Exposure & Response Prevention (ERP): Treating Children With OCD
Updated: Dec 29, 2020
It’s well recognized that pediatric Obsessive Compulsive Disorder (OCD) is more common than previously thought. Just as every child is unique, the effect OCD will have upon an individual child and their family also has singular aspects. The fact that the pediatric treatment of this condition requires quite a bit of creativity and modifications should be anticipated.
Implementing OCD treatment presents many complexities, even for teenagers and adults. This is even more so when it comes to developing interventions for children. The first challenge is to assist parents (or other caregivers) in understanding the rationale for Cognitive Behavioral Therapy (CBT), specifically Exposure and Response Prevention (ERP). The evidence for the efficacy of this approach exceeds that of any other psychological therapies. In some cases, ERP may be combined with the use of medication. However, trying ERP alone first is often recommended, especially for very young children. As might be expected, the earlier OCD is identified and addressed the better the outcome.
Since the basic instinct of parents is to alleviate any suffering experienced by their child, the idea of purposely exposing their child- even very gradually- to their worst worries seems unnatural and distressing. However, that is exactly the idea behind ERP. This is how it works: Let’s say a little girl is afraid that her mother will die if she does not tap her foot according to certain “magic” numbers. Engaging in this neutralizing behavior provides relief from her anxiety, but only temporarily. Sadly, this cycle of avoidance will only worsen her faulty belief system and physical discomfort, in the same way that avoiding any fear- like air travel- will tend to make it worse over time. The effect of ERP is exactly the opposite. In other words, by facing one’s fears, it is the discomfort that becomes temporary rather than misleading improvements. ERP not only helps lessen worrisome belief systems, it works by capitalizing on the body’s natural process of habituation. To understand what habituation means, think of a person moving to a noisy area and getting acclimated. After a while, they are desensitized and probably barely notice the racket.
Once the parents are on board (meaning they have redefined what helping OCD means) the next step is to somehow explain this to the child in a way that is comprehensible and also activates them to face their fears. Actually, effective pediatric OCD treatment is a fairly new development. Retrospectively, it may seem obvious but it took a while for practitioners to catch on that the best way to proceed is to embed ERP for young children in creative games and stories. For example, a child who obsesses about making mistakes might be taught to confront this worry by playing a game in which making mistakes results in a higher score. Similarly, a girl who is afraid of illnesses might be sent on a “germ hunting safari” while being encouraged to refrain from hand washing. Another instance would be writing a scary bedtime story together with a boy who performs rituals to ward off their fears before they will go to sleep.
Child-modified ERP has given practitioners an effective methodology for treating pediatric OCD. It has helped by providing the means to translate a complicated clinical approach into language and activities that children can relate to as well as readily understand. This approach has also had an added benefit for parents by softening some of the understandable emotional barriers associated with ERP treatment.