Cognitive - Behavioral for Obsessive Compulsive Disorder

Cognitive-Behavioral Therapy for Childrenand Adolescents with Obsessive-CompulsiveDisorder

Aureen Pinto Wagner, PhD

From the Division of Cognitive and Behavioral Neurology,Department of Neurology, University of Rochester School ofMedicine and Dentistry.

Contact author: Aureen P. Wagner, OCD and Anxiety Disorder Consultancy, 35 Ryans Run, Rochester, NY 14624-1160. E-mail: [email protected].

2003 Oxford University Press

291

Selected by experts as the treatment of choice for youngsters, cognitive-behavioraltherapy (CBT) has emerged as a safe, viable, and effective treatment for obsessive-compulsive disorder (OCD) among children and adolescents. Yet, most children withOCD do not receive CBT, at least in part due to the shortage of clinicians who are wellversed in managing the unique challenges that arise in the treatment of children. Thispaper reviews developmental factors that complicate the diagnosis and treatment ofOCD in youngsters; it discusses appropriate adaptations of CBT protocols for children;and it presents the application of CBT for children and adolescents, using adevelopmentally sensitive protocol that is flexible and feasible in clinical settings: RIDE Upand Down the Worry Hill. Illustrated is the use of this protocol with a 15-year-old girlwith forbidden thoughts and praying rituals, and a 6-year-old boy with fears of harm andreassurance-seeking rituals. Future directions for making CBT available and accessible tochildren with OCD are discussed. [Brief Treatment and Crisis Intervention 3:291306(2003)]

KEY WORDS: obsessive-compulsive disorder, cognitive-behavioral therapy, childrenand adolescents, exposure and response prevention, Worry Hill metaphor.

Obsessive-compulsive disorder (OCD) is morecommon in children and adolescents than oncebelieved, with a lifetime prevalence estimated at2% to 3% (Zohar, 1999). Childhood OCD is oftenassociated with severe disruption in social andacademic functioning, comorbid emotional and

behavioral problems, and family dysfunction(Albano, March, & Piacentini, 1999).

A substantial body of literature supportscognitive-behavioral therapy (CBT), specifi-cally exposure plus response prevention (ERP),as the key therapy for OCD among adults (seeMarks, 1997, for a review). Exposure involvespurposeful and conscious confrontation of ob-jects or situations that trigger obsessive fears;response prevention involves refraining fromthe rituals that relieve the anxiety generatedby obsessions. Exposure and response preven-tion must occur simultaneously for maximum

benefit. The most commonly proposed mecha-nism for the eectiveness of ERP is that theprocess of habituation leads to the dissipationof anxiety when exposure is sustained and fre-quent. Additionally, the realization that obses-sive fears do not materialize during ERP ap-pears to reduce the potency of the obsessions.

ERP for OCD was developed for adults and ini-tially considered neither possible nor desirablefor children and adolescents. Since the mid-1990s, several open-trial and single-case studieshave led to the emergence of CBT as a viable,safe, and eective treatment for OCD in childrenand adolescents (see March, Franklin, Nelson, &Foa, 2001, for a review). These studies haveyielded impressive and durable response rates,ranging from 60 to 100%; mean symptom re-duction rates of 50 to 67%; and maintenance oftreatment benefits for up to 18 months.

Although the results of rigorous controlledstudies are awaited, empirical and clinical re-ports thus far indicate that children and adoles-cents can utilize CBT as successfully as adults.Based on these findings, CBT is recommendedby experts as the first-line treatment of choicefor OCD in children and adolescents (March,Frances, Kahn, & Carpenter, 1997). However, itis believed that many, if not most, children andadolescents with OCD do not receive CBT fora variety of reasons. Many clinicians are nottrained in CBT for OCD and may not be familiarwith the unique developmental challenges thatarise in the treatment of children. In addition,clinicians often find that research-driven treat-ment protocols are neither practical nor realisticin clinical settings.

Although OCD in children is quite similar inpresentation to OCD in adults, developmentaldierences between children and adults arisingfrom age, maturity, conceptual ability, and lan-guage development may complicate the applica-tion of CBT for children. First, OCD in childrenmay be dicult to detect and diagnose for a va-riety of reasons. Children may not be able to rec-

ognize, label, or articulate their obsessions orfear triggers. A typical response of I just have todo it or I dont know may mislead unin-formed adults into believing the childs behav-iors are willful. Primary presenting complaintsof irritability, agitation, aggression, withdrawal,or decline in school functioning may maskOCD and may be mistaken for depression, otheranxiety disorders, or even attention deficit/hyperactivity disorders. Children may keep theirOCD a secret, and parents may be unaware of thepresence or severity or OCD (Rapoport et al.,2000). Sensitive but direct interviewing by theclinician may be necessary to uncover obsessionsand rituals that may underlie initial complaints.True OCD must also be dierentiated from nor-mal developmental rituals and fears that are com-monplace in childhood. The childs lack of abil-ity to introspect or give specific examples ofsymptoms or triggers also limits the therapistsability to design eective treatment.

Diagnosis is also confounded by the fact thatOCD in children is a highly comorbid condition.Up to 80% of youngsters meet criteria for an ad-ditional DSM-IV disorder, and up to 50% dis-play multiple comorbidities, most commonly inthe form of other anxiety disorders (26%75%),depressive disorders (25%62%), behavioraldisorders (18%33%), and tic disorders (20%30%; Rapoport, et al., 2000; Zohar, 1999).Dierentiation of tics from rituals can be sur-prisingly dicult. Depression is more commonamong adolescents with OCD than in children,and it may be reactive because it often occurs af-ter the onset of OCD. Comorbidity complicatescourse of illness in OCD, as well as treatmentoutcome (Albano, March, & Piacentini, 1999).

Second, regarding what they bring to CBT,children and adolescents vary tremendously intheir level of future orientation, ability to delaygratification, self-reliance, maturity, and inter-nal motivation. Children rarely seek treatmentfor themselves and are usually in the cliniciansoce at the behest of a parent. In fact, they may

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be more motivated to get help to avoid theirfears than to overcome them. Young children aregenerally present-oriented and therefore lesslikely to appreciate the prospect of future im-provement. Consequently, they may be reluc-tant to tolerate the potential anxiety of ERP toachieve future rewards. Compliance with ERPhomework exercises can be particularly chal-lenging because, naturally, most children dis-like and avoid homework. As a result, childrenmay require substantial structure, supervision,and assistance from the therapist and parents toparticipate eectively in CBT.

Other issues that aect accurate diagnosis andmotivation for treatment include the fact thatchildren often do not understand the nature ofOCD and have misconceptions or worries aboutbeing crazy. They are less likely than adults torealize that their symptoms are senseless and ex-cessive. Although older children may have goodinsight, their shame may lead them to minimizetheir symptoms. Children are more likely to pas-sively succumb to obsessions and rituals, andmay fear treatment because ERP can be counter-intuitive and daunting at first glance.

Third, children live in the context of a family,and parents are an integral part of their lives.OCD can quickly become a family illness be-cause children commonly involve family mem-bers in their OCD through participation in ritu-als, provision of reassurance, and assistance inavoiding fear triggers. Rage attacks may ensueif family members fail to comply. Families ofchildren with OCD may exhibit more criti-cism, parentchild conflict, and parental OCD,which may predict a worse outcome (Hibbs,Hamburger, & Lenane, 1991).

Clinicians who do not recognize and addressthese developmental issues may make the mis-take of rushing into treatment precipitously inresponse to the sense of urgency elicited by thechilds symptoms. Children, parents, and evenclinicians may abandon treatment prematurelywhen lack of progress from hastily applied treat-

ment leads them to doubt its ecacy. Carefullyassessing developmental issues, devising appro-priate adaptations, and building a child and fam-ilys treatment readiness prior to the initiationof treatment are therefore vital to success.

Recent manualized CBT protocols for childrenhave included developmental adaptations suchas psychoeducation, age-appropriate language,cognitive strategies for dealing with anxiety,use of graded exposure, rewards, and family in-volvement in treatment (March, Mulle, & Her-bel, 1994; Piacentini, Gitow, Jaer, Graae, &Whitaker, 1994). Clinical experience and recentstudies indicate that active parent involvementin the childs treatment may increase ecacyand long-term gains from treatment (Piacentini,et al., 1994; Waters, Barrett, & March, 2001).

The purpose of this paper is to describe theapplication of CBT for childhood OCD using adevelopmentally sensitive protocol that is flex-ible and feasible for clinicians in primarily clin-ical settings: RIDE Up and Down the Worry Hill(Wagner, 2002; 2003). The steps of the RIDE pro-tocol are described as follows and illustrated viaa 15-year-old girl with forbidden thoughts andmental rituals. A comprehensive assessment andtreatment strategy for childhood OCD that in-volves four phases, including the RIDE proto-col, is described later in this paper, along withits application for a 6-year-old boy with fears ofharm and reassurance-seeking rituals.

RIDE Up and Down the Worry Hill:A CBT Treatment Protocol forChildren and Adolescents

Understanding and accepting the vital conceptsof exposure, habituation, and anticipatory anx-iety, as well as the ability to tolerate anxiety dur-ing ERP, may be crucial to motivation and com-pliance. A childs success in treatment mighthinge on this understanding; yet these are notintuitive concepts. The RIDE acronym and the

Treatment of Children with OCD

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metaphor of riding a bicycle Up and Down theWorry Hill were developed to explain CBT inchild-friendly language (Wagner, 2000; Wagner,2002).

The Worry Hill depicts the relationship be-tween exposure and habituation. The bell-shaped curve of the Worry Hill (see Figure 1) il-lustrates the rise in anxiety when exposure to afeared situation takes place. Anxiety increasessteadily as exposure continues and may reach apeak. If the child persists with exposure, auto-nomic habituation sets in, and anxiety automat-ically begins to decline. If, on the other hand,the child succumbs to rituals or avoids the feartrigger, habituation is interrupted, and obses-sions are inadvertently strengthened by nega-tive reinforcement (i.e., escape from an aversivesituation). The Worry Hill is explained to chil-dren as follows:

Learning how to stop OCD is like riding yourbicycle up and down a hill. At first, facing yourfears and stopping your rituals feels like ridingup a big Worry Hill, because its tough andyou have to work very hard. If you keep goingand dont give up, you get to the top of theWorry Hill. Once you get to the top, its easy tocoast down the hill. But you can only coastdown the hill if you first get to the top.

The four-step RIDE acronym (Rename, Insist,Defy, Enjoy) encompasses the steps that thechild or adolescent must take to successfullytackle the Worry Hill. A step-by-step descrip-tion of this treatment protocol is available inWagner (2003). The RIDE was designed to sim-plify ERP for children and adolescents, enhancepreparedness for treatment, and foster endur-ance of anxiety until habituation takes place. Itincludes both cognitive and behavioral tech-niques, such as externalizing; distancing; andtaking control of OCD thoughts, exposure, andself-reinforcement. Coaching or instruction ineach of the four steps is followed by therapist

modeling, behavioral rehearsal, frequent prac-tice, and reinforcement, until the child mastersthe steps. In addition to the auditory mnemonicaid of the RIDE acronym, the Worry Hill Mem-ory Card (see Figure 1) provides a visual mne-monic aid to the child. In essence, the RIDEteaches youngsters to stop, think, take control,and respond assertively to OCD, rather than de-fault to an automatic reflexive compliance withobsessions and rituals.

The RIDE steps, as applied to 15-year-oldMarias uncontrollable images of dying babiesand her prayer rituals, are described as follows.Maria had begun to experience intrusive imageswhen she was 13. A soft-spoken teenager, she re-counted with anguish that she had seen a preg-nant woman walk past her at the mall and thatshe suddenly wished that the womans babywould die. Horrified by the repugnant thought,Maria attempted to cleanse the image out of hermind by conjuring up the image of the pregnantwoman walking by again and canceling the in-trusive thought by fervently praying that thebaby would be healthy. On another occasion,Maria was baby-sitting and suddenly had theurge to put the baby in the microwave along withhis bottle. Panic-stricken, she checked the mi-crowave and the babys crib repeatedly to ensurethat she had not carried out the urge. Althoughshe was relieved each time to find the baby sleep-ing contentedly, the doubt was relentless andtormenting. Maria was so distraught by the epi-sode that she stopped baby-sitting altogether.By the time she sought treatment, Maria wentto inordinate lengths to avoid eye contact or in-teraction with pregnant women and babies. Onsome days, she refused to leave the house. Thefour steps of the RIDE are as follows.

R: Rename the Thought

The first step involves recognizing OCDthoughts as unrealistic and distinct from thechilds rational self. Young children may find it

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helpful to personify OCD as the Worry Mon-ster or Mr. Right, whereas adolescents usu-ally prefer to refer to OCD by its name. The tech-nique of externalizing OCD has been used bySchwartz (1996) with adults and March et al.(1994) with children. When Maria recognizedand accepted that her obsessive thoughts werenot volitional or enjoyable, she distanced herselffrom them by saying, Thats OCD talking, notme. In doing so, she felt absolved of deep shameand guilt.

I: Insist That YOU Are in Charge!

The second step fosters a shift in attitude frompassive acquiescence to active assertion. It helpsthe child recognize and utilize the power ofchoice. Instead of readily succumbing to OCDsinjunctions, Maria chose to take active controlover her thoughts and actions. Statements suchas I am in charge, not OCD and Im going tochoose not to believe the tricks that OCD plays

on my mind helped Maria build the self-confidence and endurance she needed to em-bark on exposure.

D: Defy OCDDo the OPPOSITE ofWhat It Wants

The third step involves ERP, which requires achange in behavior. Exposures in Marias caseentailed purposefully encountering pregnantwomen and babies by going to public placessuch as the mall and by taking on baby-sittingassignments. Response prevention involved re-fraining from canceling bad thoughts or say-ing prayers when intrusive images of dying ba-bies assailed her. Maria talked herself throughERP by saying, Im going to ride up the WorryHill now. Its going to be tough going up the hill,but if I stick it out, Ill get to the top of the hill.Once Im at the top, it will be easy to coast downthe hill. I wont quit until the bad feeling passes.I wont give in to the rituals. As Maria encoun-



FIGURE 1The Worry Hill. 2002 Aureen P. Wagner, PhD. Reprinted with permission. From Wagner (2002).R: Rename the thought. Thats OCD talking, not me.I: Insist that YOU are in charge! Im in charge. I choose not to believe OCD.D: Defy OCD. I will ride up the Worry Hill and stick it out until I can coast down.E: Enjoy your success, reward yourself. I did it! I beat OCD. I can do it again.

tered pregnant women and babies, her anxietyescalated and peaked, then automatically beganto decline because habituation set in. Maria rodeto the top of the Worry Hill and enjoyed thecoast down the other side. The thoughts of dy-ing babies seemed meaningless and eventuallyfaded away. She was surprised that exposurewasnt as upsetting as she had expected. Ma-rias thoughts were far less troublesome with re-peated exposures, and her anxiety habituatedfaster with practice.

E: Enjoy Your SuccessRewardYourself

The final step allows the child to review her suc-cess and take due credit for eort and courage.Maria learned to give herself positive feedbackand internalize success. I did it! I can do itagain. Now I deserve to be good to myself.

The Worry Hill represents a universalmetaphor because children as young as four,adolescents, and even adults can relate to theidea of riding a bicycle up a hill. Parents, sib-lings, and teachers find the metaphor equallyhelpful in understanding how CBT works. Theeasy acronym, logical steps, and visual featuresof the Worry Hill, as well as the RIDE acronym,are simple to grasp, remember, and recall, evenin the midst of anxiety, thereby reducingchances of premature termination of exposureand habituation. Moreover, the metaphor iscomprehensive and readily lends itself to a de-scription of most elements of treatment and re-covery. For example, graded exposure is de-scribed as riding up little hills before tacklingthe big one; preparation for treatment is simi-lar to finding a good helmet, the right pair ofsneakers and having a bottle of water on hand;the use of medication is portrayed as trainingwheels on the bicycle; and relapse is depictedas you may fall o your bicycle even afteryouve learned how to ride.

Systematic and thorough assessment and

preparation for treatment, as described in thefollowing section, must precede the implemen-tation of the RIDE.

Four Phases in the Implementationof CBT for Children andAdolescents

The overall treatment strategy for children andadolescents may be conceptualized as occurringin four sequential phases. Each phase is focusedon completing specific goals or building onskills that have been mastered in the previousphase. The number of sessions in each phase isflexible to allow customization to the childsand familys unique needs. The average treat-ment extends from 10 to 20 sessions, depend-ing on the severity and complexity of the case.Straightforward cases of OCD may be treatedin as few as 6 sessions.

Phase 1: Biopsychosocial Assessmentand Treatment Plan

Phase 1 lays the essential foundation for suc-cessful treatment and may extend from one tothree sessions (one session equals the 50-minutehour typical of clinical practice). A biopsycho-social assessment focuses on a complete and sen-sitive understanding of the childs OCD symp-toms in the context of the childs personal at-tributes, physical health, family, social, andschool functioning. Rather than merely assessOCD, it is geared toward the larger issue of thechilds overall health, adaptation, strengths andlimitations; and it allows for customized treat-ment that may help avert treatment failures.Biopsychosocial evaluation involves collabora-tion among physician, therapist, parent, child,school, and other relevant players. In addition,it utilizes a variety of methods: clinical inter-views; clinician, parent, and child ratings; self-report inventories; and behavioral observations.

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Initial diagnosis is followed by OCD symptomanalysis and a treatment plan.

Initial Evaluation and Diagnosis The first stepin the evaluation is to establish a diagnosis ofOCD, assess baseline severity and impairment,and identify potentially dicult areas for treat-ment. The assessment should target current andpast fears; rituals and triggers; events surround-ing the onset of symptoms; frequency and con-text of symptoms; degree of distress and im-pairment; comorbid conditions; medical anddevelopmental history; family history; socialrelationships; and functioning at home andschool (Pinto & Francis, 1993). Although severalstructured diagnostic interviews for children areavailable, time and resource constraints makethem infeasible in most clinical settings.

Interview with the Child. Although the childmay not be the best historian, it is important forthe clinician to gauge the childs insight and ex-perience of symptoms, level of distress, and mo-tivation for treatment. The clinician must be em-pathic and resourceful in order to engage chil-dren of various ages and levels of maturity; elicittrust; and query thoughts and rituals with thelevel of detail necessary for eective treatment.Interview of the child is geared toward obtain-ing answers to many questions:

Does the child perform rituals to relieveanxiety or prevent bad outcomes?

How is each fear connected with each ritual? What would happen if he did not do a ritual? How does the child know when hes done

enough? What makes him feel better, and what

makes the thoughts dissipate? Does she believe she can overcome her

fears? Is she hopeful and optimistic, or does she

feel defeated and dispirited? How does she feel about herself as a person?

Clinical Interview of Parent(s). Interviewing par-ents is very important because children may notbe reliable informants. In addition to describ-ing the childs symptoms, parents are valuablein providing a chronology of events, develop-mental history, comorbid symptoms, family his-tory, and functioning, of which children mightnot be aware.

Self-Report and Parent Ratings. In addition tothe clinical interview, several other measureswith established psychometric properties yieldclinically useful pre- and posttreatment dataand can be ecient and time-saving in the clin-ical setting. They can be administered, scored,and reviewed prior to the first appointment,thereby allowing the clinician to target areas forcloser assessment during the initial visits. TheChild Behavior Checklist (CBCL; Achenbach &Edelbrock, 1991), an 118-item parent-reportmeasure, allows clinicians to assess a broadrange of symptoms that may be clues to bothOCD and comorbid conditions. The childs over-all anxiety can be assessed on the Multidi-mensional Anxiety Scale for Children (MASC;March, Parker, Sullivan, Stallings, & Conners,1997). The Child OCD Impact Scale (COIS; Pia-centini, Jaer, Bergman, McCracken, & Keller,2001), completed by parent and child, providesinformation on the impact of OCD on the childsschool, social, and family/home functioning.

Clinician Ratings. Several single-item clinicianrating scales, which take about a minute eachto complete, are highly practical in clinicalsettings. The NIMH Global OCD Scale ratesOCD severity and impairment. A score of 7 indi-cates clinically meaningful OCD symptoms, andscores of 13 to 15 indicate very severe symp-toms. The NIMH Clinical Global ImpairmentScale provides an overall judgment of impair-ment from 1 (not ill) to 7 (extremely ill). TheNIMH Clinical Global Improvement Scale allowsratings of improvement during and after treat-



ment on a scale of 1 (very much improved) to 7(very much worse).

OCD Symptom Analysis A close examinationof specific obsessions, compulsions, triggers, thenature and frequency of parental participation,and assistance with rituals helps the clinician de-sign targeted and eective exposures. The Chil-drens Yale-Brown Obsessive-Compulsive Scale(CY-BOCS; Scahill et al., 1997) is often the startingpoint for this information. The CY-BOCS assessesobsessions and compulsions in terms of timeconsumed, interference, distress, resistance, andcontrol. Scores of 09 are considered subclinical,1018 mild, 1829 moderate, and 30 or above in-dicative of severe OCD.

Biopsychosocial Treatment Plan The thera-pist must use the information derived from theassessment to develop a treatment plan that isdesigned to improve the well-being of thechild, not just his obsessions and compulsions.The child may need treatment to help rebuildsocial skills and improve self-esteem, family re-lationships, and academic functioning. OCDsymptoms should generally be treated first, un-less other issues interfere with the treatment.For example, severe depression or family con-flict may need to be treated before a child canengage in CBT.

Feedback and Education. The nature, course,prognosis, and contributing factors involved inOCD should be discussed with the child andparents. Blame and shame from misunderstand-ing OCD as a character weakness or the result ofpoor parenting should be eliminated. The childand parents should be oered all viable treat-ment optionsincluding CBT, medication, or acombination of both (see March et al., 1997)and assistance in making the optimal choicesfor the child. The therapist should explicitlydiscuss the pros and cons of each option, whateach treatment involves, what sort of focus and

commitment will be required of parents andchild, the possible duration of treatment, andwhen results may be expected. Families whoopt for medication should be referred to a childpsychiatrist.

Phase 2: Building TreatmentReadiness

Phase 2 is focused on planned and active prepa-ration for treatment. This phase is critical but of-ten overlooked, which jeopardizes the chancesof success in treatment. Devoting one to threesessions to cultivate treatment readiness in thechild and parent is a worthwhile investment thatenhances participation, compliance, and the easeof implementation of ERP. The four steps inbuilding treatment readiness are stabilization,communication, persuasion, and collaboration.

Stabilization of the Child and Family CrisisFamilies seeking help for a childs OCD fre-quently present in a state of crisis. They feel asense of urgency for immediate relief, and par-ents may be at their wits end. A child who isoverwhelmed and struggling to function does nothave the wherewithal to consider CBT. Over-zealous implementation of CBT in these circum-stances merely adds to the childs sense of bur-den and can therefore backfire. Stabilization in-volves providing the child with respite fromthe dual challenges of OCD and everyday liv-ing through flexible expectations and temporaryaccommodations at home and at school. In se-vere situations, the child may need medicationto reduce the severity of symptoms prior to en-gaging in CBT. Parents who are highly distressedalso need support, stress management, andconflict-resolution techniques to regain equilib-rium before embarking on CBT with their child.

Effective Communication Perhaps the mostcritical part of treatment readiness is helpingthechild and parents understand the concepts

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of exposure, habituation, and anticipatoryanxiety. When children dont understand CBT,they are unnecessarily intimidated and conse-quently unmotivated. The language of CBTmust be accessible to children. The metaphorof the Worry Hill was developed to communi-cate CBT concepts eectively in child-friendlylanguage.Most parents and children are not aware thathabituation of anxiety is an automatic physio-logic process and that it takes place naturally ifanxiety is endured for a reasonable length oftime. It is this lack of awareness and inability totolerate increasing anxiety that leads them togive in to rituals to escape the anxiety. When achild understands the metaphor of the WorryHill, it is often an aha! experience. Parents andchildren who are educated about the Worry Hillprior to beginning treatment appear to be lessanxious and more motivated to engage in treat-ment. They are often surprised to find that theanxiety they feel during exposure is far less thananticipated.

Effective Persuasion Persuasion involveshelping children see the necessity for change,the possibility for change, and the power tochange. Children are more readily persuadedonce they have an accurate understanding ofOCD and CBT. The child must be helped to seethe benefits of overcoming OCD; this convincesher of the necessity for change. When shelearns that OCD can be successfully overcomeand that many others have done it, she sees thepossibility for change. The child must learn torely on the therapists word that confrontingher fears will assuage them; she must believe inthe RIDE for herself. She must experience nocoercion and no surprises, because the childstrust in the therapist is imperative. Finally, thechild must know that she has the power tochange. She must understand that she herselfcan take charge and control of OCD, instead ofletting it control her. The recognition that she

has the power to change is usually a liberatingexperience.

Collaboration between Parent, Child, andTherapist The child, parent, and therapisthave dierent but complementary roles to playin the childs treatment. Clearly defining each ofthese roles before treatment begins can expe-dite progress in treatment by preempting theconflict and frustration that can ensue frommisunderstanding. The therapists role is toguide the childs treatment; the childs role is toRIDE; and the parents role is to RALLY for thechild:

R: Recognize OCD episodes.A: Ally with your child.L: Lead your child to the RIDE.L: Let go, so your child can RIDE on his own.Y: Yes, you did it! Reward and praise.

The metaphor of the Worry Hill is extended tohelp children and parents clearly understandtheir respective roles in treatment. The childsrole is described as follows:

No one else can ride a bicycle for you. Youhave to do it for yourself. In the same way,only you can face your fears and make them goaway. No one else can do it for you.

The parents role is conveyed as follows:

You can help your child get ready for the rideby selecting the right bicycle and gear and byholding on to the seat if hes unsteady. Even-tually, you must let go and let your child rideby for himself. Your child cannot ride on hisown until you let go of the seat.

With the therapists guidance, the child mustbe involved in setting goals and deciding thepace of treatment, as is suitable to his age andmaturity. The child is more likely to be invested



in his recovery when he perceives that he has con-trol over it. It is a good rule of thumb not to beginERP until the child voluntarily expresses willing-ness to proceed. Children rarely refuse to partici-pate in treatment when they are well informedand given the choice. When a child declines toparticipate despite proper preparation, it may bea good indicator that the child is truly not readyfor CBT and therefore unlikely to benefit from it.Additional preparation may be necessary, or otheroptions such as medication may need to be con-sidered. For some children, CBT may have to bedeferred temporarily and attempted later whenthey are older, more mature, or more willing.

Treatment reluctance in a child is generally aperplexing and frustrating situation for parentsand therapists alike, who either instinctively in-crease pressure on the child or abandon treat-ment prematurely. However, coercion and ulti-matums do not address the underlying reasonsfor reluctance, which usually stem from miscon-ceptions or misunderstanding of the treatment.Most children have the desire to be rid of OCDbecause OCD is not enjoyable; however, somechildren have diculty in channeling the desireto get well into the action to get well. A thought-ful, sensitive approach is more likely to earn achilds participation than disapproval or pres-sure. As described in Wagner (2002; 2003), astrategic five-step plan for handling treatmentreluctance recommends that parents and thera-pists slow down and go through the PACES:

P: Plan a strategy.A: Ascertain reasons for reluctance.C: Correct and remove obstacles to treatment.E: Empower to succeed.S: Stop assisting.

Phase 3: The RIDE Up and Down theWorry Hill

Phase 3 may extend between 4 to 15 sessions. Itconsists of separate plus joint sessions with the

child and parents. During this phase, the childparticipates in ERP.

Graded Exposure Graded exposure involvesprogressing in small sequential steps from theleast feared to the most feared situations. It mustbe used with children almost without exception,as children may not be able to participate in ERPif they become overwhelmed by anxiety. The rel-atively easy success experienced during gradedexposure provides positive reinforcement andboosts the childs self-confidence and willing-ness to attempt subsequent exposures. A gradedexposure hierarchy must be constructed prior tobeginning ERP.

Symptom Monitoring. Symptom monitoring pro-vides targets for the graded exposure hierarchy, aswell as data for ongoing evaluation of treatmentresponse. The child and parents list all OCD symp-toms and record their frequency on easy-to-usemonitoring sheets known as the OCD TrackingDiary and Tracking Diary for Parents. Parentsmay assist younger children or record for them.

Fear Temperature. The Fear Temperature isanalogous to the Subjective Units of Distress(SUDS) used in the treatment of adults, and it al-lows children to rank exposure targets from leastto most dicult for graded exposure. Childrenrate their Fear Temperature on a Fear Thermome-ter, a graduated scale from 1 (no anxiety) to 10(out of control) that teaches children how todierentiate, quantify, and communicate levelsof anxiety to the therapist and parents.

Cognitive Strategies The first two steps of theRIDE (Rename and Insist) are aimed at preparingthe childs belief system in anticipation of expo-sure. They include perspective-taking, refram-ing, and distancing from OCD, as well as em-powerment to take back control. The therapistmay introduce other cognitive techniques asneeded for each child.

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Exposure and Response Prevention TheDefy step of the RIDE signals the beginning ofERP. The therapist first instructs the child in thesteps of the RIDE, then models the procedureand asks the child to follow suit. For instance,the therapist eats a snack with unwashed handsto model exposure to germs. Modeling allows thechild to see that the therapist is willing to assumethe same risks that are asked of her.

Rewards Rewards bridge the gap of delayedgain from treatment and provide children withthe immediate incentive to participate andmaintain motivation. The child must be re-warded for eort, rather than success, becauseeort reflects the desired behavior. Praise andattention are preferable to material rewards,although young children often need tangiblerewards.

The Parents Role to RALLY Specific parentalbehaviors that support and reinforce the childsRIDE are discussed in each session, along withinstruction and the therapists modeling of stepsto eliminate participation in rituals. The RALLYsteps are tailored and put into action as per thespecific circumstances for each child and fam-ily, including the childs age, maturity, specificsymptoms, degree of parental involvement insymptoms, and the nature of the parentchildrelationship. Targets for working with parentsinclude helping them take care of themselves sothat they can take better care of their children;reducing parental assistance and participationin the childs symptoms; and increasing positivefamily interactions, communication, problemsolving, and child management skills.

Frequent Practice Frequent and diligent prac-tice of ERP is crucial for mastery of anxiety.Weekly graphs of progress and Fear Tempera-ture ratings give the child and family tangibleevidence of progress. The therapist assigns adaily practice, in writing, after each session in

order to reduce the chances that assignments areforgotten or misunderstood. Incomplete assign-ments are usually a sign that there is some ob-stacle to the childs participation. Sometimes,the child is willing and enthusiastic in the ther-apists oce, but she gets cold feet when shegets home. Parents may not be able to provide thesupervision or structure that allows the childto focus on completing ERP exercises. Exer-cises may not be working as expected becausethe child quits the RIDE prematurely before ha-bituation has taken place, or she replaces overtrituals with silent mental rituals. Success in CBTwill be severely limited until all barriers to fullparticipation are removed. Maintaining dailyphone contact with patients during the earlystages of the RIDE can preempt many of theseproblems. Parents and children are asked toleave a message every day, letting the therapistknow how the practice is proceeding. Doing sonot only increases accountability but also allowsthe therapist to intervene quickly if things arenot proceeding as expected.

Phase 4: After the RIDE

Phase 4 signals the end of treatment. It shouldbegin when the child has mastered the RIDE,when parents RALLY eectively, and when thechilds OCD symptoms have decreased.

Preparation for Slips and Relapses Parentsand children need to be prepared for the realitythat OCD slips, or relapses, can happen eitherunexpectedly or at times of stress and transi-tion. When prepared, they are more likely tohave an organized and productive response, andless likely to become demoralized. Relapse re-covery training involves having realistic expec-tations, recognizing the early signs of relapses,keeping things in perspective, and interveningimmediately. The metaphor of falling o a bicy-cle is used to suggest that when a slip occurs,OCD should be confronted head on by doing



ERP exercises even more vigorously. When youfall o your bicycle, you pick yourself up. If youmade no attempt to get up, you wouldnt getanywhere. If you want to move on, you get up,dust yourself o, survey the damage, attend toit, and get right back on that bicycle. It is im-portant that the child and parents not fall intothe trap of avoiding the feared situation.

Treatment Completion and BoosterSessions When treatment is completed, thechild must receive significant recognition forher eorts and success. Treatment outcome is as-sessed via CY-BOCS posttreatment scores, NIMHclinician ratings of improvement, changes inFear Temperature, and parent and child ratingsof percentage improvement. Periodic boostersessions after treatment enhance the mainte-nance of treatment gains. Booster sessionsshould be scheduled prior to completion oftreatment to reduce the rate of attrition.

The RIDE Up and Down the Worry Hill CBTprotocol shares many elements with March etal.s (1994) groundbreaking CBT protocol forchildren entitled How I Ran OCD o MyLand. Although no empirical data exists tocompare these two protocols or their relativeecacy, they nevertheless share common fea-tures. Both protocols are grounded in ERP asthe core technique for overcoming OCD, andboth include developmental adaptations de-signed to optimize the childs chances at suc-cess by making ERP child-friendly and lessanxiety provoking. Other shared features in-clude the use of metaphors, externalizing, andconstructive self-talk strategies to help thechild prepare for, and cope with, ERP, gradedexposure, provision of rewards to reinforceeort, and structured parental involvement intreatment.

March et al.s (1994) protocol focuses on cog-nitive resistance and constructive self-talk(such as bossing back OCD), otherwiseknown as the tool kit that children can use

to get through ERP. The RIDE protocol placesgreater emphasis on the childs comprehensionand acceptance of the key concepts of treat-mentexposure, anticipatory anxiety, and ha-bituation. It is the understanding of these con-cepts that makes ERP easier for the child. Whatis crucial is helping the child understand andexperience the temporal relationship amongthese three critical elements in treatment. Thechild is trained to become acutely aware of andexperienceon cognitive, behavioral, and phys-iological dimensionsthe process whereby anx-iety escalates during exposure and dissipatesduring habituation. This experiential learning,aided by the auditory and visual features of theWorry Hill, provides the child with powerfultangible feedback about the process, where fearscan either be cemented or extinguished. Theaha! experience that typically ensues allows thechild to see the perfectly logical sense behindERP. Clinical experience indicates that once chil-dren understand the metaphor of the WorryHill, they often begin to view ERP as a stim-ulating challenge and are eager to rise to theoccasion.

In addition, the Worry Hill protocol clearlyand proactively delineates the roles of parent,child, and therapist in the treatment, andplaces strong emphasis on treatment readi-ness as a precursor to beginning ERP. It alsooers a systematic step-by-step approach todismantling the childs treatment reluctance inorder to reduce the chances of premature aban-donment of treatment. The application of thefour phases in the Worry Hill protocol is illus-trated as follows.

Case Description

Daniel, a 6-year-old first grader who had beendiagnosed with Tourettes syndrome at the ageof 4, was referred by his neurologist for inces-sant checking and reassurance seeking.

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Phase 1: Biopsychosocial Assessmentand Treatment Plan (Three Sessions)

Biopsychosocial assessment consisted of an in-terview with Daniel and his parents, a phoneinterview with his school teacher, a review ofmedical records, and administration of self-report measures and rating scales. Daniel haddemonstrated many ritualistic behaviors sincehe was a toddler, including extremely rigidbedtime rituals and reassurance seeking. Sixmonths prior to referral, Daniels fears of harmand danger had escalated dramatically. He fre-quently checked for blood and bugs in hisfood, and he sought repeated reassurance fromhis parents that his food did not contain thesesubstances. He refused to eat spaghetti sauce orketchup for fear that they were blood. Familymembers were vigilant not to use the wordblood in any conversation for fear of upset-ting Daniel. Daniel made his parents check hisclosets and under his bed every night to makesure there were no bad things and bad luck.When in bed, his toys and stued animals hadto be arranged just so, and his covers had tobe tucked in tightly by his parents. Daniel re-peated nonsense phrases such as Pete teasingand how now to avert bad luck. He checkedhis underwear at least 20 times a day to ensurethat he had not accidentally soiled them, andhe also asked his parents and teacher to check.He insisted on his parents participation ingood-bye rituals that involved saying a se-ries of words in sequence and taking turnsrepeating them, as many as 10 times each day.At school, Daniel was noted to seek frequentreassurance from the teacher, to be highlydistractible, and to need frequent redirec-tion. Daniel reportedly had severe outbursts ofanger if his parents or teacher did not complywith his demands. He had frequent nighttimeawakenings and was unable to complete schoolwork or homework. Daniels tics, which con-sisted of sning, coughing, and shoulder

shrugs, reportedly caused minimal distress orinterference.

Daniels symptoms met criteria for a DSM-IVdiagnosis of OCD as well as for Tourettes syn-drome. His score on the CY-BOCS was 29, sug-gesting notable distress and functional impair-ment. Daniels symptoms merited a score of 10on the Global OCD Scale and a 5 on the ClinicalGlobal Impairment Scale. Daniel was restlessand hyperactive, and he had many negativeattention-seeking behaviors, including frequentinterruption of conversations. He acknowl-edged that he didnt like being afraid, and heexpressed motivation to overcome his fears.With regard to family history, Daniels motherhad experienced anxious preoccupations andrituals as a child and suered from panic attacksin her late teenage years.

Phase 2: Building TreatmentReadiness (Two Sessions)

The diagnosis of OCD was described to the fam-ily, along with information about its course,risk factors, prognosis, and treatment options.Daniels parents were reluctant to consider med-ication for him and opted for CBT. The metaphorof the Worry Hill was presented, and the roles oftherapist, child, and parent were discussed atthe outset. The importance of compliance andwillingness to change were emphasized. Danielclearly understood the Worry Hill and the RIDE,and was able to explain them to his parents. Therealization that he could exercise control overhis OCD appeared to increase his motivation.Daniels parents were enthusiastic in their com-mitment to RALLY for him.

Phase 3: The RIDE Up and Down theWorry Hill (Six Sessions)

Daniel and his parents completed the daily diaryand parent diary to monitor the nature, context,and frequency of obsessions and rituals. Daniel



was able to dierentiate between realistic andsilly obsessive worries and to rate his FearTemperature on the Fear Thermometer. Hejoined the therapist in constructing an exposurehierarchy with the following items:

3: Having toys in disarray5: Wearing damp underwear6: Having bed covers messed up7: Hearing the word blood8: Saying blood8: Eating spaghetti sauce or ketchup10: Seeing blood

After coaching in the RIDE steps, gradual ex-posure to each situation on the hierarchy wasconducted both in the oce and at home withthe parents help. Corresponding response pre-vention involved refraining from urges to re-arrange his toys, say Pete teasing, check un-derwear, ask for reassurance, or have his parentsfix his bed covers or check his closets androom for bad luck. Daniel used the Worry HillMemory Card as a reminder of the RIDE steps,and the Fear Thermometer to rate changes inhis anxiety from beginning to end of each ex-posure. As expected, his anxiety followed thecurve of the Worry Hill, and habituation oc-curred within 2 to 10 minutes. Daniel receivedfrequent praise and rewards for his eort.

Daniels parents learned how to RALLY forhim by reinforcing the message of the WorryHill and the steps of the RIDE, providing sup-port during exposure exercises and graduallywithdrawing participation in his rituals. Theyreceived guidance in child management strate-gies, such as consistent parental responses, struc-ture, eective redirection, and dierential re-inforcement of positive behaviors. Strategies tohelp Daniel express frustration appropriately,contain angry outbursts, and channel negativeattention seeking into positive behaviors werepresented. Daniels parents learned stress man-agement strategies for themselves. Reassurance

seeking was gradually weaned by preparingDaniel ahead of time for a change in parental re-sponse, by redirecting Daniel to consider if itwas him or OCD asking for reassurance (and toanswer the questions himself), and by graduallydecreasing the number of reassurances down toone. These steps were role-played during thetherapy session before the parents implementedthem at home. Daily practice of ERP was as-signed after each session and reviewed at the be-ginning of the following session.

Phase 4: After the RIDE (Four Sessions)

At the end of 6 sessions of ERP, Daniel and hisparents reported 80% improvement in hissymptoms and overall functioning. CY-BOCSscore was 4; Global OCD Scale score was 2; andClinical Global Improvement Scale score was 1.Bedtime, good-bye, and reassurance-seekingrituals were eliminated completely within threesessions. Fears of blood and soiling accidentallywere eliminated by the end of six sessions oftreatment. Daniels parents reported feelingmore confident about helping him manage hisOCD, and his teacher reported a significant de-crease in reassurance seeking at school.

Booster sessions were scheduled at 4, 8, 14,and 22 weeks, and every 12 weeks thereafter for2 years. They were focused on review of pro-gress, identification of areas of diculty, reca-pitulation of strategies, social skills training,and ongoing child management issues. Danielexperienced a minor relapse four months aftertreatment was completed, when the approach ofHalloween triggered fears of blood and mon-sters. Relapse recovery steps were reviewed andimplemented, and Daniel successfully overcamethe resurgence of fears within two days. AsDaniel got older, he was coached in cognitivestrategies that allowed him to test the evidencefor his fears, estimate the probability that hisfears would come true, and develop problem-solving skills. At two years posttreatment,

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Daniels score on the CY-BOCS was 3, in the nor-mal range. Other than occasional rituals that didnot cause distress or interference, Daniel wasreported to be doing very well at home and atschool.

Summary and Future Directions

Knowledge about childhood OCD and its treat-ment has progressed in leaps and bounds in thelast decade, thanks to significant research andclinical attention to the disorder. Clinicians arenow better able to provide youngsters withsymptom relief as well as the skills to manageOCD in the long-term and lead productivelives.

CBT, which was once considered neither fea-sible nor suitable for children, is now recom-mended by experts as the treatment of choicefor OCD in youngsters. However, many ob-stacles need to be overcome before this recom-mendation translates to real benefit for chil-dren and families who struggle to cope withOCD. Parents, pediatricians, teachers, andschool personnel, who function as gatekeepersfor timely recognition and referral of children,often do not have the knowledge or tools to de-tect OCD until it is severe. Moreover, most chil-dren who are diagnosed still do not receive CBTas a result of the dearth of clinicians with therequisite skills. The application of CBT withchildren calls for expertise in treating chil-dren, familiarity with developmental and fam-ily issues, a sound therapeutic relationshipwith the child and the family, and facility inadapting and customizing standard treatmentprotocols.

Future directions in making CBT accessibleand available for children include wider dissem-ination of accurate information about OCD andCBT to parents, school personnel, and healthcare professionals, as well as in-depth trainingopportunities for clinicians who treat children.

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