Treating obsessive-compulsive disorder in children and adolescents: a therapist's manual

1. The programme at a glance

Indication. Obsessive-compulsive disorder (OCD) in children and adolescents aged 7 to 17, the age range of the major trials, with at least one parent able to take part in treatment. Young children aged 5 to 7 call for an adapted format, centred even more on the parents (section 38).

Reference model. Cognitive behavioural therapy with exposure with response prevention, conducted with the family: the child gradually comes into contact with what triggers their obsessions, without carrying out the ritual that relieves them, and without a parent carrying it out for them. It is the treatment of choice of the National Institute for Health and Care Excellence (NICE), the British institute that issues good practice guidelines, when the impairment is moderate to severe (National Institute for Health and Care Excellence, 2005). The programme follows the four stages of the March and Mulle (1998) protocol, from which the therapy used in the POTS trials derives (Pediatric OCD Treatment Study [POTS] Team, 2004; Freeman et al., 2009): explaining, teaching the child to fight back against the OCD, mapping their symptoms, and exposure. It adds explicit work on family accommodation, that is, everything the family does, out of love, to relieve the child or to carry out the rituals in their place (Lebowitz et al., 2012).

Format. Fourteen 60-minute sessions, the first lasting 90 minutes, over twelve weeks: two a week for the first two weeks, then one a week, as in the POTS protocol (Freeman et al., 2009); the Nordic study, conducted in ordinary services, also had fourteen (Torp et al., 2015). Sessions 3 and 8 are reserved for the parents, the first and the last are held with the whole family, and the others end with the parents joining. This arrangement is a choice made by the programme and has not been evaluated as such: in POTS, the parents attended sessions 1, 7 and 11 (section 13). Three booster sessions follow, at one, three and six months.

Mechanism targeted. That the child discovers, by doing the opposite of what the OCD orders, what the ritual prevents them from learning: what the OCD announces does not happen, and the discomfort ends up passing, or can be borne. And that their parents stop carrying out the rituals in their place, which would make this discovery impossible at home.

Session	Focus	Session output
1	Assessing with three voices	Baseline measures, risks checked, worksheet 1 handed over
2	Understanding the OCD, and giving it a name	Name chosen, circle drawn, thermometer learnt
3	Parents' session: what the OCD makes the family do	Accommodation listed, first withdrawal dated
4	The OCD map and the ladder	Ladder rated, hidden rituals and questions listed
5	The first challenge	First challenge done in session, prediction tested
6	Challenges at home, and parents as coaches	Week's challenges written down, parents' role agreed
7	The questions, and the progress review	Severity scale repeated, plan for the questions
8	Parents' session: holding firm when the OCD gets angry	Crisis plan written, second withdrawal dated
9	Climbing the ladder: "not just right"	Challenge from the top of the ladder sustained
10	Thoughts that frighten or shame	Challenge on a thought, without neutralising
11	School, friends, the outside world	Challenge outside the consulting room, page for the teacher
12	Becoming their own coach	Challenge chosen and led by the child
13	Preparing for what comes next	Warning signs and what to do if the OCD returns
14	Review, plan and celebration	Measures repeated, plan written, boosters scheduled

The programme's vocabulary. The OCD's name is the nickname the child gives their disorder so as to treat it as an external opponent (section 34). The thermometer is the 0 to 10 scale on which they rate their discomfort or their urge to carry out the ritual. The ladder is the exposure hierarchy: the situations in which the OCD gives orders, from the easiest to the hardest. A challenge is an exposure with response prevention exercise, chosen with the child and prepared in advance (section 32). The coach is the role asked of the parents: encouraging and holding the frame, without doing either the ritual or the challenge in the child's place (section 33).

What the person takes away. Eight printable worksheets (section 40): five for the child or adolescent, two for the parents, one for the teacher.

What distinguishes this programme from the other manuals on this site. The parents are part of the treatment, with two whole sessions devoted to accommodation, which Treating obsessive-compulsive disorder in adults: a therapist's manual does not provide for. The work focuses on preventing rituals, including mental rituals and rituals in the form of questions to the parents, which sets it apart from the graded exposure of Treating anxiety in children: a therapist's manual. And one section sets out what is established, and what is not, about the PANS and PANDAS hypotheses.

2. Before you begin

The four preliminary decisions

Is it really OCD? Many young children have rituals that are not part of any disorder, and many anxious children ask questions without having rituals. The sorting is done in session 1, with sections 3 and 8.

Was the onset abrupt? OCD that appeared within a few days, especially alongside other new symptoms, calls for a medical examination, which does not delay therapy (section 11).

Does a risk come before everything else? Suicidal ideation, food or fluid restriction linked to fear of contamination, complete withdrawal from school, violent crises at home: each has its course of action in section 10.

Can a parent commit? The programme assumes that at least one parent attends sessions 1, 3, 8 and 14 and the end of the other sessions, and that they agree to change what they do at home. Otherwise, treatment remains feasible with the child alone, but this must be said, because accommodation that continues goes with a poorer outcome (section 5).

What this programme does not treat

OCD in adults, which belongs to Treating obsessive-compulsive disorder in adults: a therapist's manual, a manual that may also suit an older, independent adolescent whose parents no longer take part in the symptoms. Tics, hair pulling and skin picking, which have their own manuals: Tics and Tourette syndrome: a therapist's manual and Trichotillomania and excoriation disorder: a therapist's manual. Preoccupation with a flaw in appearance, which belongs to Body dysmorphic disorder: a therapist's manual. A medically dangerous situation, such as a child who is barely eating or drinking any more (section 10). A parent's OCD, which calls for care of its own (section 35).

How to use it

Read the whole thing before session 1, in particular sections 5, 6, 32 and 33: that is where treatment succeeds or fails. Every session follows the same framework: the aim, the steps, what you say, common mistakes and the criterion for moving on. Adaptations for age are in section 38, and the three most frequent therapist drifts, explaining without exposing, reassuring and leaving the parents on the sidelines, are in section 41.

Warn the parents from session 1 that they will probably find it harder than their child to let the treatment do its work, since they will be asked to stop doing what they have been doing for months to calm the child. Knowing this keeps them from concluding, on the first difficult evening, that the treatment is doing harm.

3. Four presentations not to be confused

When parents describe repeated actions or endless questions, four situations arise, and they do not call for the same course of action.

The normal rituals of childhood. A child of two to five always wants the same cup, the same story in the same order, and protests when the bedtime routine is changed. These behaviours are common, especially around the ages of two, three and four, and then decrease (Evans et al., 1997). They give way when one insists a little, they soothe or give pleasure, they do not take hours, and the child is not distressed when they cannot be carried out. They call for information, not treatment: saying so to worried parents is an intervention in itself.

Obsessive-compulsive disorder. Thoughts, images or sensations force themselves on the child and worry them, and the child feels obliged to carry out actions or mental operations so that the worry stops or so that some misfortune does not happen. Compulsion, distress when the ritual is prevented, the time consumed and the family's involvement point towards this diagnosis, which belongs to the programme described here.

Anxiety with reassurance seeking. The child worries about real things, their parents' health, school, the future, or cannot bear separation, and asks questions in order to be reassured. Their worries concern plausible subjects and change with what is happening in their life, without rituals of form such as counting, touching, repeating or washing until a precise sensation is reached. This belongs to Treating anxiety in children: a therapist's manual or Treating anxiety in adolescents: a therapist's manual; when it coexists with OCD, the ladder in session 4 covers both.

The repetitive behaviours of autism, and tics. The former are sought out or soothing and do not respond to a worrying thought; they call for a developmental assessment. Tics, brief and sudden movements or sounds, are preceded by a sensation in the body, not by a thought, and are not aimed at preventing a misfortune; they belong to Tics and Tourette syndrome: a therapist's manual. Both can coexist with OCD (sections 8, 9 and 35).

The three sorting questions

"What would happen if you didn't do it?" It brings out the obsession, or the feeling that something is "not just right". A young child may not know how to answer: DSM-5-TR allows for this, and it does not rule out the diagnosis (section 7).

"Do you like doing it, or do you feel you have to?" It separates compulsion from pleasure or habit.

To the parents: "What do you do when it happens?" It brings out accommodation, which is almost always present and rarely mentioned at the outset.

4. OCD in children and adolescents, as it is observed

The symptoms. The themes are those of adults: contamination, a misfortune for which one would be responsible, order and symmetry, lucky or unlucky numbers, scruples, aggressive or sexual thoughts experienced as horrible. Many children fear no catastrophe at all: they feel that something is not "just right" and repeat until the sensation goes away, which is treated somewhat differently (session 9). Mental rituals, praying, counting in one's head, replacing a bad image with a good one, and avoidance, such as no longer going to the school toilets, are not reported by the child, who does not see them as rituals: they have to be looked for (session 4).

What varies with age. In a comparison between children aged 3 to 9 and young people aged 10 to 18, the youngest had markedly poorer insight into the excessive nature of their symptoms and more often had collecting and hoarding rituals; the oldest more often had sexual obsessions, checking, counting rituals and associated depression (Selles et al., 2014). The young child describes what they do; the adolescent often hides what they think.

The parents take part. In a study of 65 families, reassurance and participation in rituals occurred daily among 56% and 46% of parents respectively (Peris et al., 2008).

OCD hides at school and erupts at home. Some children hold back all day, then catch up on their rituals in the evening: the parents describe a child they no longer recognise, and the school sees nothing. Mornings, homework, meals and bedtime concentrate the rituals and the accommodation, and provide the first targets.

Crises. Preventing a ritual, or refusing to take part in it, triggers tears, anger and sometimes violence in many children: in a survey of 122 parents of children with OCD, 62% reported at least one behaviour of this kind, linked to the OCD, occurring often or always (Guzick et al., 2019). These crises do not mean that the child is oppositional: they mean that the ritual has been prevented.

The onset is most often gradual, with rituals that spread and parents who adapt without realising it. An onset within a few days is a different presentation (section 11).

5. What maintains the disorder

The ritual and avoidance bring relief. The ritual brings the worry down, and that immediate relief reinforces it: the next time, the urge comes sooner and more strongly. Above all, it prevents the child from discovering that the announced misfortune would not have happened and that the discomfort would have subsided on its own; the child attributes to the ritual the fact that nothing happened, and, from their point of view, they are right, since they have never tried otherwise. Avoidance produces the same effect without even letting the worry appear, and gradually shrinks the child's territory.

Family accommodation. This is the most characteristic mechanism of childhood: the family takes part in the rituals, facilitates avoidance or changes its habits to relieve the child (Lebowitz et al., 2012). A paediatric study concludes that it is the norm (Peris et al., 2008), and a meta-analysis of 41 studies finds a moderate association between accommodation and OCD severity (Wu et al., 2016). Each time a parent carries out the ritual, answers the question or spares the child the situation, the child is relieved without learning that they could have done without it, and even learns that their discomfort requires an adult; the parent, relieved that the crisis has stopped, will repeat the action the next day. In a trial of family therapy, the fall in accommodation preceded the improvement in OCD (Piacentini et al., 2011), and in another study, its reduction during treatment predicted the outcome, independently of baseline severity (Merlo et al., 2009). This is the foundation of sessions 3 and 8.

The crisis that makes the parent give in. When a parent refuses to take part, the child protests; if the parent ends up giving in, the crisis stops. The child learns that the crisis ends the refusal, the parent learns that giving in ends the crisis, and the next time the crisis comes sooner and more strongly. This is not a failure of parenting, it is learning, and it is undone by holding firm, with warmth, for longer than the crisis lasts (session 8).

The meaning given to thoughts. In adolescents especially, believing that having thought of a misfortune makes it more likely, or that one would be responsible for it if one had done nothing, maintains the disorder. This cognitive model is presented in section 4 of Treating obsessive-compulsive disorder in adults: a therapist's manual; with children, it is worked on more simply, and above all through experience (section 34).

These mechanisms form the circle you draw with the child in session 2.

---