The Treatment of OCD in Young Children
By Golda S. Ginsburg, Kimberly D. Becker,
Marcy Burstein, and Kelly L. Drake
Daniel’s Story
Daniel was a 7 year old boy who lived with his parents and two sisters. Daniel had obsessive thoughts about morphing into someone/something else, particularly after eating or touching something he believed was “contaminated.” If the television was on during a meal, Daniel worried that he would turn into one of the television characters. These fears were very distressing for Daniel, who either avoided these situations or performed compulsive behaviors, such as holding his mother’s hand while he ate. He refused to take a bath in “contaminated” water or wear clothes from previous seasons because he feared he would turn into a younger boy. He also worried about sleeping in his bedroom because he thought he would turn into one of his stuffed animals or worried that he would turn into animals he saw on or in his textbook, so he avoided looking at or opening his book.
Michelle’s Story
Michelle was a 3 year old girl who lived with her parents and younger sister. Michelle’s primary OCD symptoms involved strict adherence to order and routines. Michelle compulsively closed all the drawers and doors in her house, arranged her toys in a particular way, and insisted her mother complete their morning routine in a certain order (e.g., get dressed, then eat breakfast). When her mother took her on errands, Michelle insisted they visit stores in a specific sequence. If routines were not followed, Michelle repeatedly asked questions and sought reassurance. Michelle also exhibited an intense desire to be “first” across a number of situations. She had to be first to touch the door when leaving the house, first to reach the top of the stairs, and first to use the bathroom. If she were not first, she became distressed to the point of having tantrums. Michelle also exhibited signs of perfectionism, such that she consistently refused to try something (e.g., games, activities) unless she knew that she would win and/or succeed.
OCD and Families
The stories of Daniel and Michelle illustrate how distressing and impairing OCD can be, even for young children. Yet the impact of OCD extended to their families as well. Daniel’s parents were very distressed by his fears. To ensure that he would not become upset, they turned off the television during mealtimes, held his hand, and made sure that any “scary” objects were out of sight. The family also avoided eating at restaurants so that Daniel would not come into contact with “contaminated” food. Daniel’s refusal to bathe or sleep in his bedroom resulted in arguments with his parents and they allowed him to sleep in their bedroom. The impact of Daniel’s OCD even extended to school, where his teacher removed objects that Daniel indicated were “scary” and kept them in a closet out of view.
Similarly, Michelle’s parents were very concerned about how distressed she became when things were out of order or when routines were not maintained, so they went out of their way to stick to routines at home and in the community (e.g., shopping at stores in Michelle’s preferred sequence). They consistently allowed her to be first and close doors/drawers when she desired, and they provided reassurance when she became upset. At preschool, Michelle’s teachers kept doors closed and allowed her to sit out of novel activities.
It is common for parents and others to try to minimize the burden of OCD by helping their child avoid OCD triggers or by allowing them to engage in compulsive rituals (a term referred to as “accommodation”). As in both cases presented, many families structure their routines and activities so they can help their child avoid anxiety-provoking situations. Indeed, it seems reasonable that accommodating a child’s OCD would decrease their symptoms and allow them to function. However, continued avoidance and/or reassurance can actually maintain OCD symptoms. The good news is that family-based treatments may provide parents with strategies to help manage and reduce their children’s OCD symptoms.
Behavioral Treatment of OCD in Children
Cognitive-behavioral therapy (CBT; namely exposure and response prevention or ERP) is an effective treatment for childhood OCD, yet there are a few reasons CBT may require some modifications in order to be effective for younger children. First, some components of current CBT treatments (e.g., cognitive restructuring) may be too developmentally advanced for young children. Second, because family members frequently make accommodations (e.g., help child avoid OCD triggers) that maintain OCD, it is necessary to teach family members new ways of responding to OCD symptoms. Third, because OCD can cause frustration and conflict among family members, it might be useful to strengthen the parent-child relationship and teach strategies for parental stress reduction and problem-solving. Many CBT interventions do not offer these additional parent-focused treatment components.
At the Johns Hopkins University School of Medicine’s Division of Child and Adolescent Psychiatry, we developed and tested a 12-week family-based CBT intervention to address each of the issues noted above. First, we adapted traditional CBT strategies, particularly psychoeducation and ERP, for use with our sample of young children. Given that it is challenging for young children to follow recommendations independently, parents became co-therapists in treatment, learning ERP and guiding their child’s practice exposure at home. Second, we taught skills to reduce parenting behaviors that are thought to maintain and/or worsen OCD symptoms in children. Third, we taught parents specific strategies to solve problems, reduce family conflict, and strengthen the parent-child relationship through daily one-on-one time.
Our Family-Based OCD Treatment Program for Young Children
The treatment consisted of 12 weekly 1-hour sessions delivered to each family individually. Parents and children attended the first session together and received education about OCD and the CBT treatment model. Additionally, therapists introduced the importance of regular parent-child play time (with child taking the lead) to establish a positive context that would facilitate parents’ ability to change their child’s OC behaviors.
The second and third sessions, attended by parents only, diverged from typical CBT interventions by introducing specific parenting strategies to target OCD. With the help of the therapist, parents “mapped” OCD by describing the situations in which their children experienced difficulties with symptoms. Parents also provided information about their responses to their child’s OCD, particularly with regard to family accommodation (e.g., in Daniel’s case, putting away “scary” objects while he ate). Therapists instructed parents in how to use attention, praise, and other rewards when their child faced his or her fears (e.g., in Daniel’s case, taking a bath), as well as how to reduce OCD-related symptoms by ignoring certain behaviors (e.g., in Michelle’s case, her parents were instructed to ignore excessive reassurance-seeking). Parents and therapists jointly developed a plan to gradually decrease family accommodation and help the child face fears.
Starting with session 4, parents and children participated in exposure and ritual prevention (ERP), or helping the child gradually face his/her fears while refraining from doing their compulsive ritual (e.g., in Daniel’s case, eating a snack while looking at increasingly bothersome pictures in books). This was done both in session and at home. Because of the children’s young age, parental mastery of teaching/coaching their child to engage in exposures was critical and parents were given corrective feedback during the session. To enhance motivation and success, children had the opportunity to earn small prizes for engaging in exposures and special fun time with a parent was scheduled into the family’s daily activities.
Parents attended session 7 alone, and therapists taught parents problem-solving skills to enhance their ability to solve problems effectively and reduce family conflict. Sessions 8 through 10 were attended by parents and children together and involved continued practice with ERP. During session 11, families reviewed the skills they had developed throughout treatment and learned how to plan for future stressors in order to prevent the recurrence of OCD. The final session (12) included parents and children together during which time a final ERP was conducted and treatment progress was reviewed and celebrated.
Closing Remarks
Our program represents a modified CBT treatment that incorporates skills designed to reduce parenting behaviors associated with maintaining OCD symptoms and strategies to improve the parent-child relationship using a family-based format. In our pilot study of seven families, results indicate that the intervention was associated with an average of 44% reduction in OC behaviors. Also, by the end of treatment, parents spent less time supporting, assisting, or allowing children to engage in compulsions. Additionally, parents reported that their child’s OC symptoms caused fewer problems with family activities (e.g., going to restaurants, visiting relatives), social interactions (e.g., playing with a friend, being with a group of people), and completing tasks of daily living (e.g., going shopping, doing chores, grooming). Thus, the treatment led to clinically significant changes in actual functioning. In sum, our study contributes to a small but growing body of work that supports the notion that there are effective family-based behavioral interventions for treating very young children with OCD.
Golda S. Ginsburg, Ph.D. is an Associate Professor of Psychiatry and Director of Research in the Division of Child and Adolescent Psychiatry at The Johns Hopkins University School of Medicine (JHU). Dr. Ginsburg’s research has been funded by grants from the National Institutes of Health and the International OCD Foundation, which funded the pilot study in this article. Drs. Becker, Burstein, and Drake are postdoctoral fellows at JHU and experienced CBT clinicians who have also published numerous articles in the area of child anxiety.
Back to Top