-1.07, p = 0.072), after adjusting for age, sex, diagnosis, dose, duration, adherence, and activity scores of the other assessed CYP enzymes. No associations with symptom improvement or side effects were detected for the other CYP enzymes examined. Conclusions: Our results suggest that an increase in the genotype-predicted CYP2D6 activity score was associated with a decrease in the odds of reporting symptom improvement among children and adolescents treated with fluoxetine. These findings will contribute to future updates of pharmacogenetic-based SSRI prescribing guidelines and if replicated, could inform fluoxetine treatment in children and adolescents with MDD or OCD. Clinical Trial Registration: NCT04797364.

Prevalence, comorbidity, and predictors of obsessive-compulsive disorder in Iranian children and adolescents

BACKGROUND AND OBJECTIVES

Obsessive-compulsive disorder (OCD) is a disease that causes personal distress or social dysfunction, especially in childhood. The present study aimed to provide the prevalence, comorbidity, and predictors of OCD among children and adolescents.

METHODS

This was a cross-sectional national project conducted on 29,858 children and adolescents using the multi-stage cluster random sampling in Iran. There were both genders in each cluster and three age groups (6-9, 10-14, and 15-18 years) within each cluster. The tools used in this research included a demographic questionnaire and K-SADS-PL. To analyze the data, logistic regression and cross-tab tests were used.

RESULTS

According to the results, the prevalence of OCD in children and adolescents was 3.1 in boys and 3.8 in girls. Also, gender, age, place of residence, and history of psychiatric hospitalization of parents could predict OCD. OCD had comorbidity with behavioral disorders (OR = 0.60, 95%CI: 0.39-0.92), elimination disorders (OR = 0.50, 95%CI: 0.30-0.83), mood disorders (OR = 2.92, 95%CI: 1.43-5.94), and smoking and alcohol disorders (OR = 4.33, 95%CI: 1.28-14.63).

CONCLUSION

In the development of the obsessive-compulsive disorder, other disorders and symptoms also environmental factors can play a role and are important. Based on our findings, given the prevalence rate of OCD was higher in the age groups of 10-14 and 15-18 years, are one of the most important stages of development for the prevention and treatment of mental disorders, especially OCD, clinical specialists can design appropriate clinical trials or modify existing interventions based on the results of such research.

Sub-graph entropy based network approaches for classifying adolescent obsessive-compulsive disorder from resting-state functional MRI

This paper presents a novel approach for classifying obsessive-compulsive disorder (OCD) in adolescents from resting-state fMRI data. Currently, the state-of-the-art for diagnosing OCD in youth involves interviews with adolescent patients and their parents by an experienced clinician, symptom rating scales based on Diagnostic and Statistical Manual of Mental Disorders (DSM), and behavioral observation. Discovering signal processing and network-based biomarkers from functional magnetic resonance imaging (fMRI) scans of patients has the potential to assist clinicians in their diagnostic assessments of adolescents suffering from OCD. This paper investigates the clinical diagnostic utility of a set of univariate, bivariate and multivariate features extracted from resting-state fMRI using an information-theoretic approach in 15 adolescents with OCD and 13 matched healthy controls. Results indicate that an information-theoretic approach based on sub-graph entropy is capable of classifying OCD vs. healthy subjects with high accuracy. Mean time-series were extracted from 85 brain regions and were used to calculate Shannon wavelet entropy, Pearson correlation matrix, network features and sub-graph entropy. In addition, two special cases of sub-graph entropy, namely node and edge entropy, were investigated to identify important brain regions and edges from OCD patients. A leave-one-out cross-validation method was used for the final predictor performance. The proposed methodology using differential sub-graph (edge) entropy achieved an accuracy of 0.89 with specificity 1 and sensitivity 0.80 using leave-one-out cross-validation with in-fold feature ranking and selection. The high classification accuracy indicates the predictive power of the sub-network as well as edge entropy metric.

Psychiatric Treatment and Management of Psychiatric Comorbidities of Movement Disorders

Pediatric movement disorders may present with psychiatric symptoms at many points during the course of the disease. For the relatively common pediatric movement disorder, Tourette syndrome, psychiatric comorbidities are well-described and treatment is well-studied. Managing these comorbidities may be more effective than improving the movements themselves. For more uncommon movement disorders, such as juvenile-onset Huntington disease, treatment of psychiatric comorbidities is not well-characterized, and best-practice recommendations are not available. For the least common movement disorders, such as childhood neurodegeneration with brain iron accumulation, psychiatric features may be nonspecific so that underlying diagnosis may be apparent only after recognition of other symptoms. However, psychiatric medication, psychotherapy, and psychosocial support for these disorders may prove helpful to many children and adolescents.

Classification of obsessive-compulsive disorder from resting-state fMRI

Obssesive-compulsive disorder (OCD) is a serious mental illness that affects the overall quality of the patients' daily lives. Accurate diagnosis of this disorder is a primary step towards effective treatment. Diagnosing OCD is a lengthy procedure that involves interviews, symptom rating scales and behavioral observation as well as the experience of a clinician. Discovering signal processing and network based biomarkers from functional magnetic resonance scans of patients may greatly assist the clinicians in their diagnostic assessments. In this paper, we explore the use of Pearson's correlation scores and network based features to predict if a subject has OCD. We extracted mean time series from 112 brain regions and decomposed them to 5-frequency bands. The mean time courses were used to calculate the Pearson's correlation matrix and network based features for each band. Minimum redundancy maximum relevance feature selection method is applied to the Pearson's correlation matrix and network based features from each frequency band to select the best features for the final predictor. A leave-one-out cross validation method is used for the final predictor performance. Our proposed methodology achieves 80% accuracy (23 out of 29 subjects classified correctly) with 81% sensitivity(13 out of 16 OCD subjects identified correctly) and 77% specificity (10 out of 13 controls identified correctly) using leave-one-out with in-fold feature ranking and selection. The most discriminating feature bands are 0.06-0.11 Hz for Pearson's correlation and 0.03-0.06 Hz for network based features. The high classification accuracy indicates the predictive power of the network features as well as carefully chosen Pearson's correlation values.

Obsessive-Compulsive Disorder in Paediatric and Adult Samples: Nature, Treatment and Cognitive Processes. A Review of the Theoretical and Empirical Literature

The appraisal model of obsessive-compulsive disorder (OCD) suggests that six key appraisal domains contribute to the aetiology and maintenance of OCD symptoms. An accumulating body of evidence supports this notion and suggests that modifying cognitive appraisals may be beneficial in reducing obsessive-compulsive symptomatology. This literature review first summarises the nature of OCD and its treatment, followed by a summary of the existing correlational and experimental research on the role of cognitive appraisal processes in OCD across both adult and paediatric samples. While correlational data provide some support for the relationship between cognitive appraisal domains and OCD symptoms, results are inconclusive, and experimental methods are warranted to determine the precise causal relationship between specific cognitive appraisal domains and OCD symptoms.

Use of Computer Vision Tools to Identify Behavioral Markers of Pediatric Obsessive-Compulsive Disorder: A Pilot Study

OBJECTIVES

The clinical presentation of pediatric obsessive-compulsive disorder (OCD) is heterogeneous, which is a stumbling block to understanding pathophysiology and to developing new treatments. A major shift in psychiatry, embodied in the Research Domain Criteria (RDoC) initiative of National Institute of Mental Health, recognizes the pitfalls of categorizing mental illnesses using diagnostic criteria. Instead, RDoC encourages researchers to use a dimensional approach, focusing on narrower domains of psychopathology to characterize brain-behavior relationships. Our aim in this multidisciplinary pilot study was to use computer vision tools to record OCD behaviors and to cross-validate these behavioral markers with standard clinical measures.

METHODS

Eighteen youths with OCD and 21 healthy controls completed tasks in an innovation laboratory (free arrangement of objects, hand washing, arrangement of objects on contrasting carpets). Tasks were video-recorded. Videos were coded by blind raters for OCD-related behaviors. Children's Yale-Brown Obsessive Compulsive Scale (CY-BOCS) and other scales were administered. We compared video-recorded measures of behavior in OCD versus healthy controls and correlated video measures and clinical measures of OCD.

RESULTS

Behavioral measures on the videos were significantly correlated with specific CY-BOCS dimension scores. During the free arrangement task, more time spent ordering objects and more moves of objects were both significantly associated with higher CY-BOCS ordering/repeating dimension scores. Longer duration of hand washing was significantly correlated with higher scores on CY-BOCS ordering/repeating and forbidden thoughts dimensions. During arrangement of objects on contrasting carpets, more moves and more adjustment of objects were significantly associated with higher CY-BOCS ordering/repeating dimension scores.

CONCLUSION

Preliminary data suggest that measurement of behavior using video recording is a valid approach for quantifying OCD psychopathology. This methodology could serve as a new tool for investigating OCD using an RDoC approach. This objective, novel behavioral measurement technique may benefit both researchers and clinicians in assessing pediatric OCD and in identifying new behavioral markers of OCD. Clinical Trial Registry: Development of an Instrument That Monitors Behaviors Associated With OCD. NCT02866422. http://clinicaltrials.gov.

Maternal Depression, Parenting, and Youth Depressive Symptoms: Mediation and Moderation in a Short-Term Longitudinal Study

Although multiple studies find that offspring of depressed mothers are at risk for depressive disorders, there is uncertainty about the specific mechanisms that are at work--particularly with respect to modifiable factors that might be targeted for early intervention. The present work examines that parenting behaviors may operate as mediators, moderators, or independent influences on the development of youth depressive symptoms. One hundred one mothers and their early adolescent children participated in positive and negative interaction tasks. Maternal and youth self-reports of youth depressive symptoms were collected at baseline, 9-month, and 18-month assessments. Maternal history of depression was significantly associated with maternal-reported, but not youth self-reported, depressive symptomatology. Maternal positive and negative interaction behaviors in positive contexts were associated with higher youth self-reported depressive symptoms. Maternal positive interaction behaviors in positive contexts and maternal negative interactive behaviors in conflict contexts were associated with higher youth self-reported depressive symptoms. We found no evidence for maternal interaction behaviors serving as a mediator and little evidence of maternal interaction behaviors serving as a moderator of the relationship between maternal and offspring depression. Low maternal positive engagement tended to be more consistently associated with maternal- and self-reported youth depressive symptoms. The present findings suggest that characteristics of mother-child interactions that are associated with youth depressive symptomatology are pertinent to youth with and without a mother with a history of depression.

Polypharmacy with antidepressants in children and adolescents

The aim of this study was to review current epidemiological data on the use of antidepressants in co-prescription with other psychotropic drugs in children and adolescents, as well as available efficacy and safety information. A Medline search from inception until February 2012 was performed to identify epidemiological and clinical studies, reviews and reports containing potentially relevant information on polypharmacy with antidepressants in young people. There has been an increase in polypharmacy in children and adolescents involving antidepressants in recent years. Antidepressants have become one of the drug classes most frequently prescribed in combination and are commonly co-prescribed with stimulants and antipsychotics. Most information regarding efficacy and safety of polypharmacy patterns was provided by case series and open-label studies. Efficacy studies gave some support for the use of a combination of antidepressants and antipsychotics in the management of refractory obsessive-compulsive disorder and some residual symptoms in major depressive disorder. Even less empirical support was found for a combination of stimulants and antidepressants in co-morbid attention deficit hyperactivity disorder and mood or anxiety disorders. Adverse events were similar to those found with individual medication groups, with severe adverse events mostly reported by individual case reports. The use of polypharmacy with antidepressants has become a regular practice in clinical settings. Although there is still little efficacy and safety information, preliminary evidence points to the potential clinical usefulness of some polypharmacy patterns. Further research on patients with co-morbidities or more severe conditions is needed, in order to improve knowledge of this issue.

All in the Family

Obsessive-compulsive disorder (OCD) is common in children with rates of 1% to 4% in children and adolescents. A prominent first-line treatment for pediatric OCD is cognitive-behavioral therapy (CBT) using exposure and response prevention (ERP). However, it has also been suggested that family therapy be used as an adjunct treatment in pediatric OCD cases, as family members often accommodate or contribute to the maintenance of OCD symptoms. The following case study reviews the successful treatment of a 7-year-old with comorbid OCD and oppositional defiant disorder, in which traditional CBT and ERP for OCD was integrated with family-based approaches utilizing a family systems theory framework.

Advances in the treatment of pediatric obsessive-compulsive d-cycloserine with exposure and response prevention

Exposure-based cognitive-behavioral therapy and serotonin reuptake inhibitor medications are efficacious treatment options for the management of pediatric obsessive-compulsive disorder. Despite established efficacy, many youths receiving either therapy remain symptomatic after acute treatment. Regardless of the rationale for persistent symptoms, a clear need emerges for treatment options that restore functioning efficiently to symptomatic youths. One innovative approach builds upon the identified role of NMDA receptors in the fear extinction process. Instead of breaking existing connections during fear extinction, new associations develop that eventually predominate over prior associations. Recent investigations have explored augmenting exposure-based cognitive-behavioral therapy with the NMDA partial agonist d-cycloserine, with preliminary results demonstrating expedited treatment gains and moderately larger effects above exposure and response prevention therapy alone. A large randomized clinical trial is underway to evaluate the efficacy and efficiency of this therapeutic combination in pediatric obsessive-compulsive disorder. Results from this trial may translate into improved management practices.

The nature, assessment, and treatment of obsessive-compulsive disorder

Obsessive-compulsive disorder (OCD) is an anxiety disorder that affects between 1% to 2% of individuals and causes considerable impairment and disability. Although > 50% of individuals experience symptom onset in childhood, symptoms can continue to develop throughout adulthood. Accurate and timely assessment of clinical presentation is critical to limit impairment and improve prognosis. Presently, there are 2 empirically supported treatments available for OCD in children and adults, namely cognitive-behavioral therapy and pharmacotherapy with serotonin reuptake inhibitors. This article provides an introduction to the phenomenology, etiology, and clinical course of OCD. Assessment practices used to evaluate symptom severity are described, and evidence-based treatment options are reviewed, with appropriate distinctions drawn between children and adults. Finally, recommendations for assessment and treatment practices for OCD are explicated.

Optimizing treatment for complex cases of childhood obsessive compulsive disorder: a preliminary trial

Family factors such as conflict, blame, and poor cohesion have been found to attenuate response to cognitive behavior therapy (CBT) for pediatric obsessive compulsive disorder (OCD). This study examined the feasibility and acceptability of a brief, personalized intervention for cases of pediatric OCD complicated by these family features. Twenty youth with a primary Diagnostic and Statistical Manual of Mental Disorders (4th ed.) diagnosis of OCD (M age = 12.50 years; 55% male; 60% Caucasian) and their families participated. To be included in the study, families were required to evidence poor functioning on measures of blame, conflict, and/or cohesion. Eligible families were randomly assigned either to standard treatment (ST) with 12 weeks of individual child CBT that included weekly parent check-ins and psychoeducation or to Positive Family Interaction Therapy (PFIT), which consisted of 12 weeks of individual child CBT plus an additional 6 sessions of family treatment aimed at shifting family dynamics. Clinical outcomes were determined by blind independent evaluators using the Clinician's Global Impressions-Improvement (CGI-I) scale. All families completed the study. High levels of satisfaction were reported among participants in both arms of the study, despite the added burden of attending the PFIT sessions. Both mothers and fathers attended 95% of the PFIT family sessions. Families in the ST condition demonstrated a 40% response rate on the CGI-I; families in the PFIT condition demonstrated a 70% response rate. Treatment gains were maintained in both conditions at 3-month follow-up. Preliminary data suggest that PFIT is acceptable and feasible. Further testing and treatment development are needed to optimize outcomes for complicated cases of pediatric OCD.

Family factors predict treatment outcome for pediatric obsessive-compulsive disorder

OBJECTIVE

To examine family conflict, parental blame, and poor family cohesion as predictors of treatment outcome for youths receiving family-focused cognitive behavioral therapy (FCBT) for obsessive-compulsive disorder (OCD).

METHOD

We analyzed data from a sample of youths who were randomized to FCBT (n = 49; 59% male; M age = 12.43 years) as part of a larger randomized clinical trial. Youths and their families were assessed by an independent evaluator (IE) pre- and post-FCBT using a standardized battery of measures evaluating family functioning and OCD symptom severity. Family conflict and cohesion were measured via parent self-report on the Family Environment Scale (Moos & Moos, 1994), and parental blame was measured using parent self-report on the Parental Attitudes and Behaviors Scale (Peris, Benazon, et al., 2008b). Symptom severity was rated by IEs using the Children's Yale-Brown Obsessive Compulsive Scale (Scahill et al., 1997).

RESULTS

Families with lower levels of parental blame and family conflict and higher levels of family cohesion at baseline were more likely to have a child who responded to FCBT treatment even after adjusting for baseline symptom severity compared with families who endorsed higher levels of dysfunction prior to treatment. In analyses using both categorical and continuous outcome measures, higher levels of family dysfunction and difficulty in more domains of family functioning were associated with lower rates of treatment response. In addition, changes in family cohesion predicted response to FCBT, controlling for baseline symptom severity.

CONCLUSION

Findings speak to the role of the family in treatment for childhood OCD and highlight potential targets for future family interventions.

Family accommodation in obsessive-compulsive disorder

Family accommodation refers to ways in which family members take part in the performance of rituals, avoidance of anxiety-provoking situations or modification of daily routines to assist a relative with obsessive-compulsive disorder (OCD). Our goal is to review the available data on the role of family accommodation in both children and adults with OCD. A search of available peer-reviewed English language papers was conducted through PubMed and PsycINFO cross-referencing the keyword OCD with accommodation, family relations and parents. The resulting 641 papers were individually evaluated for relevance to the scope of the review. It was found that accommodation is common in OCD and is strongly and consistently correlated with OCD symptom severity. Family accommodation also appears to be increased when the proband has cleaning contamination symptoms and increased internalizing or externalizing problems. Family accommodation is associated with increased parental OCD and anxiety symptoms. Levels of accommodation are associated with treatment outcomes for both behavioral and pharmacological treatment. Significant improvement of OCD symptoms with treatment is associated with reductions in family accommodation. Family accommodation represents important clinical data that is worth measuring, monitoring and tracking in clinical care. Therapies targeting family accommodation may be successful in improving treatment outcomes in OCD.

Controlled comparison of family cognitive behavioral therapy and psychoeducation/relaxation training for child obsessive-compulsive disorder

OBJECTIVE

To examine the efficacy of exposure-based cognitive-behavioral therapy (CBT) plus a structured family intervention (FCBT) versus psychoeducation plus relaxation training (PRT) for reducing symptom severity, functional impairment, and family accommodation in youths with obsessive-compulsive disorder (OCD).

METHOD

A total of 71 youngsters 8 to 17 years of age (mean 12.2 years; range, 8-17 years, 37% male, 78% Caucasian) with primary OCD were randomized (70:30) to 12 sessions over 14 weeks of FCBT or PRT. Blind raters assessed outcomes with responders followed for 6 months to assess treatment durability.

RESULTS

FCBT led to significantly higher response rates than PRT in ITT (57.1% vs 27.3%) and completer analyses (68.3% vs. 35.3%). Using HLM, FCBT was associated with significantly greater change in OCD severity and child-reported functional impairment than PRT and marginally greater change in parent-reported accommodation of symptoms. These findings were confirmed in some, but not all, secondary analyses. Clinical remission rates were 42.5% for FCBT versus 17.6% for PRT. Reduction in family accommodation temporally preceded improvement in OCD for both groups and child functional status for FCBT only. Treatment gains were maintained at 6 months.

CONCLUSIONS

FCBT is effective for reducing OCD severity and impairment. Importantly, treatment also reduced parent-reported involvement in symptoms with reduced accommodation preceding reduced symptom severity and functional impairment. CLINICAL TRIALS REGISTRY INFORMATION: Behavior Therapy for Children and Adolescents with Obsessive-Compulsive Disorder (OCD); http://www.clinicaltrials.gov; NCT00000386.

The therapeutic alliance in the cognitive behavioral treatment of pediatric obsessive-compulsive disorder

Although cognitive-behavioral therapy (CBT) for pediatric obsessive-compulsive disorder (OCD) is considered a first-line treatment, not all youth have a positive treatment response, suggesting need for investigating factors that may enhance or reduce treatment effects. Few studies have investigated predictors of treatment response in pediatric OCD, and there is an absence of studies examining the influence of treatment process variables (e.g., therapeutic alliance [TA]) on treatment outcome. Using a multiple-informant and multiple-time point design, the current study examined the role of the TA in family-based CBT for pediatric OCD. Analyses examined (1) the predictive value of the TA on OCD symptom reduction and (2) whether changes in the TA over time predict treatment response. Findings indicated that (1) stronger child-rated, parent-rated, and therapist-rated TAs were predictive of better treatment outcome and (2) larger and more positive early alliance shifts (as rated by changes in child-rated TA between sessions 1 and 5) were predictive of better treatment outcome. Implications for the treatment of youth with OCD within family-based CBT are discussed.

Obsessive-compulsive disorder in children and adolescents: symptom dimensions in a naturalistic setting

BACKGROUND

Obsessive-compulsive disorder (OCD) is a frequent and clinically heterogeneous disorder. The complex clinical presentation can be summarized using a few consistent and temporally stable symptom dimensions. Only few studies in children and adolescents have examined the importance of symptom dimensions.

AIMS

This retrospective study was undertaken to describe the relation between symptom dimensions, pattern of comorbidity and family disposition, in a sample of Danish children and adolescents with OCD assessed in a naturalistic setting.

METHODS

A retrospective study of children and adolescents (n=83) diagnosed with OCD in the period 1998-2004, at the Psychiatric Hospital for Children and Adolescents, Risskov, Denmark. Information from clinical records was systematically collected and Children's Yale-Brown Obsessive-compulsive Scale (CY-BOCS) scores and symptom checklists were obtained.

RESULTS

High scores on the symmetry/ordering dimension were related to OCD in first-degree relatives and high scores on the aggressive/checking dimension were associated to comorbidity with tic disorders. We showed a correlation between limited insight and younger age.

CONCLUSION

This is one of the first studies to examine symptom dimensions in children and adolescents in naturalistic settings. The results were comparable with those in adult studies, showing an association between the occurrence of the symmetry/ordering dimension and family OCD and the occurrence of the aggressive/checking dimension and comorbid tic disorders. In small children, insight into symptoms may be limited.

Psychotherapy and medication management strategies for obsessive-compulsive disorder

Obsessive-compulsive disorder (OCD) is a chronic anxiety disorder. While medication and psychotherapy advances have been very helpful to patients, many patients do not respond adequately to initial trials of serotonergic medication or cognitive-behavioral therapy (CBT) and require multiple treatment trials or combination therapies. Comorbidity may also influence treatment response. The role of streptococcal infections in pediatric OCD has become an area of intense scrutiny and controversy. In this article, current treatment methods for OCD will be reviewed, with special attention to strategies for treating OCD in children and in patients with comorbid tic disorders. Alternative psychotherapy strategies for patients who are highly anxious about starting CBT, such as cognitive therapy or augmentation with D-cycloserine, will be reviewed. Newer issues regarding use of antibiotics, neuroleptics, and glutamate modulators in OCD treatment will also be explored.

Still Struggling: characteristics of youth with OCD who are partial responders to medication treatment

The primary aim of this paper is to examine the characteristics of a large sample of youth with OCD who are partial responders (i.e., still have clinically significant symptoms) to serotonin reuptake inhibitor (SRI) medication. The sample will be described with regard to: demographics, treatment history, OCD symptoms/severity, family history and parental psychopathology, comorbidity, and global and family functioning. The sample includes 124 youth with OCD ranging in age from 7 to 17 with a primary diagnosis of OCD and a partial response to an SRI medication. The youth are a predominantly older (age 12 and over), Caucasian, middle to upper income group who had received significant past treatment. Key findings include moderate to severe OCD symptoms, high ratings of global impairment, and significant comorbidity, despite partial response to an adequate medication trial. Considerations regarding generalizability of the sample and limitations of the study are discussed.

Anxiety and mood disorders in children and adolescents: A practice update

Anxiety and mood disorders are among the most common disorders in children and adolescents. They presage later emotional difficulties and disabilities. An understanding of the disorders' presentation, common contributing factors and methods of intervention will enable paediatricians and family doctors to provide optimal support to these children and their families. The present paper briefly reviews the epidemiology of anxiety and mood disorders in children and adolescents. Phenomenology is referred to according to the major diagnostic categories for anxiety and depression. Contributing factors, including genetic and environmental components and their possible interaction, are discussed. The management of the disorders, including common strategies for encouraging coping responses, stress reduction and medication, is also described.

Evidence for successful implementation of exposure and response prevention in a naturalistic group format for pediatric OCD

BACKGROUND

Although exposure and response prevention (ERP) is an effective treatment for youth with obsessive-compulsive disorder (OCD), the majority of studies, randomized clinical trials of individual therapy, find variability in treatment response. We evaluated the potential role of individual differences in OCD presentation, comorbid disorders, age, and gender on treatment effects. Moreover, we examined these potential effects in a group format in a naturalistic, clinic-based sample of patients.

METHODS

Pediatric patients with a DSM-IV diagnosis of OCD (n=41) were treated with ERP in an intensive outpatient community-based program. OCD, mood, and anxiety symptom severity was measured at baseline, during treatment, and at discharge. Trajectories and predictors of treatment outcome were measured using linear growth models.

RESULTS

We found that group-based ERP was effective in reducing pediatric OCD symptom severity in a naturalistic treatment setting irrespective of age or gender. Furthermore, ERP was found to be effective at reducing depressive symptoms but not other anxiety symptoms. We also found inter-individual variability in the discharge levels of contamination, symmetry, and intrusive sexual thoughts and in the rate of severity reduction of intrusive sexual thoughts.

CONCLUSION

Group-based ERP is an effective treatment for children and adolescents with OCD. Several factors, including symptom dimensions and comorbid psychopathology, are associated with treatment response and outcome in this pediatric population.

Predictors of early adulthood quality of life in children with obsessive-compulsive disorder

OBJECTIVES

The goal of this study was to determine childhood clinical predictors of quality of life (QoL) in early adulthood in children with obsessive-compulsive disorder (OCD).

METHODS

A longitudinal cohort study was conducted with 36 (out of 62 eligible) children with OCD, interviewed once at childhood baseline (mean age 12.1 ± 2.1, range 8.0-15.8), and again in early adulthood after an average follow-up interval of 9 years. QoL was measured in adulthood with the longitudinal interval follow-up evaluation range of impaired functioning tool (LIFE-RIFT).

RESULTS

Forty-two percent of children experienced a remission of OCD symptoms by early adulthood. OCD appeared to most strongly impair the interpersonal relationships and work domains of QoL. QoL and severity of OCD and anxiety symptoms were significantly associated in early adulthood. Primary hoarding symptoms in childhood predicted poor QoL in adulthood. Increased symptoms in the forbidden thoughts dimension in both childhood and adulthood were associated with improved adulthood QoL.

CONCLUSIONS

Children for whom OCD symptoms remitted by adulthood showed no evidence of residual impairment in QoL, whereas children whose OCD symptoms failed to remit by adulthood showed at most mild impairment in QoL. Hoarding symptoms in childhood appear to portend not only the persistence of OCD symptoms but also poorer QoL in early adulthood.

Evidence-based pharmacotherapy for pediatric obsessive-compulsive disorder and chronic tic disorders

In recent years, much progress has been made in pharmacotherapy for pediatric obsessive-compulsive disorder (OCD) and chronic tic disorders (CTDs). What were previously considered relatively intractable conditions now have an array of efficacious medicinal (and psychosocial) interventions available at clinicians’ disposal, including selective serotonin reuptake inhibitors, atypical antipsychotics, and alpha-2 agonists. The purpose of this review is to discuss the evidence base for pharmacotherapy with pediatric OCD and CTDs with regard to efficacy, tolerability, and safety, and to put this evidence in the context of clinical management in integrated behavioral healthcare. While there is no single panacea for these disorders, there are a variety of medications that provide considerable relief for children with these disabling conditions.

Predictors and moderators of treatment outcome in the Pediatric Obsessive Compulsive Treatment Study (POTS I)

OBJECTIVE

To identify predictors and moderators of outcome in the first Pediatric OCD Treatment Study (POTS I) among youth (N = 112) randomly assigned to sertraline, cognitive behavioral therapy (CBT), both sertraline and CBT (COMB), or a pill placebo.

METHOD

Potential baseline predictors and moderators were identified by literature review. The outcome measure was an adjusted week 12 predicted score for the Children's Yale Brown Obsessive Compulsive Scale (CY-BOCS). Main and interactive effects of treatment condition and each candidate predictor or moderator variable were examined using a general linear model on the adjusted predicted week 12 CY-BOCS scores.

RESULTS

Youth with lower obsessive-compulsive disorder (OCD) severity, less OCD-related functional impairment, greater insight, fewer comorbid externalizing symptoms, and lower levels of family accommodation showed greater improvement across treatment conditions than their counterparts after acute POTS treatment. Those with a family history of OCD had more than a sixfold decrease in effect size in CBT monotherapy relative to their counterparts in CBT without a family history of OCD.

CONCLUSIONS

Greater attention is needed to build optimized intervention strategies for more complex youth with OCD. Youth with a family history of OCD are not likely to benefit from CBT unless offered in combination with an SSRI.

CLINICAL TRIALS REGISTRATION INFORMATION

Treatment of Obsessive Compulsive Disorder (OCD) in Children, http://www.clinicaltrials.gov, NCT00000384.

Peer Victimization in Children With Obsessive–Compulsive Disorder: Relations With Symptoms of Psychopathology

This study examined the frequency of peer victimization and psychological symptom correlates among youth with obsessive-compulsive disorder (OCD). The Schwartz Peer Victimization Scale, Children's Depression Inventory, and Asher Loneliness Scale were administered to 52 children and adolescents diagnosed with OCD. The child's parent or guardian completed the Child Behavior Checklist, and a trained clinician administered the Children's Yale-Brown Obsessive-Compulsive Scale (CY- BOCS). Fifty-two healthy controls and 52 children with Type 1 diabetes (T1D) who were administered the Schwartz Peer Victimization Scale as part of another study were included for comparison purposes. Greater rates of peer victimization were reported in youth with OCD relative to healthy controls and children with Type 1 diabetes (T1D). Peer victimization in the OCD sample was positively related to loneliness, child-reported depression, parent-reported internalizing and externalizing symptoms, and clinician-rated OCD severity. Peer victimization fully mediated the relation between OCD severity and both depression and parent reports of child externalizing behaviors and partially mediated the relation between OCD severity and loneliness. Recognition of the magnitude of the problem and contribution problematic peer relations may play in comorbid psychological conditions is important for clinicians who see children with OCD.

Correlates of insight among youth with obsessive-compulsive disorder

BACKGROUND

Individuals with Obsessive-Compulsive Disorder (OCD) may lack insight into the irrational nature of their symptoms. Among adults with OCD, poor insight has been linked to greater symptom severity, increased likelihood of comorbid symptoms, lower adaptive functioning, and worse treatment outcomes. Parallel work regarding insight among children and adolescents, with OCD, is lacking. The aim of this research was to examine links between insight and demographic, cognitive, and clinical factors among youth with OCD.

METHODS

Seventy-one youths with OCD (mean age = 11.7; 63% = male) were assessed as part of a larger treatment trial. Insight was measured via clinician interview.

RESULTS

Youth with low insight had poorer intellectual functioning and reported decreased perception of control over their environment. Additionally, youth with low insight were more likely to be younger, to report higher levels of depressive symptoms, and to report lower levels of adaptive functioning.

CONCLUSION

This set of cognitive, developmental and clinical factors that may predispose youth with OCD to have diminished insight. Data provide initial empirical support for diagnostic differences between youth and adults with regard to requiring intact insight. Implications for treatment are discussed.

Is anorexia nervosa a neuropsychiatric developmental disorder? An illustrative case report

We propose the concept that anorexia nervosa is a neuropsychiatric developmental disorder. In support of the concept we present a case report of a 12-year-old girl with high functioning autistic disorder who developed Tourette syndrome and obsessive-compulsive disorder. She subsequently experienced a distinct onset of partial anorexia nervosa characterized by fear of gaining weight, body image distortions, food preference idiosyncrasies including avoidance of fat, dietary restriction, a pursuit of thinness, episodic self-induced vomiting, the missing of her menstrual cycles, and a 10% decrement in expected weight for height. She fell short of the required 15% decrement in expected weight for height to qualify for the full syndrome. Our case presentation emphasizes the longitudinal commonalities and symptomatic overlap of her multiple comorbidities. We discuss treatment approaches typically used with individuals with neuropsychiatric developmental disorders which might benefit higher functioning individuals with eating disorders. We conclude with examples of a neuropsychiatric developmental approach to generate a research agenda for anorexia nervosa.

Cognitive-behavioral family treatment for childhood obsessive-compulsive disorder: a 7-year follow-up study

This study evaluated the long-term durability of individual and group cognitive-behavioral family-based therapy (CBFT) for childhood obsessive-compulsive disorder (OCD). Thirty-eight participants (age 13-24 years) from a randomized controlled trial of individual or group CBFT for childhood OCD were assessed 7 years post-treatment. Diagnostic, symptom severity interviews and self-report measures of OCD, anxiety, and depression were administered. Seven years after treatment, 79% of participants from individual therapy and 95% from group therapy had no diagnosis of OCD. These results are near identical to results found at 12 and 18 months follow-ups of the same sample. No significant differences were found between treatment conditions, self-reports of symptom severity, except that depressive symptoms were significantly more pronounced for individual treatment condition, and those in the older age group (19-24 years of age). Results suggest that CBFT for obsessive-compulsive disorder is effective 7 years post-treatment.

Psychotherapy for obsessive-compulsive disorder

Cognitive-behavioral therapy (CBT) with exposure and response prevention is a first-line intervention for adult and childhood obsessive-compulsive disorder. Methodologically rigorous controlled trials have suggested that benefits from CBT exceed those from placebo and attention-control conditions and have similar or greater efficacy than serotonergic monotherapy. This article reviews the nature of CBT and associated outcome data, highlighting recent empiric findings in the treatment literature.

Anxiety disorders in youth

Anxiety disorders are one of the most prevalent categories of childhood and adolescent psychopathology. Due to their distressing, time-consuming, and/or debilitating nature, impairments in academic, social, and family functioning are often substantial. This article reviews the nature, etiology, assessment, and treatment of anxiety disorders in youth. We conclude by reviewing implications for nurses involved in the care of youth with anxiety disorders.

The Pediatric Obsessive-Compulsive Disorder Treatment Study II: rationale, design and methods

This paper presents the rationale, design, and methods of the Pediatric Obsessive-Compulsive Disorder Treatment Study II (POTS II), which investigates two different cognitive-behavior therapy (CBT) augmentation approaches in children and adolescents who have experienced a partial response to pharmacotherapy with a serotonin reuptake inhibitor for OCD. The two CBT approaches test a "single doctor" versus "dual doctor" model of service delivery. A specific goal was to develop and test an easily disseminated protocol whereby child psychiatrists would provide instructions in core CBT procedures recommended for pediatric OCD (e.g., hierarchy development, in vivo exposure homework) during routine medical management of OCD (I-CBT). The conventional "dual doctor" CBT protocol consists of 14 visits over 12 weeks involving: (1) psychoeducation, (2), cognitive training, (3) mapping OCD, and (4) exposure with response prevention (EX/RP). I-CBT is a 7-session version of CBT that does not include imaginal exposure or therapist-assisted EX/RP. In this study, we compared 12 weeks of medication management (MM) provided by a study psychiatrist (MM only) with two types of CBT augmentation: (1) the dual doctor model (MM+CBT); and (2) the single doctor model (MM+I-CBT). The design balanced elements of an efficacy study (e.g., random assignment, independent ratings) with effectiveness research aims (e.g., differences in specific SRI medications, dosages, treatment providers). The study is wrapping up recruitment of 140 youth ages 7-17 with a primary diagnosis of OCD. Independent evaluators (IEs) rated participants at weeks 0,4,8, and 12 during acute treatment and at 3,6, and 12 month follow-up visits.

TRIAL REGISTRATION

NCT00074815.

Correlates of accommodation of pediatric obsessive-compulsive disorder: parent, child, and family characteristics

OBJECTIVE

Pediatric obsessive-compulsive disorder (OCD) is a chronic, impairing condition associated with high levels of family accommodation (i.e., participation in symptoms). Understanding of factors that may engender accommodation of pediatric OCD is limited. This study conducted exploratory analyses of parent-, child-, and family-level correlates of family accommodation, considering both behavioral and affective components of the response.

METHOD

The sample included 65 youths (mean age 12.3 years, 62% male) with OCD and their parents who completed a standardized assessment battery composed of both clinical and self-report measures (e.g., Children's Yale-Brown Obsessive-Compulsive Scale, Brief Symptom Inventory).

RESULTS

Family accommodation was common, with the provision of reassurance and participation in rituals the most frequent practices (occurring on a daily basis among 56% and 46% of parents, respectively). Total scores on the Family Accommodation Scale were not associated with child OCD symptom severity; however, parental involvement in rituals was associated with higher levels of child OCD severity and parental psychopathology and with lower levels of family organization. Comorbid externalizing symptomatology and family conflict were associated with parent report of worse consequences when not accommodating.

CONCLUSIONS

Although these findings must be interpreted in light of potential type I error, they suggest that accommodation is the norm in pediatric OCD. Family-focused interventions must consider the parent, child, and family-level variables associated with this familial response when teaching disengagement strategies.

Psychiatric morbidity with focus on obsessive-compulsive disorder in an Israeli cohort of adolescents with mild to moderate mental retardation

The study evaluated the prevalence of DSM-IV-TR-defined psychiatric disorders in adolescents with mental retardation, with a focus on obsessive-compulsive disorder (OCD), for which data at present are sparse. Eighty-seven adolescents with mild to moderate mental retardation attending the Israeli special-education system were screened for psychiatric disorders in general and obsessive-compulsive symptoms in particular. Sixty-one percent had at least one psychiatric disorder. Of the 13 participants receiving antipsychotic medication, none had an underlying psychotic disorder and most had anxiety or depressive disorders. OCD was detected in 11% of participants and was characterized by high rates of psychiatric comorbidities. The severity of autistic symptoms predicted 39% of the variance in the severity of OCD symptoms. Adolescents with mild to moderate mental retardation have high rates of psychiatric morbidities that are often inappropriately treated. OCD is prevalent in this population and is strongly associated with autistic symptoms. Further studies are required in adolescents with mental retardation to better delineate psychiatric morbidities and their appropriate treatment in this at-risk population.

Psychopharmacological treatment for very young children: contexts and guidelines

Systematic research and practice guidelines addressing preschool psychopharmacological treatment in very young children are limited, despite evidence of increasing clinical use of medications in this population. The Preschool Psychopharmacology Working Group (PPWG) was developed to review existing literature relevant to preschool psychopharmacology treatment and to develop treatment recommendations to guide clinicians considering psychopharmacological treatment in very young children. This article reviews the developmental considerations related to preschool psychopharmacological treatment, presents current evidence bases for specific disorders in early childhood, and describes the recommended algorithms for medication use. The purpose of this effort is to promote responsible treatment of young children, recognizing that this will sometimes involve the use of medications.

Pediatric obsessive-compulsive disorder: a guide to assessment and treatment

Obsessive-compulsive disorder (OCD) is an anxiety disorder characterized by recurrent or persistent thoughts, impulses, or images that are experienced as intrusive or distressing (obsessions), and repetitive behaviors or mental acts (compulsions) often performed in response to an obsession. Recent epidemiological studies have found lifetime prevalence of pediatric OCD to be approximately 1-4% in the USA. OCD begins before the age of 18 years for as many as 80% of cases and follows a chronic, unremitting course. Due to the distressing, time-consuming, and debilitating nature of OCD, impairments in academic, social, and family functioning are often substantial. Despite the relatively high prevalence rate of OCD, dissemination about effective assessment and treatment has lagged. Increasing the awareness of OCD symptoms and its treatment among nurses and other health professionals will enhance identification of children presenting with unrecognized or untreated symptoms of OCD and will stimulate appropriate referrals for treatment to improve children's psychological functioning and overall quality of life. This paper reviews the nature, etiology, assessment, and treatment of OCD, highlighting clinical implications for nurses involved in mental health care.

Repetitive behaviour in children with high functioning autism and obsessive compulsive disorder

Children with Autism Spectrum Disorders (ASD) and children with Obsessive Compulsive Disorder (OCD) were compared on a range of repetitive behaviours. Parents reported similar levels of sameness behaviour and repetitive movements in the clinical groups, although children with OCD engaged in more repetitive behaviour focussed around routines and rituals. Children with OCD reported more compulsions and obsessions than children with ASD; both groups reported more compulsions and obsessions than a typically developing comparison group. Types of compulsions and obsessions tended to be less sophisticated in children with ASD than those with OCD. Sameness behaviour was more prevalent in younger children with OCD, but for children with ASD, age was not significantly related to sameness behaviour, repetitive movements, compulsions, or obsessions.

Family-based cognitive-behavioral therapy for pediatric obsessive-compulsive disorder: comparison of intensive and weekly approaches

OBJECTIVE

To examine the relative efficacy of intensive versus weekly cognitive-behavioral therapy (CBT) for children and adolescents with obsessive-compulsive disorder (OCD).

METHOD

Forty children and adolescents with OCD (range 7-17 years) were randomized to receive 14 sessions of weekly or intensive (daily psychotherapy sessions) family-based CBT. Assessments were conducted at three time points: pretreatment, posttreatment, and 3-month follow-up. Raters were initially blind to randomization. Primary outcomes included scores on the Children's Yale-Brown Obsessive-Compulsive Scale, remission status, and ratings on the Clinical Global Impression-Severity and Clinical Global Improvement scales. Secondary outcomes included the Child Obsessive Compulsive Impact Scale-Parent Rated, Children's Depression Inventory, Multidimensional Anxiety Scale for Children, and Family Accommodation Scale. Adjunctive pharmacotherapy was not an exclusion criterion.

RESULTS

Intensive CBT was as effective as weekly treatment with some advantages present immediately after treatment. No group differences were found at follow-up, with gains being largely maintained over time. Although no group x time interaction was found for the Children's Yale-Brown Obsessive-Compulsive Scale (F(1,38) = 2.2, p = .15), the intensive group was rated on the Clinical Global Impression-Severity as less ill relative to the weekly group (F(1,38) = 9.4, p < .005). At posttreatment, 75% (15/20) of youths in the intensive group and 50% (10/20) in the weekly group met remission status criteria. Ninety percent (18/20) of youths in the intensive group and 65% (13/20) in the weekly group were considered treatment responders on the Clinical Global Improvement (chi1(2) = 3.6, p = .06).

CONCLUSIONS

Both intensive and weekly CBT are efficacious treatments for pediatric OCD. Intensive treatment may have slight immediate advantages over weekly CBT, although both modalities have similar outcomes at 3-month follow-up.

Use of psychotropic medications in Italian children and adolescents

INTRODUCTION

The evidence of psychotropic drug safety and efficacy in the pediatric population is scant and widely debated. Yet, the prescription prevalence and incidence are increasing. A drug utilization study, based on a multiregional prescription database was therefore carried out in a sample of 1,484,770 Italian children and adolescents younger than 18 years during the year 2004. Furthermore, the trend of psychotropic prescription prevalence was evaluated from 1998 to 2004. During 2004, 4,316 children and adolescents received psychotropic drugs (2.91 per thousand youths). Antidepressants were prescribed to 3,503 youths (2.36 per thousand), antipsychotics to 1,005 (0.68 per thousand), and lithium to 73 (0.05 per thousand). A total of 265 youths received drugs from more than one psychotropic class. The prevalence rate of psychotropic drug prescriptions increased with increasing age, with a statistically significant trend ([Formula: see text]; p<0.0001), and it increased in the period 1998-2004 with a statistically significant trend ([Formula: see text]; p<0.0001), reaching its highest value in 2002 (3.08 per thousand). The trend for antidepressants was similar ([Formula: see text]; p<0.0001), while the prevalence of antipsychotics did not increase.

CONCLUSION

Even though the prevalence of psychotropic drug prescriptions in Italian children is lower than that reported in other countries (e.g. United States, Canada, Netherlands, UK), the increase in antidepressant prescriptions raises some concerns. Data concerning safety and efficacy of these antidepressants in pediatrics are still limited and further studies are needed to guarantee evidence based therapeutic approaches in children, adolescents and their families.

Tolerability of selective serotonin reuptake inhibitors in thirty-nine children under age seven: a retrospective chart review

OBJECTIVE

To characterize the adverse effects of treatment with selective serotonin reuptake inhibitors (SSRIs) started in children under age 7 yr.

METHODS

We conducted a retrospective review of medical records for all children who had begun treatment with an SSRI under age 7 at an academic psychiatry department in Boston.

RESULTS

Thirty-nine children (26 males, 13 females) met the inclusion criteria. Mean age at start of treatment was 5.9 +/- 0.8 yr, and median treatment duration was 5.0 months. The target diagnoses for SSRI treatment were anxiety disorders in 54%, depressive disorders in 23%, and both anxiety and depressive disorders in 20% of patients. There were no reports of suicidal ideation or attempt. No children were medically or psychiatrically hospitalized for adverse effects (AEs). Eleven patients (28%) reported an AE of at least moderate severity; 7 (18%) discontinued the SSRI due to the AE. Six patients discontinued due to behavioral activation and 1 due to gastrointestinal upset. The median time to onset of an AE was 23 days, and median resolution was 19 days from onset.

CONCLUSIONS

The high rate of adverse effects, especially activation, in this sample argues for continued caution in using SSRIs in young children. Controlled trials are warranted.

Cognitive behavioral treatment for young children with obsessive-compulsive disorder

Obsessive-compulsive disorder (OCD) is a distressing and functionally impairing disorder that can emerge as early as age 4. Cognitive behavior therapy (CBT) for OCD in youth shows great promise for amelioration of symptoms and associated functional impairment. However, the empirical evidence base for the efficacy of CBT in youth has some significant limitations, particularly as related to treating the very young child with OCD. This report includes a quantitative review of existing child CBT studies to evaluate evidence for the efficacy of CBT for OCD. It identifies gaps in the literature that, when addressed, would enhance the understanding of effective treatment in pediatric OCD. Finally, it presents a proposed research agenda for addressing the unique concerns of the young child with OCD.

Tics moderate treatment outcome with sertraline but not cognitive-behavior therapy in pediatric obsessive-compulsive disorder

BACKGROUND

The presence of a comorbid tic disorder may predict a poorer outcome in the acute treatment of pediatric obsessive-compulsive disorder (OCD).

METHODS

Using data from the National Institute of Mental Health (NIMH)-funded Pediatric OCD Treatment Study (POTS) that compared cognitive-behavior therapy (CBT), medical management with sertraline (SER), and the combination of CBT and SER (COMB), to pill placebo (PBO) in children and adolescents with OCD, we asked whether the presence of a comorbid tic disorder influenced symptom reduction on the Children's Yale-Brown Obsessive Compulsive Scale (CY-BOCS) after 12 weeks of treatment.

RESULTS

Fifteen percent (17 of 112) of patients exhibited a comorbid tic disorder. In patients without tics, results replicated previously published intent-to-treat outcomes: COMB > CBT > SER > PBO. In patients with a comorbid tic disorder, SER did not differ from PBO, while COMB remained superior to CBT and CBT remained superior to PBO.

CONCLUSIONS

In contrast to CBT outcomes, which are not differentially impacted, tic disorders appear to adversely impact the outcome of medication management of pediatric OCD. Children and adolescents with obsessive-compulsive disorder and a comorbid tic disorder should begin treatment with cognitive-behavior therapy alone or the combination of cognitive-behavior therapy plus a serotonin reuptake inhibitor.

Obsessive-compulsive disorder in Tourette syndrome

Several lines of evidence suggest a meaningful association between obsessive-compulsive disorder and Tourette syndrome, including comorbidity, phenomenologic overlap, evidence from family and genetic studies, and the possible role of basal ganglia circuitry in both conditions. Obsessive-compulsive behaviors occur frequently in patients who have Tourette syndrome and tend to have a later onset than tics. Despite commonalities, the approaches to treating tics and obsessive-compulsive symptoms are actually quite distinct. A specialized form of cognitive behavior therapy and pharmacotherapy with a potent serotonin reuptake inhibitor are the two established first-line therapies for obsessive-compulsive disorder. An adequate trial of a serotonin reuptake inhibitor is 10 to 12 weeks in duration at doses near the upper end of the recommended range for age and weight. Cases of obsessive-compulsive disorder that do not sufficiently improve with serotonin reuptake inhibitors might benefit from adjunctive low-dose antipsychotic (eg, risperidone) medication whether or not tics are present. Warnings about an increased risk of suicidality among children and adolescents taking antidepressants for pediatric depression extend to those taking the medications for obsessive-compulsive disorder, but the risk-to-benefit ratio is more favorable in this latter population because several serotonin reuptake inhibitors have been shown to be efficacious in obsessive-compulsive disorder.