One of the more common mental health diagnoses in children and adolescents is early-onset obsessive-compulsive disorder (OCD). Current prevalence rates range from 1-3%. OCD is defined by its predominant symptoms of obsessions (cognitions) and compulsions (behaviors). Compulsions, either physical or mental, are performed generally to minimize anxiety resulting from the obsessive loops. OCD is cyclic in nature where an intrusive thought pops into one’s mind, increases levels of distress/discomfort due to said thought, and leads to us engaging in a compulsion to reduce the distress. We then may experience relief, “phew, that’s better.” However, a key feature of OCD is that the worry or fear cannot be pushed aside for too long. As Arnold Schwarzenegger has said, “I’ll be back.” And the cycle repeats.
Intrusive thought ➡ Worry/anxiety/fear/distress increases ➡ brain says, “Do something!” ➡ Compulsion
One of the most evidence-based therapeutic treatments for OCD is Exposure and Response Prevention Therapy (ExRP). ExRP involves gradually being exposed to situations that trigger kid’s obsessions and compulsions. During exposures, the child is coached to avoid performing compulsive behaviors for increasingly longer periods of time. This treatment is designed to break two types of associations that occur in OCD. The first one is the association between sensations of distress and the objects, situations, or thoughts that produce this distress. The second association is between carrying out ritualistic behavior and decreasing the distress. The treatment helps to break the automatic bond between anxious/distressing feelings and ritual/compulsive behaviors. It additionally trains the child not to ritualize when they are anxious.
An important aspect of ExRP treatment with children and adolescents is knowledge of what OCD is and what it is not. For this reason, the psychoeducational piece is crucial to the treatment success, as there are several misconceptions about OCD. While some individuals with OCD experience the stereotypical fear of germs and excessive hand-washing behaviors, others do not and still have OCD. Furthermore, there are specific differences in the child presentation versus the adult presentation of OCD. First, children have more difficulty identifying their obsessions due to the metacognitive aspect of the obsession and developmental level. Children additionally can struggle to identify the connection between the obsessional thinking and compulsive behavior. Third, kids are more likely to have fixed beliefs and “magical thinking.” Magical thinking is comprised of irrational thought patterns in which unrelated events are incorrectly linked. For example, “If I don’t hold my breath while I go up the stairs, something bad is going to happen.” All these challenges must be considered when providing ExRP to children and adolescents.
Other considerations for children with OCD include their developmental stage. For example, they may be unaware of the problem and unable to identify or articulate their fear, even when the parent knows something is not right. For this reason, parents have an integral part of EXRP therapy with their child. Often, parents are not aware that they are inadvertently feeding into the obsessive loops or accommodating the behavior, which in turn makes the fear worse. Parents will learn how to recognize and address the fear to extinguish it.
Key aspects of ExRP include teaching kids to tolerate fear (and not avoid situations) and learning their bodies are safe, even when worried. Often, the anticipation of the stressor is more anxiety-provoking than the experience of the actual stressor. The feared consequences likely do not happen. The exposure aspect of ExRP puts us into the feared situation (or enables us to confront it) and the more times we “sit” with the discomfort, the weaker the associated anxiety response becomes. The brain “gets used to it.” OCD is based in doubt and can never be satiated with reassurance, no matter how hard someone tries. Therefore, a different approach to treating the fear is “leaning into it,” as in ExRP. Let’s revisit our pathway above with an ExRP framework in mind:
Consciously thinking of intrusive thought ➡ Worry/anxiety/fear/distress increases ➡ Brain says, “Do something!” ➡ Compulsion
In ExRP, we purposefully engage in the feared thought pattern, behavior, etc. This serves to raise anxiety/distress levels to the point where the child will want to perform the compulsion. But they are instructed not to. The compulsion is not performed to demonstrate that they can have these intrusive thoughts and be okay with them. The moment passes and the more times they “sit” with the discomfort, they habituate to the situation and experience less anxiety regarding the feared or avoided situation. The goal is confidence and flexibility in an uncertain world. With ExRP, the child/adolescent can feel competent and confident rolling with the punches and adapting to our ever-changing world.
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At Cognitive Behavior Institute, several of our clinicians are currently trained and have obtained a higher level of certification in this method of treatment. For more information regarding treatment services for OCD offered through Cognitive Behavior Institute, please visit our website: