Not ‘misbehavior.’ Children—and less commonly adolescents—with this disorder may not view their obsessions as senseless or their compulsions as excessive. Even when insight is clearly present, young OCD patients often hide their symptoms because of embarrassment or fear of being punished for their behavior.
Response predictors. A key to CBT in children or adolescents is that they come to see obsessions and compulsions as symptoms of an illness. The symptoms, therefore, require a skillfully applied “antidote,” as taught by the clinician and implemented by the child, family, and others on the child’s behalf. Besides overt rituals, three response predictors include the patient’s:
- desire to eliminate symptoms
- ability to monitor and report symptoms
- willingness to cooperate with treatment.
Table 1
Pediatric OCD: 4 keys to successful cognitive therapy
| Treat OCD as a neurobehavioral disorder, not a misbehavior |
| Help the child develop a “tool kit” to manage dysphoria and faulty thinking |
| Expose the patient to anxiety-producing stimuli until he or she becomes desensitized and can refrain from the usual compulsive responses (exposure and response prevention) |
| Educate family members and school personnel |
CBT may be difficult with patients younger than age 6 and will invariably involve training the parents to serve as “coaches;” a CBT protocol for patients ages 4 to 6 is under investigation (H. Leonard, personal communication). CBT also can be adapted for patients with intellectual deficits.11
A ‘tool kit.’ Successful exposure therapy for OCD relies on equipping children and adolescents with the knowledge and skills to battle the illness. They often have tried unsuccessfully to resist OCD’s compulsions and must be convinced that EX/RP techniques will work. Using a “tool kit” concept reminds young patients that they have the implements they need to combat OCD (Table 2).
A ‘germ ladder’ and ‘fear thermometer.’
Adam’s tools include a stimulus hierarchy called a “germ ladder,” which the therapist and Adam create collaboratively. It ranks stimuli from low (his own doorknob) to very high (public toilets, sinks, and door handles).
As part of his treatment, Adam begins to touch objects in his room and house while voluntarily refraining from ritualizing. He uses another tool—a fear thermometer—to record his distress level on a scale of 1 to 10 during and after these exposures.
Adam discovers that when he comes into contact with less-threatening items his fear ratings typically return to baseline within 20 to 30 minutes. This insight helps him modify his assessment of the risk they pose.
Table 2
OCD ‘tool box’ can help patients build new behaviors
| Tool | Function |
|---|---|
| Training in exposure response prevention (EX/RP) therapy | Helps patients learn to confront rather than avoid feared stimuli |
| ‘Fear thermometer’ | Enables patients to express the intensity of their distress on a scale of 1 (lowest) to 10 (highest) |
| Positive self-statements | Teaches patients to use statements such as “I can do this” and “I’m the boss of OCD now” to build confidence that they can control their response to feared stimuli |
During office visits, he confronts similar items around the clinic, with the therapist providing encouragement and instruction for additional exposure homework. Eventually Adam works on the clinic’s public bathroom, which he perceived to be relatively clean but less so than his own bathroom. After fear in response to this bathroom is reduced, the therapist and Adam graduate to more-public facilities, such as the bathrooms at Adam’s pool and the local train station.
Exposure therapy. EX/RP is most successful when the child—rather than the therapist—chooses exposure targets from a hierarchy of fears,2 particularly when the list includes behaviors the child is resisting. In a collaborative spirit, the child takes the lead in placing items on the hierarchy and deciding when to confront them.
The therapist and child revise the hierarchy periodically, which demonstrates progress and allows them to add items as the child overcomes fears that cause less distress.
Reducing need for reassurance.
Adam has a habit of repeatedly asking his mother whether contact with particular objects in public is risky. By the third treatment session, he and the therapist agree that he will try to refrain from asking such questions.
His mother, in turn, is asked to reiterate the rationale for response prevention whenever Adam slips. She will offer encouragement and support without answering “OCD’s questions.”
ADJUNCTIVE DRUG THERAPY
While Adam is working with the behavioral therapist to reduce his anxieties and need for reassurance, he is also receiving gradually increasing dosages of sertraline. As discussed, he is considered a candidate for CBT plus medication because of his symptoms are severe. Drug treatment can benefit most pediatric OCD patients.
SSRIs. Two SSRIs are approved for pediatric OCD—fluvoxamine for ages 8 to 18 and sertraline for ages 6 to 18. Most SSRIs are likely effective for OCD in youth (Table 3),12-14 although reports have suggested a link between paroxetine and suicidality in pediatric patients. Other options may be more suitable choices unless further evidence supports the use of paroxetine as a first- or second-line agent for pediatric OCD.