Experts ID best screening tool, treatments for OCD in children

BySara Kellner

Fact checked byCarol L. DiBerardino, MLA, ELS

Key takeaways:

The eight-question Child Behavior Checklist-Obsessive Compulsive subscale was the most effective screening tool.
Exposure response prevention with or without an SSRI should be the first-line treatment for OCD.

Researchers identified the most effective screening tools and treatment options for children with obsessive compulsive disorder, according to the results of two meta-analyses published in Pediatrics.

Obsessive compulsive disorder (OCD) affects roughly 3% of youth, according to Gaelen P. Adam, PhD, MPH, MLIS, research scientist at the Brown University School of Public Health, Dale W. Steele, MD, MS, professor of emergency medicine and pediatrics at the Warren Alpert Medical School of Brown University, and colleagues.

DocConsult — Researchers identified the most effective screening tools and treatment options for children with obsessive compulsive disorder. *Image: Adobe Stock.*

“Early identification and effective treatment of OCD is important to prevent a cascade of developmental disruptions lasting into adulthood that can affect both function and quality of life, particularly in academic and social domains,” they wrote.

The researchers performed two meta-analyses based on data from the Agency for Healthcare Research and Quality’s systematic review and meta-analysis of 117 studies about OCD diagnosis and treatment that was published in December 2024. One analysis compared brief assessment tools used by primarily by primary care providers, and the other evaluated different treatment options.

Screening tools

In the first meta-analysis, the researchers investigated 22 studies comparing nine types of assessments used to detect OCD in children.

The Child Behavior Checklist-Obsessive Compulsive subscale (CBCL-OCD) — a questionnaire that parents fill out — had the most support, Adam told Healio. The screening tool — or a version of it — was evaluated in nine studies.

Two studies reported the accuracy based on percentiles with a sensitivity — the ability to identify OCD — of 98% and a specificity — the ability to rule out OCD — of 41% for scores in the 40th percentile. The sensitivity was 30% and specificity was 100% for CBCL-OCD scores in the 90th percentile.

Six studies that used an eight-question version of the CBCL-OCD reported that the questionnaire “may be sufficiently sensitive and specific to prompt specialist referral,” according to the authors. The summary area under the curve was 0.84 (95% CI, 0.74-0.91), according to the authors. The other three studies tested the accuracy of subscales with different numbers of questions, with AUCs ranging from 0.74 to 0.96.

Most of the other assessment tools were evaluated only in one or two studies, according to the researchers. However, Adam said three appeared to be sufficient with sensitivity and specificity above 80%: the Toronto Obsessive Compulsive Scale, the Obsessional Compulsive Inventory-Child Self Report, and the Spence Children’s Anxiety Scale-Obsessive Compulsive Subscale.

“Future studies should ideally be prospective cohorts, enrolling a consecutive sample of patients for whom there is clinical concern for OCD,” Adam said. “Comparative accuracy is best assessed by directly comparing two or more index tests in the same study.”

ERP most effective treatment

Steele, Adam and colleagues also analyzed 109 publications, including 71 randomized-controlled trials, to compare five different OCD treatments:

exposure and response prevention (ERP);
remote ERP;
selective serotonin reuptake inhibitors (SSRIs);
ERP with SSRIs; and
clomipramine.

They evaluated the effectiveness through change in Children’s Yale-Brown Obsessive Compulsive Scale (CY-BOCS) scores, where a change of 4 to 5 points is considered clinically significant. They also compared each treatment to one of three types of controls: pill placebo, waitlist or behavioral control.

ERP, which is a form of cognitive behavioral therapy, performed the best, according to Steele and colleagues. ERP reduced OCD symptoms significantly more than behavioral control (net mean difference [NMD] = –5.3; 95% CI, –8 to –2.7) or waitlist (pooled NMD = –10.5; 95% CI, –12.6 to –8.4). Remote ERP was also significantly more effective compared with waitlist (NMD = –9.4; 95% CI, –11.9 to –7). There was no clinically significant difference between remote or in-person ERP, the authors found.

Children with OCD were more likely to reach remission with ERP compared with behavioral control (RR = 2.7; 95% CI, 1.2-6). Compared with the waitlist groups, in-person and remote ERP increased participants’ odds of achieving remission (RR = 8.2; 95% CI, 3.7-18.5, and RR = 7.9; 95% CI, 3.5-17.5, respectively).

Both SSRIs and clomipramine were superior to placebo (pooled NMD = –4.4; 95% CI, –6.1 to –2.6; and –4.5; 95% CI, –6.8 to –2.1, respectively), Steele and colleagues reported. They did not find a clinically significant difference between SSRIs or clomipramine for reducing symptoms or achieving remission.

ERP and ERP with SSRIs appeared to be more effective than SSRIs alone (pooled NMD = –2.7; 95% CI, –5.4 to 0; and –3; 95% CI, –5.1 to – 1, respectively), according to the researchers. ERP with SSRIs was not significantly more or less effective than ERP alone.

Clinical takeaways

For screening children for OCD, the researchers concluded that the eight-question CBCL-OCD was the most effective tool.

“While the diagnosis of OCD requires an expert clinical evaluation, our review found one tool, the CBCL-OCD, had the most support,” Adam told Healio. “This tool may allow clinicians to spot potential signs of OCD earlier, facilitating referral for a comprehensive diagnostic evaluation and early initiation of treatment.”

There was insufficient information about other brief assessments, according to the researchers.

The authors recommended ERP as a first-line treatment children with OCD with or without SSRIs. They also pointed out that remote ERP is more effective than being on a waitlist for in-person treatment, and it may increase access for children who do not live near a trained ERP provider.

“We found ERP, delivered in-person or via telehealth, to be as effective as antidepressants (SSRIs and clomipramine) and ERP (alone or in combination with SSRIs) to be more effective than treatment with SSRIs alone,” Steele told Healio.

Steele said future research should include children from racial and ethnic minoritized groups and those of lower socioeconomic status to be more representative of all youth affected by OCD.