For children and adolescents living with obsessive compulsive disorder (OCD), medication can be a valuable part of treatment. Supported by the American Academy of Child and Adolescent Psychiatry, the American Academy of Pediatrics, and the International OCD Foundation, medication is considered an evidence-based first-line option for youth.
While medication can be used on its own in some cases, it’s often most effective when combined with Exposure and Response Prevention (ERP) therapy — the leading psychosocial treatment for OCD. Together, these approaches can help young people better manage their symptoms and regain a sense of control.
Treating OCD in youth often requires a different approach than other mental health conditions. Medications are typically started at low doses and gradually increased over time. In many cases, effective treatment involves higher doses and longer timelines — including several weeks of dose adjustments followed by months of maintenance care.
With the right plan and professional guidance, medication can be a meaningful step toward relief and recovery for children and teens affected by OCD.
OCD Medications in Children and Adolescents by Evelyn Stewart, MD
Medications play an important role in pediatric OCD treatment, especially when used in combination with exposure-based cognitive behavioral therapy (CBT). Serotonin reuptake inhibitors (SRIs) are the main medications used to treat child and adolescent OCD. Although they are classified as “antidepressants,” SRIs are also “anti-OCD” medications that increase activity of the chemical serotonin in OCD-related brain regions. SRIs include selective SRIs (SSRIs) and the tricyclic antidepressant clomipramine.
SSRI medications include (brand names and daily dose ranges for pediatric OCD): fluoxetine (Prozac, 10–80 mg), fluvoxamine (Luvox, 25–300 mg), sertraline (Zoloft, 25–200 mg), and paroxetine (Paxil, 5–40 mg). Citalopram (Celexa, 10–40 mg) and escitalopram (Lexapro, 5–20 mg) are the newest SSRIs. Clomipramine (Anafranil) is the most serotonergic and only tricyclic antidepressant used to treat OCD.
There are many SRIs, and poor response to one does not mean that others will not work for an individual. Clomipramine may be helpful for patients who did not respond to SSRIs; however, it may also bring worse side effects. Because of this, a few SSRIs should be tried first.
When to try OCD medications: Medication use is appropriate with at least moderate-to-severe OCD, and when CBT is unavailable, refused, or has had little impact. Medications can also help manage comorbid illnesses that might get in the way of CBT success (e.g., depression). Medications can be used alone, but have better response in combination with CBT.
Before you start taking OCD medications: Before starting an OCD medication, you and your clinician should discuss potential benefits and risks of taking and not taking it, the length of time you may spend on the medication, your expected target dose, and any lingering questions you may have. While you are on the medication, your clinician may measure changes in the severity of your symptoms over time with a tool like the Children’s Yale-Brown Obsessive-Compulsive Scale (CY-BOCS).
Myth buster: OCD medications do not “change who a person is” or their personality. In fact, medications may decrease the bullying and distracting power of OCD and help the person to be “more” themselves.
Which OCD medications will work: SRIs can vary in effectiveness depending on the person. One SRI may be helpful to one person but not another.
The good news is that there are many SRIs, and a poor response to one does not mean that others will not work. This means that people with OCD may try more than one SRI before finding the right “fit.”
Clomipramine may be helpful for patients who did not respond to SSRIs; however, it may also bring worse side effects. Because of this, a few SSRIs should be tried first.
How much OCD medication you should take, and for how long: Typically, children will start taking an SRI at a low dose, which is typically increased every three weeks as tolerated. To maximize chances of success, a healthcare provider will aim towards at least a mid-range dose.
Typical doses of individual SRIs differ from each other due to varying concentrations of their active ingredients (e.g., a mid-dose range is only 10mg for escitalopram but 150mg for fluvoxamine). Dose ranges are similar for OCD in children and adults, although individuals differ in how quickly they digest medications. Overall, doses in the lower SSRI range have less success and mid-range doses are needed for maximal impact on OCD symptoms. Response to the highest doses may be either better or worse than mid-range doses, depending on the individual.
Once you choose an SRI, you should stay on it for 8–10 weeks before deciding if it’s working. If it isn’t effective, you can then consider switching medications or adding another. Once you find a medication and dose that works for you, you should stay on it for 6–12 months. Then, potential benefits and risks of continuing versus stopping it should be discussed, while considering past OCD severity, the risk of relapse, and side effects.
OCD medications are not addictive, but dosage should generally be decreased gradually over months anyway to limit the risk of OCD symptoms returning.
Myth buster: A “golden rule” for psychiatric medication dosing in children is to “start low and go slow”. But over-caution in pediatric OCD is also discouraged. Little OCD improvement occurs beyond the first 10 weeks of taking an SRI, or when restricted to the low dose range.
Side effects of OCD medications: The damage done by OCD to a child’s current and future potential should be weighed against the possibility of side effects when considering treatment. For a specific youth, it is impossible to know ahead of time which, if any, side effects they will experience. Side effects tend to increase with higher doses, but may improve over time as the body adjusts; they disappear after stopping the medication. It is important to be patient and give the medication time to work since OCD improvement generally starts after side effects first appear. A trial-and-error approach is used to find the SRI that works best with minimal side effects for an individual.
Fortunately, SRIs are proven to be very safe for children and adolescents with OCD. Difficulty sleeping, fatigue, restlessness/activation (especially in young children), and diarrhea are the only four side effects reported in pediatric OCD more often with SSRIs than with placebos (sugar pills). Headache and stomach upset are not reported more often, nor is suicidal thinking. In general, sexual side effects are known to occur with SSRIs. Lab testing is not needed when SSRIs are used in advised dose ranges, and citalopram doses in particular should not be raised above 40 mg due to possible heart impacts.
Clomipramine side effects tend to be more troublesome than those for SSRIs, especially at high doses. These may include tremor, weight gain, dry mouth, constipation, blurred vision, dizziness, sexual dysfunction and, rarely, heart rhythm changes. To safely limit the clomipramine dose and side effects, a combination approach has been described in which it is added to fluvoxamine*. After every clomipramine dose change, an ECG test should be done to monitor heart activity. Since blood levels of this medication and its break-down product (des-methyl-clomipramine) influence OCD response and side effects, these should be tested one to two weeks after each dose change (taken 12 hours after the last dose). While SRIs have a black-box warning, risk for suicidal thinking is not increased in treatment of pediatric OCD.
What if SSRIs and Clomipramine Don’t Help Enough: If someone has had inadequate response to SSRIs and Clompiramine, the most effective treatment is to add CBT using ERP to the medication. Another approach is to add an augmenting (“helping”) medication to the SRI, although evidence for this is limited in youth. Second-generation, atypical antipsychotics (SGA) such as risperidone (Risperdal) and aripiprazole (Abilify) are the only SRI add-on medications with strong evidence in adult OCD. Other SRI add-on medications tested in OCD with mixed or limited results act on brain chemicals glutamate, GABA, or at specific serotonin receptors. The anti-inflammatory medication celecoxib (Celebrex) also shows initial promise and is being studied in childhood OCD.
Side effects of add-on SGAs may include weight gain, lipid abnormalities, and motor movements, which should be monitored every six months.
How OCD medications work: OCD is caused by a combination of genetic and many other factors within an individual. Genes inherited from one’s parents impact how the brain grows and functions. In OCD, a circuit loop connecting outside (cerebral cortex) and inside (subcortical / basal ganglia and thalamus) regions of the brain is overactive. “Brakes” (inhibitory pathways) for this loop are powered by serotonin and GABA. “Gas pedals” (excitatory pathways) are powered by glutamate and dopamine. Inflammation may also play a role in OCD, as it does for depression and other illnesses.
As such, it makes sense that medications increasing serotonin (SRIs) and decreasing dopamine (SGAs) help in OCD treatment. Medications targeting GABA and glutamate have had less consistent success in OCD studies, and anti-inflammatories like celecoxib show promise but need further research.
What the research tells us about OCD medications: Thousands of children, adolescents, and adults have participated in OCD medication studies. Recent meta-analyses combining study results have confirmed 10 important facts about pediatric OCD medication:
1) Adding CBT/ERP to SRI medication improves treatment response.
2) Using a placebo pill and/or waiting for time to pass do not make OCD go away.
3) By comparison, serotonin reuptake inhibitors (SRIs) lead to OCD improvement.
4) Clomipramine may perform better than SSRIs.
5) Different SSRIs (e.g., sertraline, fluvoxamine, fluoxetine) have similar success when compared to each other.
6) SSRI side effects in pediatric OCD alone include insomnia, fatigue, activation, and diarrhea, but do not include suicidality, headaches, or stomach pain.
7) SRI doses should be increased to the mid- or high range for best chances of success. *
8) When used alone at typical doses, clomipramine has worse side effects than SSRIs. *
9) With SRIs, improvement of symptoms begins over weeks, with little added benefit beyond two months. *
10) If OCD is unchanged after two SRIs, consider adding an SGA (especially if tics are present). *
(*Based on adult data)
SPECIAL CONSIDERATIONS:
Age: Using medications to treat OCD in preschool-aged children is not typically appropriate. The U.S. Food and Drug Administration (FDA) approves the following SRIs for use in pediatric OCD, using differing minimum ages based on limited available study data: sertraline (six years), fluoxetine (seven years), fluvoxamine (eight years), clomipramine (10 years). Off-label use of other SSRIs is commonplace in treating pediatric OCD.
Comorbidities: Most children with OCD have at least one other psychiatric or medical illness. Potential interactions with current medications, side effect impacts, and prioritizing which disorder to treat first should all be discussed. Fortunately, SRIs are also used in treatment of anxiety disorders and depression. With comorbid anxiety disorder, abdominal pain and headaches are also reported SSRI side effects. With comorbid ADHD, it is advised to focus on OCD first and to observe whether inattentive symptoms resolve, and to improve toleration of ADHD stimulant side effects. With comorbid ADHD and tics, addition of a long-acting alpha-2a agonist such as guanfacine might be helpful. The presence of tics also predicts a poorer response to SSRIs, but a better response to combining an SRI with a SGAs. If heart disease is present, special caution is required when using clomipramine or SGAs.
Acute-onset OCD Subtypes and PANDAS/PANS: See link for more information.
Pharmacogenomic testing: See <LINK> for more information.
LEARN MORE ABOUT OCD MEDICATIONS FOR CHILDREN AND ADULTS:
- Kelty Mental Health Resource Centre
- American Academy of Child and Adolescent Psychiatry (*outdated dosing for citalopram) https://www.jaacap.org/article/S0890-8567(11)00882-3/fulltext
- AACAP Pharmacogenetic Testing Statement https://www.aacap.org/AACAP/Families_and_Youth/Facts_for_Families/FFF-Guide/Pharmacogenetic_Testing-128.aspx#:~:text=To%20obtain%20the%20DNA%20for,body%20might%20process%20a%20medication
- National Institute for Health and Care Excellence (NICE) (2005, reviewed 2014)