Pediatric OCD can be very severe and debilitating. In such cases, an intensive treatment program is often the most effective plan.
What makes a child’s OCD severe enough to warrant an intensive treatment program?
The basic elements of severity include how much distress the child is in; how much of their day symptoms take up; and the extent to which OCD is interfering with school, social, and family functioning. In some cases, children may not be able to verbalize distress accurately, but it can often be noticed in their demeanor and behavior. It is common for children with severe OCD to be frustrated and take it out on their family members, including siblings.
Other children with severe OCD symptoms primarily withdraw, look very sad, and don’t want to participate in their usual fun interests. Assessment of OCD severity is also done more formally during an evaluation using instruments such as the Children’s Yale-Brown Obsessive-Compulsive Scale (CY-BOCS).
Other factors to think about when considering an intensive program are the child’s rate of progress in standard levels of treatment, such as once or twice weekly therapy sessions, and whether medication is part of the treatment plan.
Relevant questions to ask regarding intensive treatment include:
Has the child been able to make ongoing progress in treatment or has improvement plateaued? Has the OCD actually gotten worse over time?
Even if the child is receiving medication, are they concurrently receiving evidence-supported OCD treatment (EST) from a highly experienced practitioner? Presently, Cognitive Behavioral Therapy/Exposure and Response Prevention (ERP) is the treatment with the most empirical support for children with OCD.
Has intensive treatment actually been recommend and, as parents, you have been unable to take this step? There are many reasons as to why this occurs, including hoping against the odds that the child’s OCD will improve, disagreements between parents, or anxiety about the “unknowns” of placing a child in this level of treatment.
WHAT IF MY CHILD IS AGAINST TREATMENT?
Like refusing to go to the dentist, it’s not unusual for a child to oppose treatment. In fact, a common aspect of pediatric OCD is that the child desperately seeks control and may even want to “protect” their OCD. It’s hard for many parents to manage a very resistant child with severe OCD, especially as they become older and bigger. It is very possible for children to threaten aggression or self-harm if they are forced into treatment.
Unfortunately, OCD is often progressive and delaying the inevitable may just make matters worse. Most children accept intensive treatment once they learn that their fears are unwarranted and they begin to understand more about what OCD really is and how much help and support is available. They do, however, take cues from their parents.
If parents show confidence and resolve, children generally follow along. But when this doesn’t work, it’s up to the parents to seek support from a knowledgeable professional who can help them navigate the complexities of bringing a very scared, stubborn, or defiant child into treatment. It’s not easy, of course, but usually well worth it in the long run.
WHAT DOES INTENSIVE OCD TREATMENT FOR A CHILD ENTAIL?
Before saying anything else, it should be noted how important it is to modify OCD treatment according to the child’s developmental stage and level of comprehension. The most effective OCD treatments were first developed for adults, including ERP which, again, is the “gold standard.” Modifications for pediatric OCD include the way ERP is explained and the format of the therapy.
Being able to translate evidence-supported treatments such as ERP into therapeutic games and activities that children can understand and relate to requires advanced training, experience, and skill. As children and their parents learn more about this methodology, they typically find that ERP sounds scarier than it really is. Furthermore, the effectiveness of well-designed OCD intensive treatment programs for children is supported by research.
Intensive treatment requires substantial commitment for all concerned. It requires prioritizing the child’s long-term mental health needs over school, sports, or anything else—at least for the time being. To be effective, intensive treatment is typically done on most days of the week for at least one or two months. By definition it includes extended-time individualized ERP sessions, which may last 90 minutes or more as deemed appropriate. In addition, children participate in groups that provide peer support and the chance to see that they are not alone.
Activities in the community to practice exposures in a more natural environment are often needed to generalize and reinforce what they have learned in clinic-based sessions. Aside from their core OCD symptoms, many children with severe symptoms also need to work on social skills, emotional regulation, and coping strategies. Some of them will also have co-occurring diagnoses that need to be addressed for treatment to be successful. Others may have problems in executive functioning, like poor organizational skills, or have learning issues (which includes being gifted and perfectionistic) that must also be treated.
Clearly, intensive pediatric OCD treatment is best done comprehensively and at the proper “dose.” If OCD treatment is insufficient, symptoms may simply overwhelm treatment. Comprehensive OCD treatment must also include adequate follow-up and booster sessions, as this is a relapse-prone condition. Intensive treatment provides the child and their family a time to place as much focus as possible on overcoming a very difficult situation for all concerned.
Since OCD does not exist in a vacuum, family participation in the child’s intensive OCD program is key, as is ongoing communication with any other professionals and educators involved in the child’s care. Intensive treatment provides an opportunity to further review medications as well as identify any obstacles to progress that might not have been apparent in the past.
WHAT SUPPORT DO PARENTS RECEIVE?
Parents who are willing to re-define their role and learn how to interact effectively with a child suffering from OCD can make all the difference in the success of an intensive treatment program. Nevertheless, they have to realize that there are many factors affecting progress and outcome that are beyond their control. Parents of these children are, of course, in a very difficult position as their natural, loving desires to make their child feel better, safe, and comfortable just won’t work for OCD—and actually feeds into symptoms.
Intensive programs for OCD strive to engage and help parents as much as possible. As such, extensive parent training and family sessions are typically offered. This can be very complicated for some families who are undergoing other stresses or have demanding jobs—but, where there’s a will there’s a way. Intensive programs are designed to help, not to add, problems. Therefore, many intensive programs will find ways to accommodate parents’ needs whenever feasible.
NBI’S TAKE
An intensive program should be strongly considered when a child’s OCD has not responded to standard levels of treatment; severity is increasing either continuously or in a pattern of more and more serious and protracted periods of symptom exacerbation; and they are unable to move forward in their lives. Despite its many challenges, studies suggest that, when it is warranted, the advantages of committing to intensive treatment in a timely manner is what is best for a child’s welfare and is likely to far outweigh any disadvantages.