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Evidence-Based Reviews

Germ warfare: Arm young patients to fight obsessive-compulsive disorder

A ‘toolbox’ of cognitive skills and medications can help children and adolescents reclaim their lives.

Vol. 2, No. 11 / November 2003

Adam, age 10, is extremely distressed at school. Because of obsessional contamination fears, he avoids contact with other children and refuses to eat in the cafeteria. He washes his hands 20 times per day and changes his clothes at least three times daily.

His primary obsessions involve contact with bodily fluids—such as saliva or feces—and excessive concerns that this contamination would cause him serious illness.

Adam’s parents say their son’s worries about dirt and germs began when he entered kindergarten. They sought treatment for him 2 years ago, and he has been receiving outpatient psychotherapy since then. They have brought him to an anxiety disorders specialty clinic for evaluation because his obsessive-compulsive symptoms are worsening,

When treating patients such as Adam, our approach is to use cognitive-behavioral therapy (CBT) and adjunctive drug therapies to relieve their symptoms and help them reclaim their lives. Diagnosis of pediatric OCD is often delayed, and few children receive state-of-the-art treatment.1 The good news, however, is that skillful CBT combined, as needed, with medication is highly effective.

Box 1

‘Fight OCD, not each other:’ What families need to know

Although family dysfunction does not cause OCD, families affect and are affected by OCD. Control struggles over the child’s rituals are common, as are differences of opinion about how to cope with OCD symptoms. It is important to address these issues early in treatment, as helping the family combat the disorder—rather than each other—is crucial to effective treatment.

Parents need to know that neither they nor the child are to blame. OCD is a neurobehavioral illness, and treatment is most effective when the patient, therapist, and family are aligned to combat it. Families are often entangled in the child’s OCD symptoms, and disentangling them by eliminating their role in ritualizing (such as giving excessive reassurance) is important to address in therapy.

Scaling family involvement is part of the “art” of CBT, and it will remain so until empiric studies determine the family’s role in the treatment plan.2

‘Contaminated’ mother.

Adam becomes distressed when he comes in contact with objects that have been touched by others (such as doorknobs). He is especially anxious when these items are associated with public bathrooms or sick people.

Adam’s mother is a family physician who has daily patient contact. In the last 6 months, Adam has insisted that his mother change her work clothes before she enters his room, touches him, prepares his food, or handles his possessions.

As in Adam’s case, the family often gets caught up in a child or adolescent’s obsessive rituals (Box 1).2 After a detailed discussion with Adam and his parents and because his symptoms were severe, we recommended combined treatment with sertraline and CBT. Adam was willing to consider CBT and medication because he recognized that he was having increasing difficulty doing the things he wanted to do in school and at home.


Approximately 1 in 200 children and adolescents suffer from clinically significant OCD. 3 They experience intrusive thoughts, urges, or images to which they respond with dysphoria-reducing behaviors or rituals.

Common obsessions include:

  • fear of dirt or germs
  • fear of harm to oneself or someone else
  • or a persistent need to complete something “just so.”

Corresponding compulsions include hand washing, checking, and repeating or arranging.

OCD appears more common in boys than in girls. Onset occurs in two modes: first at age 9 for boys and age 12 for girls, followed by a second mode in late adolescence or early adulthood.

Two practice guidelines address OCD in youth: an independent expert consensus guideline4 and the American Academy of Child and Adolescent Psychiatry’s practice parameters for OCD.5

For uncomplicated OCD, these guidelines recommend CBT as first-line treatment. If symptoms do not respond after six to eight sessions, a selective serotonin reuptake inhibitor (SSRI) is added to CBT.

For complicated OCD, medication is considered an appropriate initial treatment. Complicated OCD includes patients who:

  • display severe symptoms—such as with scores >30 on the Children’s Yale-Brown Obsessive Compulsive Scale (CY-BOCS)
  • or have comorbidity such as depression or panic disorder that is likely to complicate treatment.


OCD is remarkably resistant to insight-oriented psychotherapy and other nondirective therapies. The benefits of CBT, however, are well-established, with reported response rates of >80% in pilot studies.6,7 Although confirming studies have yet to be conducted, successful CBT for pediatric OCD appears to include four elements (Table 1).

Exposure and response prevention (EX/RP) is central to psychosocial treatment of OCD.7,8 In specialized centers, exposure can be applied intensively (three to five times per week for 3 to 4 weeks).9 In most practices, however, exposure is more gradual (weekly for 12 to 20 weeks). With repeated exposure, the child’s anxiety decreases until he or she no longer fears contact with the targeted stimuli.8,10

Not ‘misbehavior.’ Children—and less commonly adolescents—with this disorder may not view their obsessions as senseless or their compulsions as excessive. Even when insight is clearly present, young OCD patients often hide their symptoms because of embarrassment or fear of being punished for their behavior.

Response predictors. A key to CBT in children or adolescents is that they come to see obsessions and compulsions as symptoms of an illness. The symptoms, therefore, require a skillfully applied “antidote,” as taught by the clinician and implemented by the child, family, and others on the child’s behalf. Besides overt rituals, three response predictors include the patient’s:

  • desire to eliminate symptoms
  • ability to monitor and report symptoms
  • willingness to cooperate with treatment.

Table 1

Pediatric OCD: 4 keys to successful cognitive therapy

Treat OCD as a neurobehavioral disorder, not a misbehavior

Help the child develop a “tool kit” to manage dysphoria and faulty thinking

Expose the patient to anxiety-producing stimuli until he or she becomes desensitized and can refrain from the usual compulsive responses (exposure and response prevention)

Educate family members and school personnel

CBT may be difficult with patients younger than age 6 and will invariably involve training the parents to serve as “coaches;” a CBT protocol for patients ages 4 to 6 is under investigation (H. Leonard, personal communication). CBT also can be adapted for patients with intellectual deficits. 11

A ‘tool kit.’ Successful exposure therapy for OCD relies on equipping children and adolescents with the knowledge and skills to battle the illness. They often have tried unsuccessfully to resist OCD’s compulsions and must be convinced that EX/RP techniques will work. Using a “tool kit” concept reminds young patients that they have the implements they need to combat OCD (Table 2).

A ‘germ ladder’ and ‘fear thermometer.’

Adam’s tools include a stimulus hierarchy called a “germ ladder,” which the therapist and Adam create collaboratively. It ranks stimuli from low (his own doorknob) to very high (public toilets, sinks, and door handles).

As part of his treatment, Adam begins to touch objects in his room and house while voluntarily refraining from ritualizing. He uses another tool—a fear thermometer—to record his distress level on a scale of 1 to 10 during and after these exposures.

Adam discovers that when he comes into contact with less-threatening items his fear ratings typically return to baseline within 20 to 30 minutes. This insight helps him modify his assessment of the risk they pose.

Table 2

OCD ‘tool box’ can help patients build new behaviors



Training in exposure response prevention (EX/RP) therapy

Helps patients learn to confront rather than avoid feared stimuli

‘Fear thermometer’

Enables patients to express the intensity of their distress on a scale of 1 (lowest) to 10 (highest)

Positive self-statements

Teaches patients to use statements such as “I can do this” and “I’m the boss of OCD now” to build confidence that they can control their response to feared stimuli

During office visits, he confronts similar items around the clinic, with the therapist providing encouragement and instruction for additional exposure homework. Eventually Adam works on the clinic’s public bathroom, which he perceived to be relatively clean but less so than his own bathroom. After fear in response to this bathroom is reduced, the therapist and Adam graduate to more-public facilities, such as the bathrooms at Adam’s pool and the local train station.

Exposure therapy. EX/RP is most successful when the child—rather than the therapist—chooses exposure targets from a hierarchy of fears,2 particularly when the list includes behaviors the child is resisting. In a collaborative spirit, the child takes the lead in placing items on the hierarchy and deciding when to confront them.

The therapist and child revise the hierarchy periodically, which demonstrates progress and allows them to add items as the child overcomes fears that cause less distress.

Reducing need for reassurance.

Adam has a habit of repeatedly asking his mother whether contact with particular objects in public is risky. By the third treatment session, he and the therapist agree that he will try to refrain from asking such questions.

His mother, in turn, is asked to reiterate the rationale for response prevention whenever Adam slips. She will offer encouragement and support without answering “OCD’s questions.”


While Adam is working with the behavioral therapist to reduce his anxieties and need for reassurance, he is also receiving gradually increasing dosages of sertraline. As discussed, he is considered a candidate for CBT plus medication because of his symptoms are severe. Drug treatment can benefit most pediatric OCD patients.

SSRIs. Two SSRIs are approved for pediatric OCD—fluvoxamine for ages 8 to 18 and sertraline for ages 6 to 18. Most SSRIs are likely effective for OCD in youth (Table 3), 12-14 although reports have suggested a link between paroxetine and suicidality in pediatric patients. Other options may be more suitable choices unless further evidence supports the use of paroxetine as a first- or second-line agent for pediatric OCD.

Clomipramine—a nonselective tricyclic—was the first medication studied in treating OCD in children and adolescents. It is now usually considered only after two or three failed SSRI trials because of its potential for cardiac toxicity.15-17

Table 3

Suggested dosages (mg/d) for drug therapy of pediatric OCD


Usual starting dosage

Approximate mean dosage*

Typical range

Usual maximum dosage




20 to 60










10 to 20





40 to 60





150 to 250







*Mean dosage derived from registration trials, expert recommendation, and the authors’ clinical experience

Dosing. Fixed-dose studies suggest that dosing schedules for OCD are similar to those used for depression. For example, sertraline, 50 mg/d, or fluoxetine, 20 mg/d, are as effective as higher dosages. 18

The common misconception that OCD requires higher dosages likely results from:

  • increasing the dosage too early in the time-response window for a drug effect to emerge
  • giving medication without concomitant exposure therapy. 19

Delayed response. Although many patients respond early to an SSRI, others do not respond until 8 or even 12 weeks of treatment at therapeutic dosages. It often takes 3 to 4 weeks for evidence of benefit to emerge, so wait at least 3 weeks between dosage increases. Maintain therapeutic dosages at least 6 to 8 weeks before changing agents or beginning augmentation therapy.

Two-barrel approach.

In treating Adam, we began with sertraline, using a flexible titration schedule keyed to whether he experienced OCD symptom remission.

The starting dosage of 50 mg was titrated to 150 mg over 8 weeks while he was receiving behavioral therapy. We made adjustments with a time-response window of 2 to 3 weeks, allowing us to observe a response to each dosage escalation.

Adam’s OCD symptoms responded well to CBT plus sertraline. The maximum drug effect helped him confront the most difficult EX/RP tasks at the top of his stimulus hierarchy, which he attacked near the end of treatment.

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