Cognitive-Behavioral Therapy for OCD in Children and Teenagers

Aureen Pinto Wagner, Ph.D.

Since the 1990’s, scientific studies have repeatedly shown that OCD in children can be successfully and safely treated with cognitive-behavioral therapy (CBT)—specifically, exposure and response prevention (ERP). CBT has a 65- to 80-percent success rate with youngsters, similar to the success rate with adults.

CBT is based on the premise that OCD is maintained and exacerbated because rituals and avoidance provide relief from anxiety. For instance, when 8 year-old Casey touches crayons, he worries about poison. He quickly washes his hands and then feels much better. Casey soon learns that washing his hands lessens his anxiety. However, Casey’s OCD is worsened by washing his hands because it prevents him from learning that his obsessions are unrealistic, and that his anxiety will subside naturally.

ERP teaches youngsters with OCD to face their fears to test their reality while refraining from rituals. It helps them realize that their obsessive fears do not come true and that the anxiety they experience subsides as a result of autonomic habituation. ERP for Casey would involve having him face his fear that the crayons are “poisonous” by touching them and not washing his hands afterwards.

CBT is widely considered the treatment of choice for children with OCD. However, it is estimated that the majority of children and adolescents with OCD do not receive CBT, due to the limited number of clinicians with expertise in CBT for OCD with youngsters. Therapists who treat youngsters with OCD must understand the unique needs and cognitive capabilities of children. Often, the therapist may be challenged by the child’s reluctance to engage in ERP because he thinks that facing his fears without performing rituals will simply be too scary and impossible. Children who are not properly prepared for how ERP works and what it entails are more likely to become ambivalent or afraid, withdraw from exposures, and refuse to practice.

The therapist must find a way to help the child get past the discomfort of giving up rituals that seem to protect him against overwhelming fears. To do that, the CBT therapist must use a child-friendly approach that cultivates treatment readiness before rushing into ERP. An important part of treatment readiness is helping children and families understand how rituals and avoidance strengthen OCD, that OCD is overcome by confronting fears (exposure) to learn that they are false alarms, and experiencing habituation (getting used to the anxiety).

Metaphors, analogies and games can be useful in helping children understand these concepts. When youngsters understand how exposure and habituation work, they are more willing to tolerate the initial anxiety experienced during ERP, because they know it will increase and then subside. Active parent involvement in the child’s treatment is also important. CBT is a collaborative treatment, with therapist, parents and child working together as a team to overcome OCD.

A CBT treatment plan is designed to improve the overall well being of the child, not just his obsessions and compulsions. The child may need treatment to help rebuild social skills, improve self-esteem, family relationships and academic functioning. OCD symptoms should generally be treated first, unless other issues interfere with the treatment. For example, severe depression or family conflict may need to be treated before a child can engage in CBT.

If you are a licensed clinician and wish to receive training in CBT for OCD, learn more about the BTTI.