• Diagnosis of Obsessive Compulsive Disorder (OCD)
  • Nine brief assessment tools were identified, but only one had sufficient evidence to draw conclusions. Thus, the available evidence is insufficient regarding the diagnostic accuracy of most brief assessment tools.
  • The 8-question version of the Child Behavior Checklist-Obsessive Compulsive subscale (CBCL-OCS) probably has sufficient diagnostic accuracy to identify symptomatic patients for specialist referral and comprehensive diagnostic evaluation of OCD, with a summary area-under-the-curve of 0.84 (moderate SoE).
• Treatment of OCD
  • Cognitive behavioral therapy with exposure and response prevention (ERP) is more effective than waitlist control (high SoE) and probably more effective compared to behavioral control for OCD symptoms, remission (moderate SoE), and more effective for global severity and family accommodation outcomes (high SoE)
  • Cognitive behavioral therapy with exposure and response prevention (ERP) provided via telehealth is more effective than waitlist for OCD symptoms (high SoE), remission (moderate SoE), and family accommodation outcomes (low SoE)
  • Cognitive behavioral therapy with exposure and response prevention (ERP) provided via telehealth is as effective as in-person ERP for OCD symptoms (high SoE), and may be as effective for global symptoms (low SoE)
  • Treatment with a selective serotonin reuptake inhibitor (SSRI) is more effective than placebo control for OCD symptoms and global severity outcomes (high SoE).
  • Treatment with ERP is probably more effective than treatment with an SSRI alone for OCD symptoms (moderate SoE)
  • Treatment with ERP and an SSRI is more effective than treatment with an SSRI alone for OCD symptoms (moderate SoE).
  • Treatment with ERP with an SSRI is probably equivalent to ERP alone for OCD symptoms (high SoE)
  • Treatment with the tricyclic antidepressant clomipramine may be more effective than placebo control for OCD symptoms (moderate SoE), but equivalent to treatment with an SSRI for OCD symptoms (high SoE).
  • The side effects of SSRIs and clomipramine were inconsistently reported, precluding graded conclusions.
  • Treatment with D-cycloserine to augment ERP is not more effective than ERP alone in reducing OCD symptoms (high SoE) and is probably not more effective in reducing global OCD severity (moderate SoE).
  • Studies were consistent in failing to find statistically significant associations between treatment effects and age, sex, baseline Child Obsessive Compulsive Impact Scale (COIS) score, baseline Family Accommodation Scale (FAS), or comorbid autism spectrum disorder or tics. Studies were inconsistent regarding the association between treatment effect and baseline OCD severity as assessed by CY-BOCS.

Background. Obsessive-compulsive disorder (OCD) is a common, chronic, and impairing psychiatric disorder affecting about 3% of youth (children and adolescents). Early identification and treatment of OCD is important to prevent a cascade of developmental disruptions lasting into adulthood. The 2012 AACAP Practice Parameter recommends cognitive behavioral therapy that incorporates exposure and response prevention (ERP) as a first-line treatment for mild-to-moderate OCD in youth, and recommends combined treatment with ERP (if feasible) and a selective serotonin reuptake inhibitor (SSRI) for some patients, particularly those with more severe symptoms. Clinical uncertainty exists regarding the optimal treatment strategies (and treatment combinations) that work best for specific populations and settings. In this report, we seek to evaluate the accuracy of brief assessment tools to identify OCD in symptomatic youth (KQ1) and the effects and harms of treatment options for youth with OCD (KQ2).

Methods. We searched Medline®, Cochrane, Embase®, CINAHL®, and ClinicalTrials.gov from inception to July 6, 2023. After double screening, we extracted study data, risk of bias assessments, and conducted network and pairwise meta-analyses. We evaluated the strength of evidence (SoE) using standard methods. The protocol was registered in PROSPERO (registration number CRD42023461212).

Results. We found 115 studies (reported in 158 papers) that met inclusion criteria. Of these, 31 cross-sectional studies pertained to KQ1, diagnosis of OCD. For KQ 2, treatment of OCD, we included 69 randomized controlled trials (RCTs), 2 nonrandomized comparative studies (NRCSs), and 13 single-arm studies that reported potential treatment effect modifiers. For KQ1, there is insufficient evidence regarding most brief assessment tools. Based on nine studies, the Child Behavior Checklist-Obsessive Compulsive subscale (CBCL-OCS) may have sufficiently high sensitivity and specificity to identify patients for specialist referral and diagnostic evaluation (moderate SoE). For KQ2, meta-analyses indicate that in-person ERP is more effective than waitlist for OCD symptoms (high SoE; moderate SoE vs. behavioral control), for remission (moderate SoE), for global severity (high SoE), and for family accommodation (low SoE). ERP via telehealth is more effective than waitlist for OCD symptoms (high SoE), remission (moderate SoE), and family accommodation (low SoE). SSRI is more effective than placebo for OCD symptoms and global severity (high SoE). Clomipramine is probably more effective than placebo (moderate SoE). ERP and SSRI vs. SSRI is probably more effective than treatment with an SSRI alone for OCD symptoms (moderate SoE). The side effects of SSRIs and clomipramine were inconsistently reported, precluding graded conclusions. Augmentation of ERP with D-cycloserine is as effective as ERP alone to reduce OCD symptoms (high SoE) or global severity (moderate SoE). The evidence was insufficient regarding potential effect modifiers.

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