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Allison Powell

Prof. Hughes

English Comp II

12 April 2019

The Best Treatment for Obsessive-Compulsive Disorder in Children

“Step one. I walk into the classroom with my head tilted down at a 45-degree angle. I

raise my eyes just enough to see my own feet. Doing this will keep the fluorescent overhead light

from interrupting my field of vision. I tell myself to simply avoid looking at any bulbs. I can’t

risk a migraine. There is a lamp in the room that is shorter than the rest, so I’ll be sure to sit with

my back to it. I really can’t risk a migraine. Now, for step two… I just need to go to the desk

with the dullest surface possible and claim it so that I don’t get stuck with a shiny desk. I can’t

risk a migraine. Step 3… I pull out my new textbook and spiral notebook. My textbook’s pages

are hospital-bright-white so I’ll be sure to only open it when absolutely necessary, tilting it away

from the overhead light before looking down. I’ll have to open my spiral notebook before

looking as well. The last thing I need is to see neon green in the morning. I can’t risk a migraine.

Even worse than the color, the notebook has a reflective sheen, so it simply isn’t worth the risk.

Finally, now that I have my supplies in place and a visually-safe workstation, I can go ahead and

sit down. It’s a good thing I showed up early so nobody witnessed that routine. I just need to take

deep breaths. I can’t risk another migraine today.”

Those thoughts and rituals are just a few of the many that controlled my life throughout

my childhood and teenage years. However, I wasn’t always preventing migraines. I also felt that

I was preventing others from dying, preventing my family from falling apart, and preventing

many other terrible things that no child should ever have to ruminate over. I began to struggle
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with these cycles of worries and compulsions from the time I learned to speak. My family

noticed strange habits, but had no idea what was going on inside my head. Being a child, I lacked

the self-awareness to understand that my internal rule-book didn’t line up with reality and wasn’t

a doctrine that I needed to obey. Shortly after graduating from high school, I learned that there

was a name for the 15-year internal battle that I had been facing. It was called Obsessive-

Compulsive Disorder. With this realization came very much reflection. I’ve often looked back

and wondered what could had been done to alleviate the symptoms and their impact on my life

earlier, when the obsession-compulsion cycles began, at the young age of three.

There is great debate over what the best method is for treating OCD in children. The

answer to the question “which is the best,” is of course, subject to the individual being treated,

their family members, and a variety of other factors at play. However, one particular treatment

option, Cognitive-Behavioral Therapy, stands out as the golden treatment for Obsessive-

Compulsive Disorder in children. Cognitive-Behavioral Therapy (CBT), a form of psychological

treatment involving the changing of thinking and behavioral patterns, is the best treatment

method for childhood Obsessive-Compulsive Disorder due to its insurmountable efficacy,

adaptability to developmental stages, opportunity for constructive family integration, lack of risk

to the child’s health and safety, and long-term life enhancement that cannot be provided by a pill.

OCD is a chronic and functionally impairing disorder marked by distressing symptoms

involving obsessions, or unwanted intrusive thoughts, and rituals to compensate for the thoughts

that take up a great deal of time and cause the sufferer significant distress (Krebs and Heyman 1).

According to the American Psychiatric Association, obsessions are “unwanted and involuntary

obsessional thoughts, impulses or images” (qtd. in Mantz and Abbott 1). The content of

obsessions varies depending on the individual, but some themes are found more frequently than
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others. The APA lists the most common themes of obsessions including: “concerns regarding

contamination with dirt or germs, concerns about symmetry, forbidden or taboo thoughts (e.g.,

sexual, religious, aggressive), and fear that harm may come to oneself or others” (qtd. in Mantz

and Abbott 1). The obsessions are typically followed by intense anxiety that the individual

attempts to reduce by performing compulsions. Compulsions are mental acts or ritualized

behaviors that the person feels compelled to carry out in response to an obsession. Compulsions

are also variable depending on the individual, but common themes can be seen including

cleaning behaviors such as hand-washing, repeating, ordering and counting rituals, and checking

behaviors. OCD is often thought of to be a disorder most typical in adults. However, the

prevalence of the disorder in adults seems to be due to its chronic nature, with most cases having

a start much earlier, in childhood.

Fig. 1. This image shows the cycle of obsessions and compulsions present in Obsessive-

compulsive disorder (Soule).

Obsessive-Compulsive Disorder affects as many as 1-3% of children (Walitza et al., 1).

Children with OCD can suffer devastating consequences of the disorder as it often results in

functional impairment, conflict in the family, and poor quality of life. According to the findings
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of a study by Piacentini et al., the two areas most affected by OCD-related dysfunction were

functioning at school and trouble with homework (1). Such consequences can have detrimental

impacts not only on school performance, but on the individual’s mental health as well. When all

of their mental energy is directed towards the obsessions and compulsions, there is little left over

for the things that make childhood so great, such as spending time with friends and using their

imaginations in more enjoyable ways. To make matters worse, these detrimental effects are not

exclusive to a small percentage of only the most severe OCD cases. Effects that drastically lower

a person’s quality of life are actually present in nearly every case of the disorder. In fact, in

Piacentini et al.’s study of 151 children with OCD, almost 90% reported at least one severe

OCD-related dysfunction (1). Around half of the participants reported significant impairments at

home, in school, and in their social lives (Piacentini et al. 1). Every case of OCD is inherently

troubling, causing serious problems that often are not understood by others. Because such severe

symptoms typically have an onset in childhood and rarely remit on their own (often actually

getting worse), effective and efficient treatments are essential (McGuire et al., 1). When deciding

on a treatment for a chronic and debilitating disorder, such as OCD, it is crucial to aim for a

treatment that is beneficial relatively quickly but also capable of providing lasting effects for

many years.

The general consensus in regards to treating Obsessive-Compulsive Disorder in children,

similarly to adults, is that the two best treatment options are Cognitive-Behavioral Therapy and

Selective Serotonin Reuptake Inhibitors/Serotonin Reuptake Inhibitors (SSRIs/ SRIs), a form of

medication commonly prescribed to treat depression. Studies have shown the improvement of

OCD symptoms in children with medications such as SSRIs. Many clinicians and researchers

agree that they can be effective and they are often highly recommended in combination with
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CBT when treating adults with OCD. However, cases involving children with OCD, especially

those as young as 4 years old, need to be considered even more carefully in regards to the

benefits and risks associated with pharmaceutical treatment. It is important to consider non-

pharmaceutical treatment options when treating children with psychological problems. This

holds especially true when research shows that a therapeutic option with zero risk may actually

be more effective than the riskier medication that is often prescribed.

Cognitive Behavioral Therapy is based on several core principles including the idea that

psychological problems are based on the individual’s unhelpful ways on thinking, and that the

problematic thinking is based, partially, on learned patterns of unhelpful behavior. The third

principle is the belief that unhelpful ways of thinking and behaving can be reframed and that

better ways of coping can be learned, thus leading to a reduction in symptoms of that person’s

psychological problem/disorder (APA). CBT focuses on this reframing and relearning of

thinking patterns and behavior patterns, giving the sufferer the tools they need to be more

capable of living a happy and healthy life. CBT treatment typically involves efforts in “changing

thinking patterns and in changing behavioral patterns” (APA). The changing of thinking patterns

in OCD could include learning to recognize distorted, obsessive-compulsive thinking, or magical

thinking, and then reevaluating it in light of reality. The changing in behavioral patterns often

involves facing one’s fears in an exposure treatment, and refraining from carrying out

compulsions or rituals to relieve the anxiety experienced following an exposure. Exposure

Therapy, or Exposure and Response Prevention (ERP), is the method of CBT that has shown to

be the most effective (Foa 1). Exposure and Response Prevention is a specific subtype of

Cognitive-Behavioral Therapy that involves the introduction of a feared stimuli, followed by the

client refraining, or attempting to refrain from performing a compulsion. The goal of ERP is to
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gradually and systematically expose the client to a feared stimulus and to retrain their automatic

response of compulsions/rituals by having them attempt to not engage in them. They are often

encouraged to learn to sit with the anxiety, letting the feeling be present, rather than pushing the

feeling away by performing a compulsion. The levels of exposure severity can be paced in

different ways including graded exposure, flooding, or systematic desensitization. Graded

exposure involves having the client rank feared stimuli (objects, activities, or situations)

according to the level of difficulty/anxiety produced. Flooding involves starting with the most

difficult/most feared stimuli. Systematic desensitization involves the combination of relaxation

methods with exposures, retraining the brain to associate more manageable feelings of relaxation

with the feared objects or situations (“What is Exposure Therapy” 1).

Cognitive Behavioral therapy is the top treatment option for plenty of reasons, but the

most apparent is that it simply works. And it works exceptionally well. A meta-analysis by

McGuire et al., examining treatment efficacy, treatment response, and symptom/diagnostic

remission for youth with OCD receiving either Cognitive-Behavioral Therapy or Serotonin

Reuptake Inhibitors, found that CBT had a response rate of 68%, while SRIs had a response rate

of 50% (9). The study also found there to be little to no difference in treatment response rates and

remission rates for CBT, which may suggest that the reductions in symptom severity seen after

CBT typically meet symptom/diagnostic remission, rather than only providing temporary

benefits (McGuire et al. pp.9). This study reveals that CBT not only significantly reduces

obsessive-compulsive symptom severity, but also showed maintenance of symptom reduction for

up to seven years after initial treatment (9).

A treatment with such a high level of effect longevity is unheard of in the pharmaceutical

realm of OCD treatment. In fact, treatment using SSRIs only lasts as long as the bottle of pills is
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full. The effects do not last when a patient discontinues the medication. Long-term benefits in

OCD symptoms have been observed after the use of SSRI medication as well. However, the

long-term effects are only seen in conjunction with a maintenance medication. Reemergence of

the symptoms is likely to occur after discontinued use according to McGuire et al. (3). Further

evidence of CBT’s long-term efficacy can be seen in a study by Barret, Farrell, Dadds, and

Boulter (2005) that found that 70% of child and adolescent participants receiving individual CBT

and 84% of those receiving group CBT maintained their improvements at 18 months after

treatment and no longer met the diagnosis for OCD (ctd. in Mantz and Abbott 7). A symptom

reduction significant enough for a client to no longer meet diagnosis requirements is yet another

result that could not be achieved with medication alone.

Such successful treatment results are seen with Cognitive-behavioral Therapy because it

is a method that gives the child being treated essential cognitive “tools”, has long lasting effects,

and is adaptable. The only tool required for the child to have in treatment and in treatment

maintenance is the child’s very own brain. Skills learned in CBT are skills that the child can

always refer to when things get tough. Jerry Bubrick, PhD, a senior clinical psychologist in the

Anxiety Disorders Center and director of the Obsessive-Compulsive Disorder Service at the

Child Mind Institute, describes the power of CBT as a treatment method, saying, “What we are

teaching children (and their parents, who are essential allies in fighting their OCD) is skills to

counter and master the fears that have come to dominate them”(6). He explains that although it

takes a great deal of commitment and repetition, Cognitive-Behavioral Therapy, specifically with

Exposure and Response Prevention allows both the child and their family to have a sense of

control over the disorder. It allows the disorder to be seen in a way that is much more

manageable and much more trainable. Bubrick explains further: “Exposure and Response
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Prevention therapy (ERP) involves a lot more work than taking a pill to reduce anxiety, but it

trains kids in skills they can use for the rest of their lives when they find themselves in danger of

slipping into obsessive-compulsive patterns” (6). Cognitive-Behavioral Therapy has proven to

have levels of symptom remission and reports of long-term results that no other treatment option

can provide. These are two outcomes that are desperately needed for sufferers of OCD,

especially children. Because OCD is a chronic illness with an onset that typically occurs in

childhood, early action in treatment is crucial.

Also important to OCD treatment, in children specifically, is adaptability. CBT is a

therapeutic technique that is highly adaptable to the child’s developmental stages and levels of

cognitive understanding- from young childhood through adolescence. Because a child’s

cognitive functioning goes through many developmental changes in a short amount of time, all

while being at the core of the obsessions and compulsions, a treatment program capable of

adapting to these changes is essential. One way CBT allows for this is by its ability to

incorporate the family into therapy for young OCD sufferers.

A benefit that is unique to CBT is its ability to incorporate the most influential aspect of a

child’s life into the treatment program: their family. The role of family, especially of parents, in a

child’s treatment is important because they are often key parts of the child’s obsessions and

compulsions. As a result of their vital role in the child’s life and in their disorder specifically,

parents and family members are capable of either aiding in treatment or accommodating

unhealthy behaviors (McKay and Kennedy 181). For example, if a child is afraid that one of their

parents will die, their compulsion may be to seek reassurance by asking how the parent is feeling.

When the parent complies and gives constant reassurance, the child’s compulsion (reassurance

seeking) is reinforced. This fuels the cycle of obsessions and compulsions. Even though the
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parent may not intend to worsen the severity of the child’s unhealthy thinking and behaviors,

treatment will inevitably be slowed down or halted if the obsession-compulsion cycle is fed fuel

by those close to the child. Knowledge of the family system and its role in the child’s OCD helps

to minimize damage, but even better than knowledge is integration.

Integration of the family is possible through Family-Based Cognitive-Behavioral

Therapy. Similar to typical CBT, the focus remains on thinking and behavioral patterns, but more

specifically on the patterns at play within the family. Siblings are often involved, learning about

the OCD cycles at play, as well as learning how to live with a sibling that is suffering from the

disorder. Throughout treatment, parents have an important role, serving 3 purposes. According to

Freeman et al., “First, parents are trained as coaches for their children and play a key role in

shaping treatment and ensuring adherence and motivation outside the session. Second, including

parents directly addresses parents' tendency to accommodate their child's OCD behavior. Third,

treatment has an “exposure” function for parents as well because they are asked to tolerate their

own distress in the face of assisting their children with often upsetting exposure exercises and

homework tasks”(Freeman 3). The study Freeman et al. used this method for, a family-based

CBT on over 100 different child-family subjects, found that children experiencing early

childhood–onset OCD greatly benefited from this treatment method due to its focus on the family

and the developing cognition of the child. The CBT program was effective in both decreasing

OCD symptoms and, more important, helping a large number of children, 69%, achieve a clinical

remission (Freeman 3).

When choosing a medication of a therapeutic treatment method for a child, it is important

to consider the risks involved in the different options. Safety or the child should always come

first when treating psychological problems, or so one would hope. However, a systematic review
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and meta-analysis by Locher et al., Including 36 trials with a total of 6778 participants, found

that although SSRIs showed improvement compared to those not treated, the use of SSRIs also

led to a significant increase in treatment-related risks such as suicidal ideation, suicide attempts,

as well as study discontinuation due to various adverse events” (pp. 4). Locher states, “There is

some evidence for the benefit of SSRIs in children and adolescents, but owing to the higher risk

of severe adverse events, a cautious and individual cost-benefit analysis of risk is important” (4).

With risks as severe as these, it is hard to imagine a potential outcome that would make the risk

“worth it,” if the case of OCD being treated does not have deadly risks on its own. However,

treatment with SSRIs is often chosen and sometimes preferred over CBT and other

psychotherapeutic methods without even attempting them first. This is dangerous and also brings

forth the question: If the majority of childhood OCD cases are not severe enough to take drastic

measures, rushing toward symptom reduction, then why should typical cases of OCD be treated

in a way that poses unnecessary risk? In the majority of cases of childhood OCD, why choose an

option that is high-risk, potentially moderate-reward, when there is a therapeutic treatment option

that is low-risk high-reward?

The only risk involved in CBT is the emotional vulnerability that is key in healing. The

risk is purely emotional, rather than physical, as the client is letting go of control and subjecting

his/herself to an anxiety-provoking situation. This “risk”, taken in a controlled, therapeutic

environment with a licensed professional, can hardly be considered a true risk in comparison to

the those associated with medications such as SSRIs. Seeing all of the positives, along with the

lack of negatives, it is difficult to imagine that there is any kind of debate between the better

treatment method overall.

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Obsessive-Compulsive Disorder in children, although identical in diagnostic criteria to

OCD in adults, should be researched and treated with special care due to the young ages it

affects and the severe risks associated with unnecessary medications. Highly effective and

beneficial beyond even the most used medication group, SSRIs, Cognitive Behavioral Therapy

has proven again and again to be the optimal treatment for OCD in children. CBT is an adaptable

treatment, capable of fitting the developmental needs across all ages and having higher, longer-

lasting effects than any other treatment- all while posing zero risk to the child’s safety.
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Works Cited

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(5th ed.). Arlington, VA: American Psychiatric Publishing.

Bubrick, Jerry. “Why Behavioral Therapy Is the Best Way to Treat OCD in Kids.” Child Mind

Institute, https://childmind.org/article/behavioral-therapy-treat-ocd-in-kids/. Accessed 17

March 2019.

Foa, Edna B. “Cognitive behavioral therapy of obsessive-compulsive disorder” Dialogues in

clinical neuroscience, vol. 12,2 (2010): 199-207.

Freeman, Jennifer B et al. “Early childhood OCD: preliminary findings from a family-based

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adolescents.” Archives of disease in childhood vol. 100,5 (2014): 495-9.

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Disorders Among Children and Adolescents A Systematic Review and Meta-analysis.”

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McGuire, Joseph F., et al. “A Meta-analysis of Cognitive Behavior Therapy and Medication for

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