Child Psychology and Psychiatry

Challenges in child and adolescent obsessive-compulsive disorder
Who is
responsible
for care?
What is the focus?
Type of
care
Step 6
CAMHS Tier 4
OCD with risk to
life, severe neglect,
or severe distress
or disability 
Reassess,
discuss options
and care
coordination.
As per Step 4
and consider
augmentation
strategies,
admission or
special living
arrangements
Step 5
CAMHS Tiers 3 & 4
OCD with
significant
comorbidity, or
more severely
impaired
functioning and/or
treatment
resistance, partial
response or relapse 
Reassess, discuss
options.
As per Step 3 and
consider referral to
specialist services
outside CAMHS if
appropriate
Step 4
CAMHS Tiers 2 & 3 
OCD with
comorbidity or
poor response to
initial treatment 
Assess, review, discuss
options.
CBT (including ERP),
then consider combined
treatments of CBT
(including ERP) with
SSRI, alternative SSRI or
clomipramine
Step 3
CAMHS Tiers 1 & 2 
Management and
initial treatment 
Guided self-help, CBT
(including ERP), involve
family/carers and consider
involving school 
Step 2
CAMHS Tier 1
Recognition and
assessment
Detect, educate, discuss treatment
options, signpost voluntary support
agencies, provide support to young
people, families/carers/schools.
Refer if necessary 
Step 1
Individuals, public organisations, NHS
Awareness and
recognition
Provide, seek and share information
about OCD and its impact on
individuals and families/carers
Figure 26.1
NICE (National Institute for Health and Clinical Excellence) stepped-care model for
obsessive-compulsive disorder (OCD) in children and adolescents [22]. CAMHS, child and adolescent
mental health services; CBT, cognitive—behavioural therapy; ERP, exposure and response-prevention;
SSRI, selective serotonin reuptake inhibitor. Adapted from NICE Guideline 31, The Stepped-Care Model
2005.