case-Based review
Obsessive-Compulsive Disorder in Children and
Adolescents
Case Study and Commentary, Phoebe S. Moore, PhD, Suzanne U. Allard, BA, and Martin E. Franklin, PhD
Abstract
• Objective: To review the application of cognitive
behavioral therapy (CBT) for the treatment of obsessive-compulsive disorder (OCD) in children
and adolescents.
• Methods: Presentation of treatment model with example dialogue.
• Results: Pediatric OCD is a prevalent, distressing, and functionally impairing anxiety disorder. The
psychosocial treatment for OCD that has the most
empirical support is CBT using an exposure and
response prevention technique, in which the child
gradually exposes him- or herself to OCD-related
anxiety or discomfort and then resists ritualizing. As the child learns experientially that anxiety associated with OCD is tolerable and remits over time,
more challenging tasks can be accomplished, leading to improvements in symptom severity. Both the
child and family learn about the neurobehavioral
basis of OCD and form a team with the CBT clinician to “battle” the disease entity.
• Conclusion: Hierarchical use of exposure and re­
sponse prevention in a supportive environment permits habituation to and eventual mastery of OCD
symptoms.
P
ediatric obsessive-compulsive disorder (OCD) is a
prevalent, distressing, and functionally impairing
anxiety disorder. By late adolescence, the lifetime
prevalence of childhood OCD is estimated to be 2% to 3%
[1], while point prevalence estimates are between 0.5% and
1% of the pediatric population [2]. In many to most untreated cases, OCD tends to persist in a waxing and waning
course through adolescence and into adulthood, indicating
a need for early intervention [3]. With treatment, symptoms
can often be reduced to subclinical levels, and relapses are
less frequent and less intense.
OCD is characterized by 2 main symptoms: obsessions
and compulsions. Obsessions are recurrent and persistent
thoughts, images, or impulses that are ego-dystonic, intrusive,
and, for the most part, acknowledged as senseless. Obsessions
are generally accompanied by negative affects, such as fear,
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disgust, doubt, or a feeling of incompleteness and are distressing to the affected individual. Young persons with OCD
typically attempt to ignore, suppress, or neutralize obsessive
thoughts and associated feelings by performing compulsions,
which are repetitive, purposeful behaviors performed in response to an obsession, often according to certain rules or in
a stereotyped fashion. Compulsions, which can be observable
repetitive behaviors, such as washing, or covert mental acts,
such as counting, exist at least in part because they serve to
neutralize or alleviate obsessions and accompanying distress
in the short run. Compulsions can relieve the anxiety or
sense of discomfort caused by obsessions, and in this case the
compulsive behaviors are strengthened through a process of
negative reinforcement. Occasionally, compulsions occur in
the absence of reportable obsessions and are experienced as
a response to an urge or feeling that one simply must do the
ritual; the relief that ensues can also be a negative reinforcer.
In children and adolescents, it is common for compulsions to
include family members (eg, reassurance seeking). In addition, in contrast to most adults with OCD, children (especially
young children) may lack insight into the irrational nature of
the obsessions and compulsions [4].
OCD can interfere severely with role functioning, causing impairment in school performance, friendships, family
relationships, and vocational functioning [5,6]. For example,
children and adolescents may drop out of activities they
used to enjoy, avoid social contact, experience academic
problems as a result of ritualizing, and lose sleep when
obsessions are more salient at night. Thus, in addition to
the risk of OCD symptoms persisting into adulthood and
causing impairment, pediatric OCD can severely divert the
course of normal development, leading to long-term deficits
across many areas of functioning.
There are a variety of effective treatments for children and adolescents with OCD [7]. Pharmacotherapeutic
From the Program in Child and Adolescent Anxiety Disorders, Departments
of Psychiatry and Psychology, Duke University Medical Center, Durham,
NC (Dr. Moore and Ms. Allard); and the Center for the Treatment and Study
of Anxiety, Department of Psychiatry, University of Pennsylvania School of
Medicine, Philadelphia, PA (Dr. Franklin).
Vol. 13, No. 7 July 2006 JCOM 405
OCD in children and adolescents
ap­proaches that have garnered empirical support from multicenter randomized controlled trials include clomipramine
[8], fluvoxamine [9], sertraline [10], and fluoxetine [11].
However, the typical response to medication treatment is a
30% to 40% reduction in symptoms, which usually results in
clinically significant residual impairment [12]. Cognitive behavior therapy (CBT), particularly models including exposure with response prevention, has also been supported in
randomized controlled trials for pediatric OCD [7,13,14]. The
effect of CBT may be even larger than that of medication,
although methodologic differences between pharmacotherapy and psychotherapy trials make direct comparisons
challenging [15]. The maximum benefit may come from a
combination of the 2 treatments, and experts recommend
that children with OCD be started either with CBT alone or
with the combination of CBT and medication [7].
The psychosocial treatment for OCD that has the most
empirical support is CBT using a specific technique known
as exposure and response prevention (EX/RP). The current
version of the treatment [7,16] typically involves 14 sessions
over 12 weeks. The first 4 sessions focus on psychoeducation
and cognitive training, with an emphasis on the externalization of the OCD as a neurobehavioral problem independent
of the child’s self. Using this knowledge—that OCD is “not
me” but an external force that is vulnerable to the child’s
attempts to regain control—a hierarchy of exposure tasks
is developed, starting with easy ways to resist compulsions
(eg, touching a bathroom wall at home and not washing),
and building up to very challenging EX/RP tasks (eg, touching a toilet seat in a public restroom and not washing). The
child is encouraged to “poke OCD with a stick” by doing
activities that provoke OCD-related anxiety or discomfort
and then resist the ritual that OCD demands be performed.
EX/RP tasks are completed in session and as homework,
and the child charts his or her anxiety/discomfort level over
time using a “fear thermometer” ranging from 1 (easy) to 10
(hardest ever). As the child learns that the anxiety associated with OCD is tolerable and remits over time regardless
of ritual performance, more and more challenging tasks
can be accomplished. The process of habituation that occurs
during the exposures facilitates a sense of control for the
patient, and also tends to reduce both the frequency and the
intensity of the child’s obsessions and urges to ritualize. In
many cases (up to one third of children treated with CBT
and up to a half of children receiving CBT plus medication),
subclinical status can be attained within the 12 weeks.
The family context has special importance in the treatment of pediatric OCD. The messages that the affected child
receives from parents and siblings have great impact on how
the disorder evolves. For example, many parents believe that
the child is being defiant or does not want to resist OCD,
leading to a patient-blaming stance and a punitive environ406 JCOM July 2006 Vol. 13, No. 7
ment. In contrast, other families respond to OCD with attempts to placate, resulting in entire families accommodating
OCD-related patient discomfort with extra cleaning rituals,
avoiding “contaminated” areas, or other adaptations.
CASE STUDY
Initial Presentation
Emily, age 15, presents with her parents to the university clinic with the initial complaint of family
conflict. In the course of the intake evaluation, it becomes
evident that Emily is experiencing intrusive images (obsessions) of herself harming her younger sister, Kayla, age 8.
History
When these images occur, usually in the context of feeling angry at Kayla over some small issue, Emily becomes
upset and locks herself in her room crying. Her parents are
inferring from her behavior that Emily harbors “repressed
anger” toward Kayla and that she actually has an intention
to hurt her, and they respond by taking Kayla out of the
house when conflict appears to be brewing. In addition, they
are taking extreme measures to “maintain safety” in the
home, keeping all sharp objects and “potential weapons”
locked in a kitchen cabinet. Emily is deeply distressed by
these obsessions and by her parents’ interpretation, as she
reports no wish to harm her sister. The parents’ goal at the
initial session is to understand why Emily feels so much
anger toward her sister. Emily’s goal is to make her parents
understand that she does not wish ill toward her sister and
to get help “getting the pictures out of [her] head.”
A detailed exploration of the nature of the obsessions is
indicated, and the clinician interviews the patient alone.
• What are the goals of the patient interview?
In this interview, it is important to establish the unwanted
nature of the violent image. The clinician should rule out
the case where the patient is excited by violent images or expresses intention toward acting out the images. In addition,
the presence of any psychotic symptoms should be evaluated; while uncommon, it is important to ensure that there is
no disturbance of thought process or reality testing. A careful evaluation of how the image interacts with the patient’s
anger level is also important in this case, as the intrusions
are sometimes triggered by angry affect on the part of the
patient. The clinician should carefully disentangle normative, ego-syntonic fantasies that occur in the context of anger
(eg, thinking “I’d like to just hit her!” or imagining a minor
violent act) from obsessional, ego-dystonic content (eg, intrusive and more elaborated images of extreme or gruesome
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case-Based review
violence). The tendency to try to neutralize or get rid of the
violent images is a cardinal feature of this subtype of OCD,
whereas intentionally elaborating on the image for pleasure
or gratification is not consistent with the diagnosis of OCD.
The clinician’s stance in this interview is important. The
clinician should be matter-of-fact about the patient’s obsessions, conveying the message that the clinician has heard
such things before, even in much more frightening variations from other patients—that is, the patient’s experience is
“old hat” to the clinician. For example:
Clinician: I’ve met a lot of kids like you, who get thoughts
they don’t like or want to have. Sometimes the
thoughts can be pretty scary. Can you tell me
about the thoughts you have about your sister?
Emily:
It’s hard to talk about.
Clinician: I know that it can be hard to talk about it. How­
ever, I also know that what your brain is coming
up with in these moments has nothing to do
with what you want or wish.
Emily:
I really don’t want it! That’s why I go in my
room. There’s just something wrong with me,
that I think these things!
Clinician: What I think is happening here is that you are
getting something called an obsession, which is
a medical term for a kind of brain hiccup that
some kids have. Obsessions are thoughts that
you don’t want to have, that have nothing to do
with who you are or what you want. I’ve seen
kids who get all kinds of scary images—images
about hurting their family members or pets,
about hurting themselves, or wrecking things.
They don’t want to get these thoughts; it’s
just that their brain is kind of misfiring and
giving them these images. Is that what you are
experiencing?
Emily:
Yes. I have these images of hurting my sister
with knives or hitting her with things. Do other
kids really get thoughts like that?
Clinician: Absolutely. I’ve heard all kinds of things like
that from other kids. And you know what?
None of them has ever done anything violent
like the images that bother them!
This element of normalization, combined with some reassurance by the clinician about the low risk of simply having obsessions, can be very helpful for instilling hope and allowing
the patient to share important information with the clinician.
The clinician makes it clear early with her words and behavior that the patient’s intrusive thoughts, while upsetting, are
not meaningful in terms of her motivations, wishes, desires,
or personality nor do they make her a risk to her sister.
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Table. Common Symptoms of Obsessive-Compulsive
Disorder in Children and Adolescents
Common Obsessions
Common Compulsions
Contamination
Harm to self or others
Aggressive themes
Sexual ideas/urges
Scrupulosity/religiosity
Symmetry urges
Need to tell, ask, confess
Washing
Repeating
Checking
Touching
Counting
Ordering/arranging
Hoarding
Praying
In patients with obsessions and compulsions, it is important to assess for any additional symptoms of OCD (Table).
An assessment tool such as the Children’s Yale-Brown Obsessive Compulsive Scale [17] can be useful.
Further Workup
An assessment of Emily’s OCD reveals that she
has some additional symptoms beyond the violent
intrusions. She frequently does visual checks to make sure
her sister is physically OK and becomes distressed if her sister is hard to locate. She also has some symptoms of doubt,
frequently feeling unsure of herself and repeatedly asking
her parents for reassurance about whether she is correct (eg,
about homework assignments, family rules). Finally, she has
some mild contamination symptoms, fearing that she will
spread toxins to her family members, and she avoids touching surfaces that may have chemicals on them and washes
for 5 to 6 minutes when she does touch something that she
thinks may have a toxic residue.
The clinician also evaluates for the presence of other
anxiety disorders, mood disorders, attentional and behavioral issues, and trauma/violence/abuse history using the
Anxiety Disorders Interview Schedule for children and parents [18]. Emily has some distress and sad mood associated
with her OCD symptoms but no full-blown mood disorder
nor any comorbid anxiety disorders or trauma history.
• What are next steps in evaluation and treatment of
OCD?
Once symptoms of OCD are identified, they should be
separated into domains (in this case, harm images, checking rituals, and contamination concerns), and the patient
should reflect upon the degree of control she feels over
each domain. Children and adolescents often have more
control over OCD symptoms than they initially realize. For
Vol. 13, No. 7 July 2006 JCOM 407
OCD in children and adolescents
example, Emily can often resist checking on Kayla if Emily
is engaged in other activities, such as talking on the phone
with friends. In other situations, however, it is too hard for
Emily to resist. The circumstances that make compulsions
easier or harder to resist should be delineated.
This information is then used to build the hierarchy,
which is essentially a list of exposure and response prevention tasks that the child can complete, in order from easiest
to most difficult. Starting with easier tasks (eg, in response
to an urge to check, delaying a visual check on her sister for
a few moments) and working her way up (eg, fully resisting the urge to check), the patient can practice experiencing
obsessions (exposure) and then resisting rituals (response
prevention). Most symptom domains require a hierarchical
approach in order to keep the patient’s distress at a tolerable
level. However, if the child already has experienced nearly
complete success in refraining from compulsions in a particular domain, an efficient strategy may be to “start at the
top” (ie, fully resist compulsions in that domain).
• How can one make a hierarchy for a symptom such as
Emily’s violent intrusions?
The idea of staying in the room with her sister in the presence of the violent obsessions is a “10” on Emily’s feelings
thermometer. The key to making the hierarchy is finding
items below this “10” rating. This is a situation where the
use of imaginal exposure can be useful. Imaginal exposure
involves the use of the patient’s imagination to develop the
full obsession in the form of mental imagery. In Emily’s case,
imaginal exposure would involve creating, via discussion, a
fully developed mental image of her violent obsession about
Kayla (eg, “What is OCD telling you will happen if you
get the scary thoughts about Kayla and you don’t leave the
room?”). While this sounds counterintuitive to many clinicians, exposure to the content of this violent intrusion can
promote habituation and thus reduce the urge to ritualize
in response to the violent obsessions. In order to be most
effective, the clinician must get the important details of the
story. In doing so, the clinician can also convey to the patient
that the content of her obsessions, no matter how violent or
gruesome, is unimportant. The message that the clinician
has “heard it all before” can enhance patient comfort level.
For example:
Clinician: Now, you and your parents have all alluded to
upsetting and violent images that OCD some­
times gives you. Kids with OCD have different
kinds of upsetting thoughts; sometimes they
are really gruesome, like out of a horror movie.
408 JCOM July 2006 Vol. 13, No. 7
Emily:
Clinician:
Emily:
Clinician:
Emily:
Clinician:
Emily:
Clinician:
Emily:
Clinician:
Emily:
One thing that is important to know is: what is
the scariest thing that OCD is showing you? For
some kids, the scary part is the violence—like
seeing an image of themselves stabbing a family
member, and the details of that, like the blood
and the scared reaction of the family member,
are the worst. For other kids, the worst part is
the consequence of the violent act—like getting
sent to prison, going to hell, or having their other
family members stop loving them. Which of
these is more like what your OCD throws at you?
I don’t think it’s about the consequence. It’s just
so scary when I think about hurting Kayla.
OK, that helps us, because we need to know the
scariest part of what OCD is showing you in
order to make it boring.
Make it boring! How could it ever be boring?
Well, imagine with me for a minute the scariest
movie you’ve ever seen. What movie was it?
I saw “The Ring” about a year ago at a friend’s
house. I couldn’t get the image of that girl com­
ing out of the TV out of my head for weeks!
OK, perfect. So the first time you saw that scene,
with the girl crawling out of the TV, you were
scared. But what do you think would happen if
you watched that scene 10 times in a row?
I don’t know; I might still be scared.
How about if you watched it 50 times, over and
over. Do you think it would still be scary?
I don’t know. Actually, I think I’d probably get a
little bored of it.
Exactly. So let’s pin down OCD together, today,
and make OCD tell its story. Then we’ll watch
the “OCD video” 50 times together, in our imag­
inations. What do you think will happen then?
Maybe the OCD image won’t scare me so much…?
The clinician and Emily put together the story for the
imaginal exposure carefully, making sure it is well developed with sensory and emotional details (including, for a
stabbing image, the spurting blood, Kayla’s fearful facial
expression, and Emily’s feelings of anger, fear, and intense
feelings of remorse). They practice exposing Emily to the
story, told by the clinician, repeatedly. Repeatedly checking
on Emily’s fear level using the feelings thermometer shows
empirically the rate of habituation.
A hierarchical approach can be used for imaginal exposure as well. If Emily felt that the full content of her obsession was too hard to consider, then an imaginary, OCD-like
image containing less scary details (maybe an image of
hitting her sister or tripping her) can be illustrative. The
key components of learning that occur in these therapeutic
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case-Based review
exercises are (1) that the thoughts, no matter how scary,
eventually can be made boring, and (2) that thinking about
the OCD images, even in elaborated detail, does not make
the patient take violent action.
Eventually, the images will recede in threat level enough
to make in vivo (real life) exposures a possibility. Imaginal
exposures will make it easier for Emily to try staying in
the room with her sister when obsessions are present, and
eventually to stay in the room with her sister while holding
a potential weapon (eg, dinner knife; baseball bat). Once the
highest levels of exposure are tolerated, the OCD is generally under the patient’s control and tends to fade in intensity
and frequency.
• What if the patient resists doing the EX/RP tasks?
For most child and adolescent patients, a challenge awaits
the clinician: assisting the patient in finding the motivation
to take on the exposure tasks. Resistance or reluctance can
occur at any stage in treatment—when conceptualizing
OCD, when mapping and planning the hierarchies, when
beginning EX/RP tasks, and when the EX/RP tasks reach a
level of high challenge. At each step, the clinician can assist
the patient in finding the motivation to move forward.
First, as alluded to earlier, it is important for the clinician
to be completely accepting of the child and his/her symptoms. In addition, EX/RP tasks should start at a level that
is not too challenging for the patient but provokes enough
anxiety for the patient to understand the habituation process
and to begin to believe in the efficacy of EX/RP. Careful
evaluation around failures to complete homework and resistance in session can help identify the reason for reluctance.
If the task is too hard, brainstorming ways to make it easier
and giving the child control over the level of difficulty can
be helpful. The clinician can draw an analogy to physical
training: the exposures are important because they build
“muscle” or strength in the battle against OCD, just like
lifting heavy weights or running sprints. Sharing examples
of other hypothetical patients with the same concern can
also be useful. Finally, the use of contingent rewards can be
motivating for children who lack internal motivation or who
are feeling discouraged; small rewards (eg, stickers) can be
useful, as can token systems that allow the child to earn a
larger reward. Effort at attempting exposures, engaging in
response prevention, and in using cognitive coping techniques, rather than success, should be rewarded; rewarding
only successes can be discouraging, especially for particularly challenging EX/RP tasks.
An excellent motivator can be a discussion of what role
OCD has played in the child’s life story so far and what the
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child’s story could be like in the future without OCD as a
major character. In Emily’s case, the projected story could
include a better relationship with her sister, less conflict at
home, more self-trust and self-esteem, and a sense of control
and autonomy around her own thoughts rather than a feeling of being victimized by them.
Sometimes children and adolescents possess low motivation to complete the therapeutic work because they perceive
the effort involved in resisting OCD to be more challenging
than the effort involved in experiencing obsessions and
performing compulsions. This can be common in families
that work hard to minimize OCD-related distress, that is,
families with high levels of accommodation. In this case, the
distress is felt by family members more than by the patient,
and thus the family resorts to assisting with OCD rituals.
Thus, the therapeutic work must be done in the family
format. The withdrawal of family support for symptoms is
placed on the hierarchy and approached in that manner. If
the patient completely refuses to participate, the parents can
withdraw their support gradually. This often will change
the contingencies enough to increase patient motivation to
control their OCD symptoms.
• What if family processes impede treatment progress?
The first step in family work for OCD is psychoeducation.
Family members need to realize that OCD is a separate phenomenon from the patient, and the clinician can assist the
patient and her family members to “form a team” together to
resist OCD symptoms. There is often a shift in parent reaction once the biobehavioral model for OCD is presented. It
is important to explain to parents that OCD is illogical and
meaningless in its content, no matter how morally loaded
the content seems to be.
Emily’s parents view her violent images as “repressed
anger” and view her as a danger to Kayla. It will be important that the clinician help the parents to change their view
and instead see the obsessions simply as meaningless “brain
hiccups.” Up until now, the family had been taking steps to
keep Kayla safe (removing her from the house, removing
“weapons” from Emily’s access), and the clinician must insist
that the family stop these behaviors and replace them with
behaviors that show that they trust Emily and realize that
Emily is not a danger to Kayla. Thus, allowing Emily to babysit for Kayla when Emily feels ready will be an important part
of the treatment. It shows support for Emily and reinforces
the message that, in the absence of any history of violence or
any pleasure taken in the thoughts about harming her sister,
the obsessions she experiences are meaningless.
Finally, parents or other family members are often drawn
Vol. 13, No. 7 July 2006 JCOM 409
OCD in children and adolescents
into compulsions in a pattern called family accommodation.
Parents are often called upon to give reassurance, for example.
Other common compulsions that involve family members
include bedtime rituals (parents must read a certain story),
giving forgiveness, or assisting the patient with checking or
cleaning rituals. Again, when family members are embedded in the ritual, withdrawing their involvement needs to be
included as part of the hierarchical approach to treatment.
Further Course
Partway through treatment, Emily has gotten into
the habit of asking her mom to reassure her that the
violent thoughts are “just OCD.” Her mother is responding
with reassurance and hugs for Emily, which is supportive,
but it soon becomes apparent that this is a new checking
ritual. If reassurance is withheld, Emily becomes distressed.
The clinician and Emily discuss the situation, and Emily
decides that she is ready for her mother to give just 1 reassurance. Emily will try to resist asking for extra reassurance,
but if she does ask, she wants her mother to ignore the
question.
Over the course of 14 sessions, Emily habituates to the violent intrusions via imaginal exposures and then works on
in vivo exposures with response prevention, staying in the
room near her sister (resisting the compulsion to leave the
room), even in the presence of violent intrusions. She comes
to understand that “OCD’s thoughts” (ie, her obsessions) are
not meaningful and that she does not need to accommodate
her behavior to “OCD’s rules” (compulsions). She also is
able to stop her visual checks on her sister, and through a
few targeted contamination exposures with prevention of
washing rituals, she regains control over her obsessions
about toxins and cleaning rituals. At the end of treatment,
she reports that she controls 98% of her emotional and behavioral “territory” and that her OCD controls a scant 2%.
• How are recurrences prevented?
It is common for children and adolescents to still report
some level of OCD symptoms, usually occasional obsessions, at the end of treatment. For many children and adolescents, OCD symptoms tend to take a waxing and waning
course, and even successfully treated symptoms may recur
in the context of stress or developmental changes. Thus, it is
important to spend time over the last few sessions of CBT
to discuss this possibility and plan for the future. When
patients have a firm knowledge of the principles guiding the
fight against OCD, they are usually able to intervene early
and successfully against recurring obsessive or compulsive
symptoms. We often use a “case consultation” model in
410 JCOM July 2006 Vol. 13, No. 7
which we ask the patient, now an expert the EX/RP model,
to consult with us on treatment approach for other hypothetical youngsters with different presentations of OCD.
Using this case-based approach, the clinician can evaluate
how well the patient understands (1) externalizing OCD,
(2) differentiating obsessions from compulsions, (3) the
tool kit for fighting OCD, (4) the hierarchical approach to
exposures, and (5) the principles underlying EX/RP. Any
areas of knowledge deficit can be shored up through this
mechanism, as noted below:
Clinician: I have a patient who feels like his shoes need
to be lined up perfectly in his closet; his OCD
tells him that they need to be perfect or he’ll
be uncomfortable for the rest of the day. What
would you recommend for him?
Emily:
Well, he could try throwing his shoes all over
the place and leaving them like that, all messy.
Clinician: That would certainly be resisting OCD! How do
you think I can convince him to do that? He’s
just starting treatment, and he really thinks that
OCD might be telling him the truth.
Emily:
Well, maybe he could do something a little
easier?
Clinician: What would you recommend?
Emily:
I guess he could use the feelings thermometer to
figure out what might be easier. Maybe if he just
moved 1 shoe out of line a little bit? Or maybe
he could start a little harder, like 1 pair messed
up but the rest lined up.
In this way, the clinician draws Emily’s attention to the importance of the hierarchical approach to exposures and thus
increases her probability of success in the face of recurring
OCD symptoms.
SUMMARY
Understanding therapeutic principles, first by the clinician and
then by the patient, is vital for improvement and maintenance
of treatment gains. The first step is careful and thorough assessment, with systematic evaluation of comorbidity and differential diagnosis. Once pediatric OCD is identified, the child
and family learn about the neurobehavioral basis of OCD and
thus form a team with the CBT clinician to battle the disease
entity. Carefully planned, hierarchical use of EX/RP in this
supportive environment will then permit habituation to and
eventual mastery of OCD symptoms, feelings, and behaviors.
Finally, training in relapse prevention and as-needed consult
and booster sessions with the CBT clinician can prevent OCD
from recurring at anything beyond a mild intensity.
Corresponding author: Phoebe S. Moore, PhD, Duke Child and
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case-Based review
Family Study Center, 718 Rutherford St., Durham, NC 27705,
[email protected].
Financial disclosures: None.
9.
Author contributions: conception and design, PSM, MEF; drafting
of the article, PSM, MEF; critical revision of the article, SMA, MEF; administrative or technical support, SMA.
10.
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