Assessment and treatment of OCD in youth is much more nuanced than a top-down extension of approaches to OCD in adults, for good reason. What are some of the fundamental ways in which cognitive-behavioral approaches to juvenile OCD differ from their adult counterparts? How do juvenile OCD doctors adapt to the large differences between younger children and adolescents?
1. Consider the process of presentation and evaluation of symptoms
Parents may report concerns about repetitive or rigid behaviors that are normative of younger children’s development, especially during times of stress or transition. A young child who insists on completing a bedtime routine with specific steps in a particular order may appear to exhibit ritualistic behavior, but OCD symptoms are often more severe, persistent, and associated with interference with functioning. Additionally, young children often have sensory-related or incompleteness symptoms, such as hitting or fixing something repeatedly until it seems “just right.”
Because young children are less likely to identify the content of obsessive thinking and the function of their compulsions, it may be helpful to assess compulsions before obsessions. Parental report is often especially important at younger ages; However, the opposite is often true for adolescents who have greater awareness of their internal experience but may not communicate symptoms to parents due to feelings of shame, particularly when the obsessive themes concern sexuality, religion, and aggression. . Doctors can help normalize these symptoms by providing specific examples using candid language in a neutral tone of voice. For example, to assess aggressive obsessions, a doctor may ask: “Have you had thoughts that you could hurt someone, such as pushing a family member down the stairs or stabbing them with a knife?” Clinicians can increase the chances of obtaining an accurate picture by conducting at least part of the assessment with adolescents individually and being explicit about protecting privacy beyond immediate safety concerns.
2. Tailor treatment approaches to cognitive abilities and developmental level
For children under 9 years old, consider emphasizing behavioral approaches and parental responses to OCD symptoms rather than cognitive interventions. Younger children often need more guidance to identify and challenge negative expectations. Metaphors are especially useful in helping younger children understand abstract concepts relevant to the treatment focus. For example, engagement with OCD can be framed as a rigged game of tennis to help younger children understand the need to free themselves from compulsions, since OCD always returns the ball harder and the only Way to beat OCD is to drop your racket and stop playing. the game. Additionally, consider providing concrete examples that introduce limited amounts of information, using developmentally appropriate language, and checking the youth’s level of understanding before introducing additional information. Clinicians may need to more directly monitor how younger children manage spontaneous intrusive thoughts, as the need to resist compulsions may not generalize from planned exposures.
Adolescents are likely to understand more abstract concepts related to cognition. Although it may be tempting to use the same metaphors and approaches to externalizing OCD that work well with younger children, adolescents are often more receptive to content typically used with adults. Clinicians can demonstrate awareness and respect for adolescents’ advanced cognitive abilities by using more sophisticated language, examples, and visuals.
3. Approach motivation and goals differently
It is a challenge to motivate young people who have less knowledge of their symptoms and those who may not consider the benefits of treatment to be worth the substantial effort required. Younger children, especially, may benefit from extrinsic motivators or rewards to support their participation in therapeutic work. For example, a young child may earn rewards such as choosing what dinner the family has for dinner or what movie they watch on the weekend for their efforts to resist compulsions and participate in exposure between sessions.
Teens’ desire not to be naïve, mocked, or taken advantage of can be harnessed to encourage them to choose actions that are not dictated by OCD. For example, clinicians can appeal to adolescents’ growing sense of independent thinking and skepticism by pointing out, “You wouldn’t let another debater get away with an argument like that. Why does it sound more convincing coming from OCD?” Adolescents are also particularly sensitive to potential threats to their autonomy. Consider how treatment may compromise perceived autonomy and identify ways to join the adolescent in her work to overcome OCD. It may be helpful to pay close attention to young people’s own values and identify concrete examples of how OCD interferes with their lives in ways they would like to change. Clinicians can also help address discrepancies between parents’ and youth’s goals by framing treatment as a collaborative process in which youth, clinicians, and parents work together against OCD. It may be particularly important to emphasize with adolescents seeing the patient as an expert on their own OCD.
4. Involve families and schools
Parental involvement is a key difference in the treatment of juvenile OCD, and the degree of involvement often varies depending on the developmental level of the youth and how coping parents are with the symptoms. Naturally, younger children are more dependent on their parents and engage in an automatic process of asking for and receiving reassurance. Clinicians are tasked with evaluating whether these patterns maintain OCD symptoms and the developmental appropriateness of parental responses. Parents of younger children are often fully integrated into the treatment approach to help them develop skills that replace accommodation behaviors when necessary.
Adolescents may benefit from greater independence and ownership over treatment that comes with less parental involvement. However, some may require parental support to implement out-of-session exposures, and parental adaptation may still be quite high at older ages. Clinicians often need to model direct approaches and train parents on how to identify and change responses when parents have difficulty tolerating the discomfort that comes with reduced accommodation, the current accommodation is extensive, or the parent’s own perception is limited. Many other factors within the family system could also interfere with treatment and may need to be addressed, within or beyond the family component of OCD treatment, including the role of siblings, caregivers’ own physical and mental health, and family conflicts.
Beyond parental involvement, clinicians may also find it necessary to collaborate with schools to align educators with the treatment approach. Symptoms of OCD that teachers often see include avoiding touching objects, going to the bathroom too long and frequently, spending too much time on schoolwork, and seeking reassurance. Youth whose symptoms interfere with the classroom or lead them to avoid school especially benefit from coordinating care with schools. In summary, clinicians who provide OCD treatment to developmentally informed youth are engaged in unique efforts that also provide exceptional opportunities to change the trajectory of OCD and its impact across the lifespan.
Additional information from the Anxiety in the Classroom resource center on addressing OCD and anxiety in schools can be found here: Strategies in the classroom
For families seeking help for juvenile OCD: Lumate Health