Obsessive Compulsive Disorder Responds Well to Cognitive Behavioral Therapy 5

By Lourdes Valdés, Ph.D.

For Samantha to study, her notebook must be exactly aligned with the edge of the desk. She must line up all books on her desk in height order. Her pens and pencils must be lying down next to one another, and they must be aligned with the edges of the desk. Samantha knows this is silly, but she just can’t seem to stop herself.

Each time Jenny says goodbye to someone she loves, she must kiss them on the left cheek, then on the forehead, and then she must say, “See you later, alligator” (in that order). She worries that if she does not do that, something terrible will happen to them.

Every morning in the car, Preston must ask his mother three times if he is going to have an okay day at school, and his mother must say “yes, of course” all three times. If his mother says anything else, he will become very upset.

Sarah gets very upset if her mother stirs her chocolate milk towards the right instead of the left.

Michael must be perfect at school. He must make perfect letters. His clip must stay on green at all times. He must only make “A” grades. If he is not perfect, he must do it over and over again until he gets it perfect. The helpful mistakes that we all make when learning so upset Michael that it is hard to acquire new skills.

Over one million children and adolescents in the United States have obsessive-compulsive disorder (OCD). Obsessions are thoughts that are irrational, intrusive, repetitive, and seemingly uncontrollable to the person who is experiencing them. Compulsions are actions; impulses to repeat an irrational act or behavior over and over again. Sometimes compulsions develop to try to relieve obsessions. Jenny in the example above has an obsession with the idea that something terrible might happen to someone she loves. Her OCD has also developed a compulsion—her goodbye ritual—to prevent the tragedy that she worries about. Scientists believe that OCD runs in families. They believe the symptoms are due to communication disruptions between the front part of the brain and the deeper structures.

Children and adolescents with OCD may have difficulty finishing homework, doing chores, or making friends. Their disorder takes up so much of their time and energy. As in the examples above, those with OCD often engage family members as part of their rituals. Parents and teachers easily become impatient with these children, and can perceive their behavior as defiant or oppositional. When this happens, people around the child can feel very frustrated, and interpersonal struggles with the child may ensue. Children with OCD ofren feel ashamed. They are aware that what they do seems silly to others, but they feel unable to stop.

Despite all its seeming intractability, OCD responds very well to treatment. OCD is particularly responsive to cognitive behavioral therapy (CBT). In fact, this is the single most effective treatment for OCD. Cognitive behavioral therapy works by giving children effective tools to manage their anxiety while gradually and gently allowing exposure to the very things that make them anxious. These tools might include relaxation, breathing training, positive self-talk, imagery, and habit reversal. Children and their families learn techniques such as “talking back to their OCD.” They then practice their skills in a safe environment before they try them out at home or school.

As much as possible, clients guide the treatment. They set goals, determine which behaviors will be easier and harder to manage, and decide which are tackled first. With the therapist’s guidance, they determine how far to push themselves. Feeling that they are in control of their treatment helps children, who often feel very out of control, feel comfortable and safe. Knowing that they played a key role in their treatment plan enhances their feelings of accomplishment when they achieve success with OCD. The child’s family is always an important part of the treatment since families are often very involved with OCD symptoms. .

A child’s developmental level, specific symptoms, and needs tailor the treatment. At the beginning of her treatment, Samantha learns about OCD. Then, she will familiarize herself with relaxation and distraction techniques. She may also learn to rate her perceived anxiety on a scale from 1 to 10. Samantha may then imagine that she is doing a homework assignment and that the notebook is not quite perfectly aligned with the edge of the desk. She may rate her anxiety and then engage in a relaxation exercise to try to bring that number down. Once her anxiety is low and she can easily tolerate imagining the notebook where it is, Samantha will bring her actual homework to the therapy session. She will then begin practicing in the room. The next step may be to use her strategies while imagining studying in her room with all the pens and pencils “out of place.” Treatment will slowly and gently progress until Samantha is comfortably doing her homework with all materials at various angles from the edge of the table. Soon, she finds that she can study without first organizing everything on her desk. In fact, she can study in the library and at friends’ houses. At that time, the next compulsion or obsession is then tackled.

CBT is not the only treatment available for OCD, but recent studies have found that CBT alone meets and exceeds the effects of medication alone. However, in combination, CBT and medicine provide a very powerful treatment. I use a multimodal approach to assess and treat OCD. I treat the thoughts that maintain the obsessions, and the family that is affected by the disorder. By learning specific tools that they can use to beat their OCD, children like Samantha, Jenny, Preston, Sarah, and Michael can and do become competent managers of their health.