Cognitive Behavior Therapy
Treatment for OCD in children is still being researched. Numerous research studies have shown behavior therapy (BT) to be a very effective treatment for OCD in adults. Although fewer studies have been conducted with children and adolescents, the results have been positive and suggest that this treatment can be as equally successful with youngsters as it has been with adults. In general, behavior therapy is closely based on that for adults, however, the treatment has been modified to make it more appropriate for use with younger patients. In our program at UCLA, we have used this modified version of behavior therapy to successfully treat OCD in children as young as five years of age.
Differences between OCD In Children and Adults
Unlike other disorders, OCD in children and adolescents is quite similar to OCD in adults. For example, the types of OCD symptoms (e.g., washing, checking, arranging, doubting, etc.) and the relative frequency of these symptoms is very consistent across the age range. A few differences do exist between OCD in children and adults, however, and these differences have important implications for treatment. Most of these differences are related to the developmental limitations of younger children as compared to adults. First, the relationship between obsessions and compulsions is much less clear in children than in adults. Most adults are able to describe specific obsessions and to say that the purpose of their compulsions is to make these obsessions go away.
Children, on the other hand, are typically unable to describe specific fears and they often report that they don't know why they do their rituals. Children are also much less likely than adults to describe their OCD symptoms as senseless or unreasonable (i.e., they tend to show poorer insight.) Although youngsters with OCD may say that they don't like having OCD or that their OCD is "stupid" or "icky", they often insist that their rituals are necessary or something that they need to do. From a developmental perspective, young children are more present-oriented than adults, and as a result, are oftentimes less motivated to engage in difficult activities in order to achieve a future reward. This is especially important for children starting behavior therapy for OCD since the motivating aspect of future improvement is likely to be heavily outweighed by the high degree of anxiety and distress associated with the initial treatment exercises. Related to the developmental limitations described above, many children with OCD have poor frustration tolerance and coping skills and when they feel stressed by their symptoms they may respond with shouting, arguing, tantrums, or even aggressive outbursts.
Another difference is that children with OCD are much more likely than adults to involve other family members in their rituals. While mothers are most commonly involved, some children with OCD have developed compulsions which incorporate their entire families. Common examples of family involvement include requiring the mother or father to repeat certain reassuring words or phrases, demanding excessive washing of clothes or other belongings, prohibiting family members from using certain objects or words or from engaging in certain activities that might be upsetting, and not allowing the family to eat certain foods for fear of illness or contamination. If left unaddressed, family involvement can result in distortions in family roles and relationships, negative feelings towards the OCD child by both parents and siblings, and heightened levels of family conflict.
Cognitive Behavior Therapy
Similar to behavior therapy for adults with OCD, cognitive-behavior therapy (CBT) for children with OCD is based on a technique called exposure plus response prevention (ERP). The first step in treatment consists of developing a rank-ordered list of all of the child's fears and rituals along with the situations in which these symptoms are most likely to occur. Following this, youngsters are systematically exposed to these situations starting with the least anxiety-provoking and working up to those that are most difficult. During the exposure, which leads to an initial increase in anxiety, youngsters are encouraged to resist their urges to ritualize. When the feared consequence of not ritualizing fails to occur the child learns that his or her fears are not based on reality and they diminish in intensity. Thus, children learn that their anxiety returns to normal levels even when they don't do their rituals. Through repeated exposures, the child's anxiety and fear decrease further through a process called autonomic habituation. Habituation is a process by which an individual gradually becomes accustomed to something over time. For example, most people living close to an airport will, at first, be greatly bothered by noise from the airplanes. Over time, however, they will gradually get used to the noise and after a few weeks, they may no longer notice the noise at all. In OCD treatment, repeated exposure to obsessions leads to a weakening and oftentimes dramatic reduction in obsessive fears and compulsive behaviors.
Modifications for Children and Adolescents
As described earlier, the original exposure plus response prevention program has been modified to address the unique developmental needs of children and adolescents with OCD. In the program at UCLA, these modifications include an increased reliance on cognitive techniques to facilitate an understanding of the illness and increase motivation for treatment and the use of cognitive coping strategies for dealing with anxiety (hence the name Cognitive Behavior Therapy), the use of charts and graphs to provide visual feedback of progress, the use of behavioral rewards for compliance with in-session and homework tasks, and greater family involvement in therapy. These modifications are described more fully below.
Cognitive restructuring is used throughout treatment to help youngsters change the way they think about their OCD. Children are taught to "distance" themselves from their OCD symptoms in order to manage extreme anxiety during exposure and response prevention exercises. Along these lines, patients learn how to recognize and relabel their obsessive thoughts, urges, and feelings in a more realistic fashion, i.e., "I'm not really going to get sick if I touch this, it's just my OCD talking." In order to increase motivation and resolve towards OCD treatment, children and their families are also instructed to redirect any negative feelings they have about themselves or towards each other to their OCD instead, for example, "When you feel mad at your mom because she won't let you wash your hands, get mad at your OCD instead. It's not your mom's fault, it's your OCD's fault." Within each session and during homework, children graph their anxiety ratings on charts or may use regular graph paper. Graphing provides the children with immediate and easily understood feedback regarding habituation and is also useful in identifying areas of success and difficulty in OCD treatment.
A behavioral reward program, in which children are systematically rewarded for completing in-session tasks and homework assignments is also used to enhance compliance with treatment requirements. This reward program is especially important for younger children who are less able to balance the future benefits of OCD treatment against the increased initial anxiety associated with exposure treatment. As youngsters develop a greater sense of mastery over their symptoms, concrete rewards (i.e., stickers, candy, baseball cards, etc.) are phased out and increased emphasis is placed on praise and encouragement from the therapist and family members. At the end of each session, patients are given daily homework assignments consisting of 30-60 minutes of exposure and response prevention to the situations and objects addressed in session. In the UCLA program, parents and other family members meet with the therapist regularly over the course of their child's treatment. During these meetings, the therapist educates the family about OCD, works with the family to establish guidelines for resisting the OCD child's attempts to include them in his or her rituals, and helps the parents to develop strategies for dealing with any coexisting behavior problems the child may have.
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Credits: Reprinted from the OCSDA Newsletter. J Piacentini, Ph.D. Director, of the UCLA Child and Adolescent OCD Program in the Division of Child and Adolescent Psychiatry at the UCLA Neuropsychiatric Institute.