What does obsessive-compulsive disorder (OCD) really look like? And how do you treat it in kids? Jerry Bubrick, PhD, a clinical psychologist at the Child Mind Institute, has devoted much of his career to helping children and teens conquer the debilitating thought patterns (obsessions) and repetitive rituals (compulsions) that are defining symptoms of OCD.
Here he shares insights into pediatric OCD and the transformations that can come through intensive treatment.
Let’s say I’m a 14-year-old girl who’s afraid of germs. How will my treatment work?
Okay. You’ve had your diagnostic evaluation, and we’ve had a feedback session with you and your parents to talk about your diagnosis. We’ve determined you have OCD with contamination worries—not ADHD—and we’re going to treat this, based on the severity, in 90-minute sessions, three times a week, using exposure and response prevention (ERP). One of the first things we’re going to do at this point is map out your symptoms and set up a fear hierarchy. To effectively treat you, I have to understand the intricacies and everyday impact of your condition. And I have to gain perspective on how disturbed you are by your different symptoms.
So how do you “map” the symptoms?
I’m going to ask you a series “what if” questions and have you answer them on a scale from 0 to 10 how anxious you’d be. So, how anxious would you be if I dropped my pen on the floor and you picked it up?
Four or 5.
What if you used a tissue to pick it up?
That would be a 3.
What if you did 10 push-ups on the floor and didn’t wash your hands?
What if you rolled around on the floor and then opened a piece of gum and put it in your mouth?
That would be a 10.
So after this I’d know what’s very challenging for you and what’s not so challenging. We could then begin talking about the exposures we were going to do. We’d start with and master the easier ones and then work up to the harder ones.
Can you give me examples?
Well, if someone has an aggressive obsession, a fear of hurting someone… Let’s say that any time I hear the word “kill,” I have to say “life.” I actually had a teen girl whose favorite band was The Killers, but every time she heard “The Killers,” she had to say “The Lifers” or she’d worry she was going to have to kill someone. So we determined that writing “The Killers” was a 3 for her on a 0-to-10 scale of anxiety. In our sessions, she’d write “The Killers,” and she did that over and over, and we went from an anxiety level of 3 to 1.
And this took time, right? More than one session?
Yes. And that’s the problem with those reality shows about OCD treatment. There’s no building process. They just do the most intense exposure—what would be in the 9 or 10 range for a patient—and there’s no working your way up the fear hierarchy or ladder. If someone has severe OCD, he or she can’t function, and once-a-week treatment is not going to do anything. We have to do the same exposure session after session until you get used to the anxiety and it no longer interferes with your functioning. Then we can work our way up to the next one.
You talk about OCD as if it’s a “bug” that a child has to get out of the body. Why do you do that?
I talk to kids and their parents about “externalizing the condition.” What that means is they can give OCD a name, and it becomes this external thing we’re all fighting against. For example, Sophie—she’s 10. I saw her intensively over the summer, and she called her OCD “Leaf.” She’d heard something about how the brain’s basal ganglia is involved in OCD, and that reminded her of the word “leaf.” So from then on, we weren’t talking about OCD, we were talking about this thing in her brain, Leaf. It was all of us working together to fight Leaf. She drew pictures of Leaf. It was this dark, weedy, ugly thing. I had a teenager call her OCD “Mr. Bossy.” And another teen girl called it “Shithead,” so when OCD was telling her what to do, we’d say, “Shithead is full of shit. We don’t have to listen to that.”
So OCD is treated like a bully.
Yes, definitely. I often talk about OCD as a bully. We’ll go through a whole dialogue. I mean, how do bullies get their power? Bullies use fear and intimidation. A bully might say, “Give me your money or I’ll punch you.” If you’re really afraid, you’ll give the money. This might temporarily make the bully go away, but then, most likely, he’ll seek you out the next day. So how do you get rid of this bully? The best answer I ever got was from a 5-year-old. She said, “Punch him in the nose.”
What is the “psychoeducation” part of OCD treatment?
That’s where we educate parents and the child about OCD, but I really see the whole psychoeducation component as a time for developing a team mentality—and then talking together about our plan to fight the OCD. We want parents involved at every step, so I also do individual sessions with parents to get a better sense of how the child’s OCD interferes with family life. I give parents a lot of dos and don’ts—tips for how to be supportive of the child without blaming or making symptoms worse. Sometimes I call these meetings “damage control sessions.”
How can parents make OCD symptoms worse?
Their “reassurances” have got to be one of the biggest things.
What’s wrong with reassuring the child?
Let’s say every night I insist that my mom say goodnight in a very particular way. Mom has to say, “Goodnight, I love you.” But if there’s any background noise, she has to say it again, and if the phone rings, she has to say it again, and if I don’t like the way it sounds, she has to say it again. And once is never enough. It’s relentless. Any good parent will want to “say it again”—offer that reassurance—because that temporarily eases the child’s anxiety. But then, in the future, the child’s symptoms just get worse. The child believes that the only way to get through anxiety is by relying on Mom to “say it again,” participating in a ritual.
What are some “dos” for parents of kids with OCD?
We work very hard on limiting parent participation in a child’s rituals. So for a child who won’t open doors because he fears contamination—his parents have to stop opening the doors for him. We don’t want his parents saying, “Stop, this is ridiculous, cut it out.” But we want them to say something like, “I know this is hard for you, but if you fight this, you’ll get stronger and the OCD will go away.”
So the message is, “Hold tight, it’ll be okay.”
Yes. It’s like if you jump into a very cold pool on a hot day. If you stay in the pool for a bit, your body pretty quickly adapts to the cold water. In treatment, we start modeling this idea. We say to a child, “You can stop doing these rituals, and you’ll be uncomfortable for a while, but it will be okay.”
Homework is a big part of the treatment for OCD. What does that involve?
Kids practice the exposures we do in session. So maybe you have a child who has aggressive obsessions—for example, a boy who’s afraid he’ll hurt his sister. We might practice writing in a notebook, “I will throw my sister down the stairs.” Maybe we’ll write that 20 times in a session, and then, for homework, he’ll write this a certain number of times each day.
The idea, then, is that he slowly proves to himself that he’s not going to hurt his sister?
Yes, he learns that thinking something doesn’t make it true. I mean, I could tell him I’m a 4’2″ elderly woman. Does that mean I am? No. It just means I think that. Having a strange thought can be very scary. But that’s very different from having it be true.
What about medication? Is that typically part of a child’s treatment?
In more severe or extreme cases, the best possible treatment is a combination of cognitive behavioral therapy (CBT) — exposure and response prevention is one specific type of CBT that’s most commonly and effectively used—and medication. But once a child is stable and progressing in therapy, we can reduce or eliminate the medication. That’s a fairly common scenario. You discontinue medication but continue CBT to combat symptoms.
I’ve heard that OCD is often misdiagnosed as ADHD. Why is that so?
Let’s say I’m a 9-year-old in a classroom. I’m having obsessive thoughts about throwing up after school because the kid sitting next to me is coughing and sneezing. One day my teacher asks me to answer a question on the board. Well, I have no idea how to answer because I’ve been thinking about the kid next to me and my ritual of throwing up.
So it’s not that the child has an underlying attention problem. It would just be easy for an adult to think that.
Right. Misdiagnosis is a big, big issue. Plus, children who’ve been misdiagnosed have often also been prescribed all these psychostimulants they shouldn’t be taking. So it’s misdiagnosis and mismedication. We end up having to say the child, in so many words, “You came here thinking you had ADHD. But you don’t have that. You never did. You have OCD, and here’s how we’re going to team up and treat it.”