Maria was 9 years old when she heard a TV news item about an outbreak of hepatitis that originated at a local bakery. Long after the alarm had subsided, she couldn't stop worrying about it. At first, she feared that she might have contracted hepatitis and began washing her hands with increasing frequency. Then she began to worry that she herself could spread hepatitis and be responsible for the deaths of others. She refused to touch or hug anyone, including her parents. This was followed by a constant fear that she'd contaminate the seats on which she sat at home, at school, and on the bus. Maria began wiping herself clean to the point that she was chafed and bleeding. By the time she came in for treatment a year later, she was spending 45 minutes in the shower, 30 minutes at the sink each time she washed her hands, and 45 minutes cleaning up after each time she used the toilet. She barely made it to school most days. Maria's mother felt compelled to assist her daughter with her cleansing rituals and to provide endless reassurance that she wouldn't get hepatitis. If she didn't do so, Maria could be in the bathroom for four to six hours, and definitely wouldn't make it to school that day.
Maria has obsessive-compulsive disorder (OCD), an often debilitating condition that affects from one to three percent of children in the U.S. A growing body of evidence suggests that neuropsychiatric, genetic, immunologic, behavioral and cognitive factors may all play a role in the development and maintenance of OCD. Over the past 15 years, the literature has repeatedly shown that OCD in children can be successfully treated with cognitive-behavioral therapy (CBT)—specifically, exposure and ritual prevention (ERP). CBT has a 65- to 80-percent success rate with youngsters, similar to the success rate with adults. ERP involves gradually facing one's fears to test their reality while refraining from rituals. It helps people with OCD realize that their obsessive fears don't come true and that the anxiety they experience subsides as a result of autonomic habituation.
But while CBT is widely considered the treatment of choice for children with OCD, effectiveness is contingent on overcoming a formidable obstacle: children's reluctance to engage in ERP because they think that facing their fears without performing rituals will be too scary and impossible. The therapist and the children's families must find a way to help the children get past the discomfort of giving up rituals that seem to protect them against overwhelming fears. To do that, I've devised a CBT treatment approach tailored to the special needs and cognitive capabilities of children. It's aimed at thoughtfully cultivating treatment readiness before embarking on ERP.