Medication for Pediatric OCD

The best treatment for pediatric OCD includes both medication and a type of cognitive behavioral therapy (CBT) called exposure and response prevention (ERP) therapy. Medication should only be considered when there are moderate to severe OCD symptoms. Click here to learn more about ERP and therapeutic approaches used to treat OCD.

If you child does not initially respond to ERP, your pediatrician or psychiatrist may decide to try medication to help manage symptoms and to potentially lower anxiety enough that your child can try ERP therapy again with more success.

The information provided below is meant for information only to help you make an informed decision together with a physician or psychiatrist experienced in treating OCD in kids and teens. Any decision to start or stop taking medication or change dosages should always be discussed with your prescribing physician.

When should medication be considered for children with OCD?

Both ERP and medication effectively treat OCD in children and adolescents. Their use is supported by the treatment guidelines of the American Psychiatric Association (APA) and the American Academy of Child and Adolescent Psychiatry (AACAP). Medications should only be considered when there are moderate to severe OCD symptoms and when exposure and response prevention (ERP) has not worked to treat symptoms.

What kind of medications can help treat OCD in children?

Antidepressants are usually the first kind of medication that a doctor will try. Your doctor might refer to these medications as “serotonin reuptake inhibitors” (SRIs).

SRIs include:

  • Citalopram (Celexa®)
  • Escitalopram (Lexapro®)
  • Fluvoxamine (Luvox®)
  • Fluoxetine (Prozac®)
  • Paroxetine (Paxil®)
  • Sertraline (Zoloft®)
  • Clomipramine (Anafranil®)

Will medication “cure” my child’s OCD?

OCD medications control and decrease symptoms, but do not “cure” the disorder. OCD is usually well controlled when proper treatment is in place. Symptoms often return when the child stops taking the medication, especially if he or she has not received ERP therapy.

How long does it take for OCD medications to work?

All OCD medications work slowly. It is important to not give up on a medication until it has been taken at the right dose for 10 to 12 weeks. Studies have also shown that improvement of childhood OCD can continue for at least a year after starting medication.

Are these medications approved for use in children?

Only four OCD medications have been approved by the United States Food and Drug Administration (FDA) for use in children: clomipramine (Anafranil®), fluoxetine (Prozac®), fluvoxamine (Luvox®) and sertraline (Zoloft®), but doctors can prescribe any OCD medications to children if they feel it is needed.

What dose is typically used?

The best dose of OCD medication should be determined on an individual basis by your prescribing physician. Children should start at a lower dose than adolescents. However, OCD symptoms often require the use of higher, adult-sized doses. This is important since most doctors are used to using lower doses for treating depression and anxiety, but that may not work for OCD. If the child has difficulty swallowing pills, a liquid or other version may be available.

The following dose ranges may be necessary:

  • Fluvoxamine (Luvox®): 50-300 mg/day
  • Fluoxetine (Prozac®): 10-80 mg/day
  • Sertraline (Zoloft®): 50-200 mg/day
  • Paroxetine (Paxil®): 10-60 mg/day
  • Citalopram (Celexa®)*: 10-40 mg/day*
  • Escitalopram (Lexapro®): 10-20 mg/day
  • Clomipramine (Anafranil®): 50-200 mg/day

* The FDA has issued some warnings on the use of citalopram in doses higher than 40mg. Please check with your physician.

Which OCD medication should be tried first?

A child’s response to each of the OCD medications varies. No two children respond in the same way. In general, clomipramine (Anafranil®) is not usually tried first because of its side effects.

Factors that may guide the medication choice include:

  • Positive response to a certain drug by other family members
  • Presence of other disorders
  • Potential for side effects
  • Cost or availability

How helpful are these medications?

In the largest child OCD treatment study to date (POTS) [1] remission (absence of any major symptoms) occurred in about 1 in 5 children on medication and in more than half of those with medication and cognitive behavior therapy (CBT). In addition, many more children had improvement (but not full remission). Some patients will have no response at all, which does not mean that other medications will not help.

Are there side effects?

Every type of drug has potential side effects, which must always be weighed against its benefits. In general, SRIs have been found to be safer than clomipramine (Anafranil®). Some more common side effects include:

  • Nausea or stomach upset
  • Inability to sit still
  • Sleepiness or insomnia
  • A heightened sense of energy
  • Weight gain

Clomipramine (Anafranil®) may also cause:

  • Drowsiness
  • Dry mouth
  • Racing heart (requiring EKG monitoring)
  • Concentration problems
  • Problems with urination
  • Weight gain

Your doctor may decide to add a low-dose of fluvoxamine to limit the side effects of clomipramine. They will also need to monitor blood levels if using clomipramine.

For all antidepressants in children and adolescents, the FDA has issued “black box warnings” about associated suicidal thoughts and urges. The highest risk period for this is when starting or increasing the dose of the medication. However, a recent study found no increase in suicidal thoughts or behavior from pediatric OCD groups studied.

Are there permanent side effects?

These medications appear very safe with long-term use and side effects typically reverse when the medications are stopped. There is no current evidence that they do permanent damage to the body.

What happens if the first OCD medication my child tries doesn’t work?

It is important to understand that if the first medication does not improve OCD, another one should be tried. Trying several OCD medications at high enough doses for long enough periods (10–12 weeks) may be needed. Many people have better results if ERP is added to medication treatment. If a medication and ERP don’t work, combining more than one medication may be tried.

Will my child have to take these medications forever?

Many doctors suggest that OCD treatment should continue for at least one year even after symptoms have stopped. Unfortunately, OCD drugs do not “cure” the illness. When medication is stopped, symptoms often return within a few weeks to months, especially if your child has not received ERP therapy. If symptoms return, most children will respond well after restarting the medication.


Sources:

  • [1] The Pediatric OCD Treatment Study (POTS) Team. Cognitive-Behavior Therapy, Sertraline, and Their Combination for Children and Adolescents with Obsessive-Compulsive Disorder: The Pediatric OCD Treatment Study (POTS) Randomized Controlled Trial. JAMA, 2004; 292(16): 1969–1976.