Although we often think of obsessive compulsive disorder (OCD) as a condition that affects mainly adults, clinical research suggests that between 1% and 2% of children develop OCD. While many of the psychological treatments that work for adults are also effective for children, there are subtle but important differences in the way they are implemented.
Psychological Treatments are Effective
Experts now agree that psychotherapy in the form of exposure and response prevention (ERP) or cognitive behavior therapy (CBT) should be the front-line treatment for children with mild to moderate OCD. While severe cases of pediatric OCD often call for the use of medication, even in those instances treatment outcomes can be often be improved by using psychotherapy.ERP involves exposing you to the anxiety that is provoked by your obsessions and then preventing the use of rituals to reduce your anxiety. This cycle of exposure and response prevention is repeated until you are less troubled by your obsessions and/or compulsions. Although the structure of the treatment may vary, ERP usually involves 15 to 20 exposure sessions that last about 90 minutes. These sessions usually take place at the therapist's office, although you are usually asked to practice ERP at home.
CBT for OCD is based on the idea that distorted thoughts or cognitions cause and maintain harmful obsessions and compulsions. CBT examines these harmful thought patterns and comes up with plausible alternatives that are more realistic and less threatening. Behavioral experiments are sometimes used to gather evidence about thoughts. Like ERP, CBT is usually done over the course of 15 to 20 sessions.
ERP/CBT for children with OCD is very similar to that used with adults; however, the parents are usually involved as co-therapists, the language used is often simplified and there is increased emphasis placed on behavioral, rather than cognitive, strategies. In cases where the child has an autism spectrum disorder or low cognitive function, behavioral strategies, including the use of rewards, may be particularly important.
Barriers to Effective Psychotherapy in Children With OCD
Although psychotherapy is effective, it is important to remember that up to 30% of people either do not agree to begin therapy or terminate therapy prematurely due to overwhelming fear of undertaking exposure exercises. Although this can usually be addressed through gradual increases in the intensity of exposure exercises, some individuals simply are not able to cope with the demands of treatment.Psychotherapy for OCD is also often very expensive, with varying amounts of coverage supplied by third-party insurance providers. Psychotherapy for OCD is often long-term and many families find treatment to be unsustainable.
In addition, many children with OCD do not recognize the excessive or unreasonable nature of the OCD thoughts they are experiencing. Indeed, studies suggest that almost of half of children with OCD have what is called poor insight into the severity and impact of their symptoms. Of course, if someone does not believe there is a problem it is very difficult to engage in the exposure exercises that are part of psychotherapy for OCD.
Finally, family members may be unknowingly or unintentionally reinforcing of OCD symptoms through extensive accommodations, including helping with rituals (e.g., helping to wash hands), providing excessive reassurance around obsessions (e.g., "Mommy looked and your hands are definitely clean") or giving in to a child's demands (e.g., throwing away a perfectly good shirt because it might be contaminated). If psychotherapy is to be effective, reinforcing symptoms has to stop.
Considerations for Parents
As with any illness, a problem must first be properly diagnosed before treatment can begin. Unfortunately, research suggests that many children and adolescents with OCD do not receive a proper diagnosis until they reach adulthood.Potential OCD symptoms in children need to be taken seriously; if there is a suspicion of OCD, the child should be taken to a health professional where a formal clinical assessment can be undertaken. Although the specific themes and/or content of obsessions can differ between children and adults, generally speaking, the symptoms of OCD in children are very similar to OCD symptoms experienced by adults.
Getting the diagnosis right early is important as it reduces suffering, family stress and, importantly, begins the process of the child receiving the necessary psychotherapy for his or her OCD.
Finally, if your child is only offered treatment with medication, be sure to ask about options such as psychotherapy that can be included in the overall treatment plan.
Sources:
Storch, E.A., Bjorgvinsson, T., Riemann, B., Lewin, A., Morales, M.J., Murphy, T.K. "Factors associated with poor response in cognitive-behavioral therapy for pediatric obsessive-compulsive disorder" Bulletin of the Menninger Clinic 2010;74, 167-185.
Mancuso, E., Faro, A., Joshi, G., & Geller, D. "Treatment of Pediatric Obsessive-Compulsive Disorder: A Review" Journal of Child and Adolescent Psychopharmacology 2010; 20, 299-308.
