Exposure and Response Prevention for Obsessive-Compulsive Disorder (OCD)

The majority of the work in helping your child or teen “boss back” the OCD will involve your child gradually facing his/her fears via exposure as outlined in the prior sections on this page. However, there are several key differences, as follows:

  • Unlike other types of anxiety where ladders generally have 10-20 steps, OCD ladders often have many more steps within each category. For example, it is not uncommon for a teen with contamination fears to have a ladder with 50 or more steps on it. You will also want to have different ladders for each fear category, such as a contamination ladder, a symmetry ladder, etc.
  • In facing fears for other types of anxiety, the exposure “challenge” is being in the situation (e.g. staying home alone for 5 minutes). However, in OCD, the child must not only be exposed to the feared situation (e.g. touch dirty floor) but also must do something to block or prevent the compulsion (e.g. not wash hands), which is called “response prevention.” Thus, in OCD, the child does exposure and response-prevention (E/RP).
  • In OCD, some exposure steps will require changing the compulsion or ritual. For example, OCD makes your child wash her/his hands with 3 pumps of soap, for 3 minutes, with 3 paper towels. The first exposure step might be to use 2 pumps, for 2 minutes, with 2 paper towels. However, other steps on your child’s OCD ladder might require eliminating the ritual entirely. For example, OCD makes your child wash his/her hands after touching a doorknob. The exposure step would be to not wash hands at all.
  • In doing E/RP, some “challenges” will take longer than in others for your child to overcome. It’s not unusual for children’s fear ratings to remain high for upwards of an hour or more. Stay with it, and remember not to end the exposure until the rating comes down by half.
  • Alternatively, if your child’s anxiety rating rapidly drops to 0 after a few minutes of the exposure, be suspicious. OCD loves to trick youth into making deals. For example, you have coached your child to touch a dirty rag and not wash her/his hands. His/her rating climbs to 6 in the first 3 minutes, but after 5 minutes he says he’s no longer anxious. On further questioning, you learn that OCD convinced your child to sneak a hand wash 15 minutes from now when you plan to collect your other child from soccer.  Be careful not to blame your child. Rather, praise him for being honest and join forces to prevent further OCD trickery.