Treatment Strategies for
Children with Obsessive-
By: Chrissy Snead
What is Obsessive-Compulsive
• Obsessions such as
1. Persistent and recurrent thoughts, images, or
impulses, that are experienced, at some time during
the disturbance, as inappropriate and intrusive and
that cause marked distress or anxiety.
2. Impulses, images or thoughts are not simply
excessive worries about real-life problems.
3. The person attempts to suppress or ignore such
thoughts, images, or impulses, or to neutralize them
with some other thought or action.
4. The thoughts, images, or impulses are a product of
his or her own mind and are not imposed.
• Compulsions such as:
1. Repetitive behaviors that the person feels
driven to perform in response to an obsession.
2. The behaviors are aimed at preventing or
reducing a situation or dreaded event.
* The person recognizes that the obsessions or
compulsions are excessive or unreasonable.
• The obsessions or compulsions are time
consuming, cause marked distress, or
significantly interfere with the person’s routine.
• It is not due to the physiological effects of a
substance problem or general medical
• The obsessions or compulsions are not
restricted to another Axis I disorder such as an
Common Obsessions Common Compulsions
Contamination-fear of germs Washing and Cleaning
Harm to self or others Checking-rechecking locks
Symmetry-needing things to be Symmetry-if you bump the left
even or lined up hand then bumping the right
Doubting-being sure you’ve Counting-making sure the t.v. is
completed common task such on a certain number, having
as locking the door to count while doing task
Numbers-having to do such as putting on clothes
something a certain number Repeating/Redoing-opening and
of times closing doors or turning lights
Religiosity-fear that you have on and off, rereading till
sinned or a need to pray perfect.
continuously Hoarding-Unable to throw items
Hoarding-fear of throwing out away
objects Praying-confessing every bad
Sexual themes-doubts about thought or continuous
sexual orientation or fears of praying.
How common is it?
• Over 1 million children have OCD
• 1 in every 100 young people
• Boys tend to develop OCD earlier than
girls. More boys are diagnosed 3:2.
• The average age of diagnosis is between
7-10 years old.
• It is unknown why some children become
checkers and others become washers.
Where does it come from?
• During the middle ages it was thought to be “of
the devil.” as a result of the religious movement.
• Next it was thought to come from illness or
• Psychoanalysis (Freud) thought that overly
rigorous toilet training and intrusive parenting
practices during the anal stage of development
lead to OCD about cleanliness.
• It is now known to be biologically driven. Having
a parent with anxiety or OCD increases the
possibility of a child being diagnosed.
• It has been found that some
children with lots of strep
infections increase the
prevalence of OCD.
This is because the strep virus
can cause damage to the basal
ganglia in the brain. The body’s
own immune system attacks the
basal ganglia instead of the
Thus there is a connection to
neurotransmitters that are
information from one cell to the
next. In OCD it is thought that
these message circuits do not
function properly. Thus the use
of SSRI medications to increase
To Medicate or Not Medicate?
• Selective Serotonin Reuptake Inhibitor or SSRI’s are
most commonly used with OCD. Examples of these are
Zoloft, Prozac, and Paxil.
• FDA approved medications for treatment in children with
OCD is Fluoxetine or Prozac and Zoloft.
• Studies have shown that SSRI’s are effective in the
treatment of anxiety, OCD, and major depressive
disorders in children.
• Studies also show a low risk for suicide with the use of
• Research has shown that cognitive-behavioral therapy is
as effective as SSRI treatment of OCD.
Cognitive Behavioral Therapy
* CBT is a psychotherapeutic approach that aims to
influence dysfunctional behaviors, emotions, and
cognitions through a goal-oriented, systemic procedure.
* It shares a base in behavioral learning-Pavlov and Mary
Cover Jones (work on unlearning of fears in children)
* Cognitive Psychology-Albert Ellis and Aaron T. Beck
* The approaches were combined in the 1980s and 1990’s.
* Therapy is often brief and time limited
* Can be used in individual or group settings
Cognitive Behavioral Therapy
• Includes a variety of approaches such as..
-Keeping a diary of significant events and
associated behaviors, feelings, and thoughts.
-Testing and questioning assumptions,
thoughts, evaluations and beliefs that might be
unrealistic or unhelpful.
-Gradually facing things previously avoided
-Trying new ways of reacting or behaving.
Introducing CBT to Children with
Up and Down the Worry Blink, Blink, Clop, Clop:
Hill. Why do we do things
we can’t stop?
This book introduces This book uses farm
common OCD animals to describe
behaviors and common thoughts
thoughts, going to see and behaviors. It
a therapist, introduces CBT
introduction to CBT concepts such as
concepts. saying no to the
Using CBT with OCD
• What to do when you
worry too much book.
– This book is a helpful
resource for therapist
and parents. It has
many CBT strategies
such as logical
strategies. The book
is suggested for kids
Resource for Parents
Freeing your child from Obsessive Compulsive
This book is good for parent’s, teachers, or
therapist wanting to learn more about OCD. It
talks about what OCD is and where it comes
from. The book also helps parent’s to gain
insight into how their behavior is impacting their
child’s OCD. It introduces CBT concepts and
Family Therapy is also beneficial for helping
parents to discontinue their participation in the
child’s rituals and also gives the parents support.
• Have been shown to be effective in
treatment with OCD
• Require compliance and a high level of
effort on the part of the parent and patient.
• Examples of this are…
• Brave Behavior Chart
• The Hand Wash Count
Play Therapy and OCD
Play therapy techniques are useful in addressing…
Resistance-Many children have a fear of changing
Feelings of Shame-Kids often feel that they are
weird or are ashamed of their OCD symptoms. This
can also been seen as lower self esteem.
Social Adjustment-They may not be doing typical
activities such as going over to a friends house or
spending the night away from home due to their
fears. They may withdraw from social activities so
that others will not notice their OCD symptoms.
• Allows the child to express feelings and
gives insight into the child’s world.
• Displacement-this is a technique in which
a therapist describes the experiences of a
hypothetical problem rather than speaking
directly to the experiences of the client.
Examples of displacement are dramatic
play, sand tray play, art work, puppet play,
books or stories, and movies.
Once Upon A Time…Therapeutic Stories
that Teach and Heal.
By Nancy Davis, Ph.D.
These are a collection of stories that can be
used for a wide range of ages and
diagnosis. There are over 21 stories
related to anxiety or obsessive-compulsive
Stories to help with nightmares.
A is a four year old female who was referred to
treatment by her PCP. Her parents’ primary concern
was her compulsively pulling out and chewing on her
hair. No stressful or traumatic events were reported.
She had a sister age 6 months. She had occasional
aggressive behaviors such as hitting with peers at
Therapy focus on implementing a behavior modification
plan, and utilizing play therapy. During play therapy
she was inconsistent about acknowledging her
symptoms. Her behavior modification was that she
could have a small squishy toy to squeeze when she
had the urge to pull her hair. She was awarded points
for telling her parents about her urges to pull her hair.
Play therapy focused on her resistance to the behavior
modification. On the first session of play therapy,
patient found the skunk puppet in the play room. She
picked up the skunk and reported “this guy stinks” and
threw it out the door of the play room. The therapist
used this as an opportunity to talk about how the
skunk must feel. About halfway through treatment the
patient decided that the skunk was not as stinky and
allowed it to remain in the room, but placed it in the
trash can. A also used the dollhouse to depict a story
of a family and their pet cat. The family would reject
the cat for different reasons and would get other pets
that were “better.” Through this story she was able to
express her fears of being replaced by her younger
sibling. Through her play the family began to accept
the cat and have love for the cat as well as others.
Play therapy also focused on allowing patient to
express her feelings. Her parents’ were
educated on allowing patient to “use her words”
to express feelings at home and being able to
reflect these to patient.
She did test limits in the play session as was
evident when she wanted to pour water on the
play-doh. The therapist gave her some choices
and used this as an opportunity to show
unconditional positive regard.
During her course of treatment her hair pulling
improved to the point were normal hair growth
was seen and parents did not observe any
pulling behavior. Her aggressive behavior at
school improved also. Towards the end of
therapy she announced that the skunk had
taken a bath and smelled okay and was
allowed to join her in the play room.