OCD Treatment for Children and Teenagers

I just had the honor of attending the OCD Foundation’s first-ever Behavior Therapy Training Institute on Pediatric OCD, which was held at Rogers Memorial Hospital in Wisconsin in mid-September. The treatment for children and teens with OCD is not all that different from adults. The main components of OCD treatment include:

• Education/Rapport Building (what is OCD? building the client’s trust)
• Cognitive Therapy (motivation, naming and externalizing the OCD, responding to content vs themes, etc)
• Exposure and Response Prevention (identifying triggers and gradually exposing the child until anxiety declines)
• Family Therapy (teaching parents how to help their child)
• Contingency Management (setting up a reward plan to increase motivation)
• Relapse Prevention (what to do at the early signs of anxiety or stress)

While we do use cognitive strategies especially for motivation with children, we emphasize behavioral strategies even more with children. Children often aren’t able to articulate the thoughts driving their rituals. They may say “I don’t know” or “It just feels right” or “I can’t help it.” As children and teens mature, it may seem their OCD is becoming more sophisticated because they start attributing reasons to why they do things.

When we are assessing OCD in children, teens or adults, the process is the same. The therapist will be thinking about these factors:

• Triggers: What stimuli trigger the obsession?
• Obsession: What is the core fear?
• Compulsions: How does the person attempt to neutralize the obsession?

There are four main steps in designing a personalized OCD treatment program for your child or teen.

Step 1: Define the Obsessions and Select the First Target Obsession to Work on

First, we need to determine if the thought is an obsession. If your child has a strange or irrational thought and can dismiss it, it’s not an obsession. Normal people have intrusive thoughts but the difference is that people without OCD do not attribute much meaning to them. Most people just shrug it off as a strange thought and go on with their day.

People often confuse the obsessions associated with OCD with the worries associated with Generalized Anxiety Disorder. It’s a worry if the content focuses on everyday problems that cause stress. GAD often has the same obsessional, repetitive feel to it except the theme of the worries are about real problems happening in the child’s life such as school, health, friends or family issues. An obsession, in contrast, is an intrusive, repetitive thought with senseless content. In children, common obsessions include doing things repeatedly until it feels “just right,” bad thoughts about sex or violence, superstitious thinking, and irrational concern about germs.

Step 2: Identify the Obsessions/Triggers and related Compulsions

Next, we need to identify the compulsions (rituals) that go along with the obsessive thoughts and what triggers the obsessive-compulsive cycle. External triggers are easier to work with because they are things, people, places or situations that scare people and trigger the OCD cycle. The types of OCD that usually involve external triggers include contamination, just right/not right obsessions, and doubt and uncertainty

Internal triggers, on the other hand, are the thoughts themselves, usually about sex, violence and blasphemy. For a thought to be a trigger, the thought itself must be perceived by the person as being dangerous. There are two categories of thoughts that people perceive as being toxic: the fear that having the thought can make it happen and/or the fear that having thought means something bad about the person who is experiencing the thoughts.

Step 3: Develop the Exposure Hierarchy

Exposure and Response Prevention (ERP) is the gold standard for treating OCD in all age groups. ERP is teaching you and your child an approach to life. Your child will learn that when something makes him afraid, he will face it. He will learn to approach his fears systematically through the Exposure Hierarchy. To develop a hierarchy, we will identify all the internal and external triggers for the obsessions and rank order them by level of difficulty. We will then proceed by working with you and your child in baby steps to approach their fears. We’ll use the feeling thermometer to help your child rate the difficulty of tasks. We will ask the parent to serve as the child’s ERP coach to help remind your child to practice their exposures during the week.

Step 4: Identify Response Prevention Guidelines for the Compulsions

The final step is to identify the compulsions (rituals) and to develop Response Prevention Guidelines that sound like this:
“When I get urge to (do my ritual), I will resist the urge and do this instead: XYZ.”

There are two categories of compulsions: Behavioral vs. Mental. Behavioral compulsions are things you can see your child doing such as washing, checking, reassurance seeking, straightening, etc. Mental compulsions are done in the child’s head and you may not even know they are doing them. These include counting, praying, figuring things out, replacing bad thoughts with good thoughts and mental checking.

We also need to determine if the compulsions are non-functional vs dysfunctional. Non-functional compulsions (rituals) are behaviors have no function other than to reduce anxiety related to OCD anxiety. Since these are non-sensical behaviors (like tapping three times on a door), our treatment plan will focus on eliminating these behaviors entirely because they have no function.

Dysfunctional compulsions (rituals) are excesses of normal behavior. We can’t completely eliminate these behaviors because done in moderation, they are normal behaviors like normal washing normal checking and normal prayer. For these, we help your child develop new rules for normal behavior.

During planned daily exposure time there is a schedule and specific tasks to be completed each day. Planned exposure time is generally 30 min to one hour per day. We’ll teach your child to engage in the obsessive thought while resisting the urge to ritualize. We will teach them that “When I get urge to …., I will resist the urge and do this instead …” We will also do some cognitive restructuring work where your child will learn to accept and even welcome anxiety and uncertainty by purposely choosing to expose himself to his triggers, knowing this will trigger his obsessive thoughts and urges to neutralize the anxiety with rituals.

The rest of the day, the child is taught how to deal with spontaneous exposures, or when the obsessive thoughts are triggered outside of planned exposure time. Again, we will teach your child that “When I get urge to …., I will resist the urge and do this instead …” We will help him learn to try to resist doing the compulsion and to focus on what he needs to doing instead (doing homework, watching TV, listening to music, paying attention in class, talking with friends, etc). The child will also have a list of guidelines to follow for any dysfunctional compulsions he may have an urge to do.

The key to Exposure and Response Prevention is to be ready to face your fears and to do your homework every night. You and your child will learn to ride up and down the OCD anxiety hill and beat OCD.