Intensive Treatment of Pediatric OCD: The Case of Sarah

Lara J. Farrell, Rachel Sluis, and Allison M. Waters

School of Applied Psychology and Menzies Health Institute QLD, Griffith University
While cognitive behavior therapy (CBT) either alone or in combination with pharmacotherapy (e.g.,
selective serotonin reuptake inhibitor) has received strong empirical support for obsessive-compulsive
disorder (OCD; Geller & March, 2012), this treatment is often inaccessible for children and their families.
Barriers to accessing CBT include a lack of trained therapists, clinician and patient beliefs about CBT,
and geographical and financial barriers (Goisman et al., 1993; Marques et al., 2010; Turner, Heyman,
Futh, & Lovell, 2009). Furthermore, while the majority of therapists endorse a CBT orientation, exposure
therapy is rarely used in routine clinical practice (Whiteside, Deacon, Benito, & Stewart, 2016). This
case study therefore describes an intensive 2- or 3-session treatment of childhood OCD (e.g., Farrell
et al., 2016) to improve efficient and rapid delivery of evidence-based treatment. The case of Sarah
illustrates this intensive treatment model and highlights clinical considerations for therapists when
delivery a concentrated, time-limited treatment.  C 2016 Wiley Periodicals, Inc. J. Clin. Psychol.: In

Session 72:1174–1190, 2016.

Keywords: OCD; CBT; exposure therapy; intensive treatment

Obsessive-compulsive disorder (OCD) is a severe mental health disorder, which during childhood
is associated with significant impairments at home (Cooper, 1996; Piacentini, Bergman, Keller, &
McCracken, 2003; Valderhaug & Ivarsson, 2005), with peers (Allsopp & Verduyn, 1990; Storch,
et al., 2006; Weidle, Jozefiak, Ivarsson, & Thomsen, 2014), and at school (Honjo et al., 1989; Toro,
Cervera, Osejo, & Salamero, 1992). Indeed, for many children with OCD, life can take a dramatic
turn in regard to their quality of life as well as that of other family members. While cognitive
behavior therapy (CBT) that incorporates exposure and response prevention (ERP) either alone
or in combination with pharmacotherapy (e.g., selective serotonin reuptake inhibitor [SSRI]) has
received strong empirical support (Gelller & March, 2012), this treatment is often inaccessible
for many children and their families; it is also a costly and lengthy commitment for families.
Research with adults suggests the majority of patients simply do not receive CBT treatment; that
is, they take medication alone or receive alternative (e.g., non-CBT) psychological treatments
(Blanco et al., 2006; Goodwin, Koenen, Hellman, Guardino, & Struening, 2002; Marques et al.,
2010). Sadly, it is also now widely accepted that only a small proportion of children with OCD
actually receive evidence-based CBT.
Barriers to accessing CBT for families include a lack of trained therapists, clinician and
patient beliefs about CBT (e.g., reluctance to engage in exposure therapy; Young, Ollendick, &
Whiteside, 2014), geographical and financial barriers, and the time intensive nature of treatment
(Goisman et al., 1993; Marques et al., 2010; Turner, Heyman, Futh, & Lovell, 2009). For
example, CBT for OCD may require children to attend upwards of 10 to 16 weekly sessions.
This time commitment can be challenging for families, especially when health service opening
hours frequently coincide with children’s school hours and parents’ work hours (Booth et al.,
2004). Consequently, there is a need to provide more cost- and resource-efficient, evidence-based
treatments to increase their accessibility.
Intensive approaches offer a number of advantages, including more rapid relief and recovery
from symptoms; provision of a service to families living outside the geographical location

Please address correspondence to: Lara J. Farrell; School of Applied Psychology & Menzies Health
Institute of QLD, Griffith University, Gold Coast Campus, Southport, QLD, Australia, 4222. E-mail:
l.farrell@griffith.edu.au

JOURNAL OF CLINICAL PSYCHOLOGY: IN SESSION, Vol. 72(11), 1174–1190 (2016) 

C 2016 Wiley Periodicals, Inc.

Published online in Wiley Online Library (wileyonlinelibrary.com/journal/jclp). DOI: 10.1002/jclp.22397

 Intensive Treatment of Pediatric OCD 1175

who would not otherwise have access to a practitioner trained in CBT for OCD; and various
efficiencies in regards to costs of treatment, particularly for families engaging in suboptimal
treatment approaches that lack empirical support (Farrell & Milliner, 2015; Whiteside et al.,
2014). Given the heightened distress that OCD inflicts upon the child and the entire family,
including the negative impact it can have on a child’s psychosocial and academic functioning,
more efficient delivery of therapy aimed at reducing symptoms for the child relatively quickly
may serve as both a more acceptable and effective approach to treatment.
In the only randomized controlled trial of intensive CBT for pediatric OCD to date, intensive
CBT delivered daily for 3 weeks was found to be as effective as weekly treatment (Storch et al.,
2007). While offering promise for more concentrated CBT, 3 weeks of daily therapy poses several
problems, including the potential for significant expense, due to short-term relocation to access
these specialized treatments for remote families; the potential burden of parental leave from
work; and issues related to children missing school.
In an effort to reduce this time burden, a novel 5-day intensive CBT approach that incorporates
10 sessions of CBT (2×50–75-minute sessions per day) has been developed and tested. In an
initial case series, reductions in OCD symptoms were observed for three adolescents with OCD
(Whiteside, Brown, & Abramowitz, 2008). In a subsequent study with 16 youth (aged 10–
18 years), significant reductions were observed in OCD severity from pre- to posttreatment, and
symptoms continued to decline out to the 5-month follow-up (Whiteside & Jacobsen, 2010).
Most recently, the effectiveness of the 5-day program was evaluated in a controlled baseline
trial (N = 22, aged 7–18 years), and OCD symptoms were improved after the baseline period;
moreover, at the 3-month follow-up, 65% of the sample was diagnosis free (Whiteside et al.,
2014).
While the aforementioned studies provide preliminary support for intensive CBT, they con-
tinue to follow a 1-hour session model delivered either once weekly or intensively across 1 to
3 weeks. An alternative, more concentrated model to treatment aimed at circumventing time and
costs associated with accessing treatments as well as potentially enhancing exposure therapy
outcomes involves even fewer CBT sessions, though for a longer duration (e.g., 2–3 exposure
sessions of up to 3 hours; Farrell & Milliner, 2015; Farrell et al., 2016). This approach stems
from the work of Öst (1989) and later Ollendick and colleagues (Ollendick et al., 2009), who
developed the one-session treatment approach for specific phobia in adults and children.
The basis for the approach is that concentrated, prolonged exposure may provide greater
opportunities for the extinction of fear through more continuous exposure to the feared stimulus,
thus allowing for greater consolidation of learning (Farrell & Milliner, 2015). Three-hour sessions
may provide a more efficient model as well as a stronger dose of exposure, relative to existing
1-hour sessions of CBT, which may only allow for up to 30 minutes a week/session of exposure;
that is, the opening and closing of hourly sessions–including reviewing homework, challenges,
reteaching the model of exposure, and reviewing and setting homework sessions–may consume
at least 30 minutes of time.
Farrell and Milliner (2015) described this treatment approach with an 11-year-old boy who
presented with severe OCD (Children’s Yale-Brown Obsessive-Compulsive Scale [CYBOCS]
score = 30; Scahill et al., 1997). Treatment comprised an education session, 2×3.5-hour massed
ERP sessions, followed by 3×45-minute weekly e-therapy (Skype) sessions. After treatment,
the boy displayed significant improvements on various measures of OCD severity. Delivering a
small number of web-based or telephone CBT sessions (Storch et al., 2011; Turner, Mataix-Cols,
Lovell & Heyman, 2009) after intensive sessions allows participants the flexibility to return home
and may also assist in the generalization of treatment gains across contexts within the home.
Indeed, both web (14 weekly sessions; Storch et al., 2011) and telephone (14 weekly sessions;
Turner et al., 2009) delivered CBT treatments have been found to be effective in preliminary
trials for pediatric OCD.
This two-session treatment has now been evaluated in a controlled multiple baseline design,
whereby 10 children and youth with severe OCD were given two ERP sessions after one session
of psychoeducation, combined with three brief weekly Skype sessions to assist in the at-home
maintenance of skills. Overall, there were significant reductions across time on almost all
measures; moreover, the majority of the sample (80%) were considered reliably improved and
1176 Journal of Clinical Psychology: In Session, November 2016

meeting the criteria for clinically significant change. At posttreatment, 60% were in remission of
symptoms, and at the 6-month follow-up, this increased to 70%. These findings collectively
provide promising support for intensive, time-limited approaches to ERP-based CBT for chil-
dren and youth with OCD and, importantly, may provide greater access and more rapid relief
to children and families with OCD. In the following section, we present a case example of this
time-limited intensive treatment approach, wherein the treatment involved psychoeducation,
followed by three (3 hour long) concentrated sessions of exposure therapy for a young girl with
severe OCD.

Presenting Problem and Client Description

Sarah (a pseudonym), a 12-year-old Caucasian female, was referred by her general practitioner to
participate in an intensive treatment program for OCD offered at Griffith University (Australia).
Consistent with a typical diagnosis of OCD during childhood, Sarah presented with a broad
range of obsessional symptoms related to contamination, religion, and her health; she also
displayed some magical-thinking obsessions. Her contamination fears primarily revolved around
germs (e.g., she was very fearful of contact with her father when he returned from work in his
dirty work clothes), fear of becoming sick from contamination (in particular a fear of vomiting),
and fear of contamination from food that might also make her sick. As such, Sarah reported
that she feared becoming ill or catching a disease from prepackaged food that someone else
had opened in her absence, food that did not look “quite right,” or food that someone else had
touched before her eating it.
Sarah’s underlying fear of contamination was that she would become extremely sick from
contamination, which would result in a violent vomiting episode. In an attempt to avoid becom-
ing contaminated and neutralize her fear of being contaminated by food, Sarah avoided certain
foods, engaged in excessive use of soap when washing her hands before and after eating, and
sought excessive reassurance from her mother that she would be ok if she ate certain types of
food. Sarah would also avoid using door handles or touching things when out in public to avoid
becoming contaminated by germs. In conjunction with being hypervigilant toward checking
food, she engaged in numerous “magical rituals” that she felt would protect her from becoming
sick. For example, she would repetitively check and rearrange the toothbrushes in the bathroom
to ensure the head of the toothbrushes in the bathroom were facing inwards toward each other,
rather than facing outward in the toothbrush holder because this reminded her of someone
leaning over a toilet and vomiting.
Sarah’s obsessional fears about dirt and germs also led her to avoid any contact with her
father when he returned from work until he had showered and changed, requesting that he
leave his work clothes in the laundry out of her sight and his work boots outside of the house.
Sarah’s father, Matthew, worked in the building industry and, as such, Sarah was concerned that
he would come into contact with asbestos that would be passed on to her. As a result of this
obsession, Sarah had avoided contact with her father for the past 6 months to the extent that
she would not hug or touch him at the time of her initial presentation. The avoidance caused by
fear of contamination from her father was having a detrimental effect on Sarah and Matthew’s
relationship and was extremely upsetting for both of Sarah’s parents.
In addition to her obsessions about becoming sick, Sarah was also extremely fearful of become
physically disabled or impaired; similarly, she was fearful that either she or a family member
would be diagnosed with cancer. She feared that she would wake up deaf or blind if she had been
exposed to loud noises or bright lights and that she would catch a disability from coming into
contact with others who had a disability. For example, Sarah reported that there was a child in
her class at school who had a “droopy eye,” as she described it. Sarah would avoid going near
or touching this child (or objects that this child had been in contact with) for fear of “catching
a droopy eye.”
Sarah’s fears of cancer led to a number of magical obsessions and compulsions to prevent
getting cancer. For example, she would consistently check her writing to make sure that each
letter she wrote was clearly separated; should any letters be touching, she believed that this would
cause either her or someone in her family to get cancer. Sarah was also fearful of the numbers
 Intensive Treatment of Pediatric OCD 1177

12, 17, and 21 because she believed these numbers would cause either herself or a loved one to
get cancer. As such, Sarah’s constant attempt to avoid these numbers meant that many of her
daily or school activities were either interrupted or completely avoided, which caused significant
interference. For example, Sarah reported that she found it difficult to read books because of
avoiding page numbers and would become distressed when doing math school work because she
found these tasks difficult to complete.
In order to neutralize her fears associated with cancer, Sarah would engage in a short mental
ritual that involved internally saying the name of each member of her family in relation to not
getting cancer (e.g., “mum won’t get cancer’). If Sarah’s mental ritual was interrupted, then she
would need to start over again, to complete saying each person’s name in relation to not getting
cancer.
At the time of presentation, Sarah was also tormented by religious obsessions, whereby she
had persistent thoughts that she would not wake up in the morning if she did not believe in
God. Sarah and her family were not religious and Sarah had not been raised with any religious
traditions, aside from celebrating Christmas and Easter. She also attended a public school and
had not been exposed to any religious beliefs or institutions aside from interactions with a few
peers at school who were religious. Sarah reported that she did not believe in God but was aware
that others held various belief systems relating to God and religion. Given that Sarah did not
believe in God, she was extremely fearful that she would not wake up each morning because of
being a nonbeliever. To decrease her distress relating to this fear, Sarah would ask her mother
repeatedly for reassurance before going to sleep at night that she would wake up in the morning
even though she did not believe in God.
While Sarah exhibited high levels of avoidance and checking related to each of her obsessional
fears, Sarah’s primary and most interfering compulsion involved constantly seeking excessive
reassurance from her mother. She would seek reassurance from her mother consistently through-
out all times of the day, as well as asking a ritualized set of questions relating to each of her
obsessional fears before going to bed each night.
Given that Sarah had been avoiding contact with her father over the previous 6 months, Sarah
would seek reassurance exclusively from her mother and insisted that she be the only one to
answer the ritualized set of questions before bed each night. This meant that Sarah would also
avoid sleeping the nights she spent at her grandparents’ or friends’ houses. Failure to answer the
set of ritualized questions before bed would result in extreme levels of distress in the form of
intense crying and screaming, which could last up to an hour. Given Sarah’s extreme levels of
distress when reassurance was not given, the degree of family accommodation, particularly from
her mother, was very high. While Sarah was experiencing substantial functional impairment at
school, the effect that OCD was having on the family and at home was causing severe interference,
which prompted Sarah’s parents to seek treatment. Please refer to Table 1 for a summary of
Sarah’s presenting symptoms.

Background History
Sarah was born in a major capital city in Australia, and she and her younger brother Nate (aged
5 years) lived with their biological parents in a middle-class suburb. Both of Sarah’s parents
worked full-time. Sarah was described as a shy, sensitive young child, who met all of her milestone
within normal time parameters. She was described as clingy and found initial separation difficult
when she started child care at 3 years of age. This settled down after a period of a few months,
once she had settled into her routine and was comfortable with the teachers. This was a pattern
for the commencement of each year at school, up until about 8 years of age. She attended a public
school located in the suburb where they lived, and her academic performance was above average
(but was deteriorating as a result of her symptoms over the past two school terms). Sarah was
quite creative and enjoyed drawing and creating colourful posters. Sarah also reported that she
had a few close friends at school that she enjoyed catching up with on the weekends; however,
this had decreased of late. Although Sarah had close relationships with all of her family, her
OCD symptoms had been interfering significantly in her relationships at home for the 6 months
before seeking treatment.
1178 Journal of Clinical Psychology: In Session, November 2016

Table 1
Summary of Sarah’s Presenting Obsessive-Compulsive Symptoms

Obsessions Compulsions

Contamination Become ill Checking food

Checking and arranging placement of toothbrushes
Excessive use of soap when washing hands
Avoiding food that is already unpackaged/ touched
Avoidance of door handles and objects in public places
Avoid touching/hugging dad
Reassurance seeking
Religious Won’t wake up if she doesn’t Reassurance seeking
believe in God
Health Will go deaf or blind Avoidance of loud noises and bright lights
Reassurance seeking
Will catch a disability Avoids with people who have a disability
Reassurance seeking
Will get cancer Repeated checking of written work
Repeated rubbing out and rewriting of written work
Mental ritual–safety phrase about family
Reassurance seeking
Unlucky numbers 12, 17, Avoidance of numbers
and 21

Sarah first experienced OCD-like symptoms 3 years ago, aged 9 years, when she was in
Grade 4 at primary school. Sarah’s mother, Dianne, reported that a stressful event happened
at school midway through Grade 4, whereby another child in Sarah’s class was physically ill,
vomiting on her desk, which was shared with Sarah. This resulted in Sarah becoming extremely
distressed, to the extent that she had to be collected from school immediately after the incident.
Dianne reported that Sarah’s first symptoms of avoidance and reassurance seeking started not
long after this incident; however, these were manageable up until the past 6 months when her
symptoms appeared to become more acute, diverse, and excessive. Her symptoms appear to have
been exacerbated when around this time her best friend from school moved interstate, triggering
a number of concerns regarding feeling more isolated that in turn caused Sarah to experience
significantly more anxiety when at school.
Dianne reported that she also experienced persistent anxiety, though she had never been
formally diagnosed. She reported that she too was hypervigilant about contamination from
germs and found it difficult to calm down when she felt anxious. She reported that she had felt
anxious for most of her life and indicated that her sister and mother also experienced persistent
anxiety throughout their lives. Dianne reported that her worries about Sarah’s OCD caused her
own anxiety levels to increase and expressed concern that she may have contributed to Sarah’s
problems. There was no family history of anxiety or OCD on her father’s side.

Assessment
After an initial interview, a number of assessments were administered as part of Sarah’s par-
ticipation in the research trial of intensive treatment for pediatric OCD. Dianne was inter-
viewed using the Anxiety Disorder Interview Schedule for Children, Parent Version (ADIS-
IV-C/P; Silverman & Albano, 1996) to identify anxiety, mood, and externalizing disorders
based on the Diagnostic and Statistical Manual of Mental Disorders Fourth Edition Text Re-
vision (American Psychiatric Association, 2000) criteria. Dianne was also interviewed using
the Kiddie-Sads-Present and Lifetime version diagnostic module (K-SADS-PL; Kauffman,
Birmaher, Brent, Rao & Ryan, 1996) to assess for autism spectrum disorder (ASD) and tic dis-
order symptomology. Sarah was administered the gold standard clinical interview for OCD, the
CYBOCS (Scahill et al., 1997) to assess the presence of obsessions and compulsions and the
 Intensive Treatment of Pediatric OCD 1179

overall severity of OCD. Her score (24) fell within the severe range of symptomology for OCD.
As is common with pediatric OCD, Sarah was also diagnosed with comorbid separation anxiety
disorder (SAD) and generalised anxiety disorder (GAD). Sarah did not meet criteria for ASD
or tic disorder.
Sarah also completed a number of diagnostic interviews and self-report measures to assess
general symptoms as well as her overall functioning. The Multidimensional Anxiety Scale for
Children (MASC; March 1997) was used to assess for comorbid anxiety symptomology, and the
Children’s Depression Inventory (CDI; Kovacs, 1992) was used to assess for comorbid depressive
symptoms. Sarah’s score on the MASC (total score = 35) and the CDI (total score = 4) fell
within the average range. Sarah’s OCD general functioning was rated using the Children’s Global
Assessment of Functioning Scale (CGAS; Schaffer et al., 1983). Her overall functioning on the
CGAS (55) fell within the range of “variable functioning with sporadic difficulties.”
Sarah’s three most troubling obsessions and compulsions were identified from the CYBOCS
interview and used to monitor her severity and response to treatment over the course of therapy.
This involved Sarah rating her distress on a scale of 0 (not bad at all) to 8 (very, very bad)
for each of her target OCD thoughts and behaviors. Her target symptoms were measured at
pretreatment, each treatment session, posttreatment, and the 3-month follow-up. Sarah’s three
target obsessions were as follows: (a) fears of getting cancer, (b) fears about not waking up in
the morning because I don’t believe in God, and (3) fears of becoming contaminated/unwell
from touching dirty things. Her three target compulsions were as follows: (a) night-time question
ritual with mum, (b) avoiding touching dad and his work clothes, and (c) mental ritual associated
with cancer (safety phrase for family members).

Case Formulation
The development and maintenance of Sarah’s OCD can be explained using a cognitive-
behavioral model (see Figure 1).

Predispositions. Sarah may have had a biological vulnerability for OCD given the strong
maternal history of persistent anxiety. Additionally, Sarah appeared to have a behaviorally in-
hibited temperament as a younger child and continues to be generally quite anxious, finding
separation from her parents particularly challenging at present. In conjunction with a biological
vulnerability, Sarah may also have been predisposed to developing anxiety through maternal
modeling of anxious behavior and experiencing a parental rearing style characterized by over-
involvement and overprotection—due to Dianne’s own anxiety difficulties. These early social
learning experiences may have served to increase Sarah’s hypervigilance and avoidant tendencies.

Precipitating events. The onset of Sarah’s OCD was precipitated by a particularly stressful
event at school–a child in close proximity to Sarah in her class was being physically ill. This
may have reinforced Sarah’s vigilance for danger and belief that the world is a dangerous place,
instilling a fear of illness and disease and sources of contamination. Sarah’s OCD symptoms
increased gradually over a period of 3 years; however, they became acutely worse after the loss
of her best friend from school, which may have left Sarah feeling isolated, vulnerable, and lonely.
Sarah’s obsessional thoughts were triggered by coming into contact with anything she per-
ceived to be contaminated by germs, illnesses, or disabilities (e.g., dad’s work clothes, certain
foods, people with disabilities). Her appraisals of threat likely play a strong role in perpetuating
her fears, due to her tendencies to overestimate the probability and severity of danger as well as
underestimate her ability to cope when confronted with triggers. Sarah also experienced magical
thinking biases, whereby she believed that thinking certain thoughts would lead to something
bad happening, a process described as thought–action fusion, whereby thoughts of danger are
fused with anxious feelings, making them feel more real and more likely to come true.

Perpetuations. In an attempt to prevent her obsessional thoughts related to germs and

illnesses coming true and reduce her heightened state of fear, Sarah would avoid external fear
triggers and engage in excessive ritualizing, In the short term, Sarah’s distress was temporarily
1180 Journal of Clinical Psychology: In Session, November 2016

Figure 1. A cognitive-behavioral formulation of Sarah’s OCD.

reduced as a result of avoiding triggers or engaging in rituals, checking, and hand washing
compulsions; however, these strategies prevented her from acquiring corrective evidence that
her obsessions were inaccurate and that she could indeed tolerate uncertainty. Thus, Sarah’s
avoidance and ritualizing behaviors served to maintain her dysfunctional beliefs and exacer-
bate her OCD symptoms through a vicious cycle of negative reinforcement of her anxiety
symptoms.
Sarah’s familial relationships may have also played a maintaining role in her OCD. Her
mother’s history of anxiety and hypervigilance toward germs likely led to the transmission of
these fear to Sarah via multiple pathways, including facilitating avoidance of germs; modeling
anxious avoidant responses when exposed to germs or illness; and sharing negative verbal
information about germs and illness (e.g., bathrooms are very dirty; you must always wash your
hands; be careful what you eat). Sarah’s avoidance coupled with her parents allowing her to
escape from anxiety triggers regarding illness thus prevented Sarah from acquiring corrective
evidence regarding her fears of contamination, health, and illnesses. As such, Sarah’s avoidance
behaviors and constant reassurance seeking from her mother have likely been reinforced from
an early age, subsequently maintaining and exacerbating the OCD cycle.
 Intensive Treatment of Pediatric OCD 1181

Table 2
Overview of Sarah’s Treatment

Session number Session Content

Psychoeducation (clinic) Psychoeducation

Nature and symptoms of OCD
Cycle of OCD
Causes of OCD
Introduction to ERP and rationale for intensive treatment
Fear thermometer and monitoring OCD
Rewards
The role of family accommodation in the maintenance of OCD
Session 1 CBT (clinic) Introduction to ERP
Review and psychoeducation
ERP hierarchy development
Practice of ERP in session: contamination, health, religion
Homework: Practice ERP at home with rewards
Session 2 CBT (home visit) ERP
In session ERP practice: contamination, health, religion
Practice ERP at home with rewards
Session 3 CBT (clinic) ERP
In session ERP practice
In session exposure to obsessional thoughts: Worry script (religious and
cancer fears)
Homework: Practice ERP to thoughts and stimuli being avoided

Note. OCD = obsessive-compulsive disorder; ERP = exposure and response prevention.

Furthermore, given Sarah’s extreme and extended reactions to OCD-related stress, both her
parents consistently accommodated to her demands in an attempt to de-escalate the distress
that this caused for the whole family. For example, Sarah’s mother always accommodated to the
demands of OCD by providing reassurance, and her father would make every effort to ensure
his work boots and work clothes were not even seen by Sarah, as well as showering when Sarah
demanded him to. This cycle of poor family functioning and family accommodation served
to maintain and escalate the ongoing pathological cycle of OCD and current family discord.
Figure 1 illustrates the cognitive-behavioral formulation.

Protective factors. Despite the persistent cycle of OCD that was detrimentally affecting
Sarah’s life and her family relations, she had loving and supportive parents who were motivated
towards improving her wellbeing. Sarah also had peer support in the form of a few close friends
with whom she shared common interests. Furthermore, Sarah appeared to show a moderate to
high level of insight into her OCD symptoms, acknowledging the irrationality of her magical
obsessions, which she agreed could not possibly cause cancer.

Course of Treatment
Sarah attended an intensive treatment program for OCD offered at Griffith University. The
treatment involved a single 1.5-hour psychoeducation session, which occurred immediately after
assessment, followed by three weekly 3-hour intensive sessions of CBT (one of which was
conducted as a home visit; see Table 2 for summary). Sarah and her mother attended each
appointment together, with her father being present for sessions 1 and 3.

Psychoeducation
Sarah and both her parents attended the initial psychoeducation session. This occurred imme-
diately after the initial assessment session, at the same clinic visit, to reduce the time burden on
1182 Journal of Clinical Psychology: In Session, November 2016

the family and enhance the overall efficiency of the treatment. Psychoeducation included the
following components:

r What is OCD? And what are the different faces of OCD (e.g., symptom clusters)?
r The causes of OCD, including developing a neurobehavioral framework
r The cycle of OCD, including the role of neutralizing and avoidance behaviors
r The importance of externalizing OCD–“giving OCD a nickname” to cultivate detachment
from OCD and help the family ally with the child to fight OCD
r Facing and fighting OCD–providing a rationale for intensive ERP, including establishing fear
hierarchies
r Using a fear thermometer (0–10) to rate levels of distress or avoidance and monitor OCD
symptoms
r Establishing a reward system to provide motivation for ERP
r The role of family accommodation in the maintenance of OCD and plans for reducing family
accommodation in treatment.

Given that an intensive treatment approach, such as the one described herein, requires com-
mencing ERP in session 1, the psychoeducation session is viewed as paramount in terms of
readying the child and family for therapy. The session provides a rationale for the treatment
approach and describes the intensive sessions as a “kick-start” to overcoming OCD; it also
highlights the importance of both between-sessions ERP practice and ongoing ERP after the
three intensive sessions.
During this session, Sarah was provided with a workbook to record homework tasks and
monitor her progress throughout the program. Given the high levels of family accommodation,
Sarah’s parents were also provided with education on how to monitor signs of accommodation
to OCD and develop plans to gradually reduce accommodation over the course of therapy while
providing a warm and supportive environment for Sarah. Parents are never encouraged to cease
accommodation in the early stages of treatment because this often leads to distress for the child
equivalent to the top of their fear hierarchies; however, in collaboration with their child, they
are encouraged to develop graded step ladders for the gradual reduction and withdrawal of
accommodation behaviors.

Intensive Exposure and Response Prevention

Consistent with routine practice of expert CBT for childhood OCD, the majority of Sarah’s
intensive treatment sessions involved ERP, which was graduated, therapist assisted, and done at
a pace that Sarah found manageable. Given the nature of the intensive treatment approach, the
structure and format of treatment sessions require careful consideration. For example, it is often
advisable to schedule sessions in the morning to assure optimum engagement from the child
when he or she is more likely to feel refreshed and rejuvenated. Should afternoon appointments
be unavoidable, then it is recommended that the child have no other commitments during the
afternoon, allowing for some quiet time after the ERP session. During the session, brief breaks
are offered as required, depending on the child’s motivation and momentum during intensive
ERP; these usually comprise either one break halfway through the session or a break each hour.
Furthermore, to extinguish fear across multiple contexts and attenuate renewal of conditioned
responding, in-session intensive ERP is often conducted outside of the therapy room. This tends
to foster an increase in the child’s engagement in therapy and prevents potential fatigue that may
occur as a result of long-drawn-out hours of sitting in one room. Finally, while intensive ERP
treatment is occurring, a reduction in homework is usually recommended so as not to “wear the
child out” and exhaust his or her motivation to engage in therapy.
During intensive ERP, Sarah’s exposure hierarchies were formed for each major symptom
cluster of her OCD and broken down into steps from the least distressing to the most distressing
fear to be addressed. Sarah completed most ERP sessions with her mother; however, she was
encouraged over the course of treatment to complete ERP tasks on her own to demonstrate that
 Intensive Treatment of Pediatric OCD 1183

she could cope and would habituate to the anxiety without her mother’s support (and to some
extent reassurance).
To further enhance ERP and help address her dysfunctional beliefs, Sarah was provided with
education about the various “OCD thinking traps.” This involved challenging her thought–
action fusion beliefs (e.g., challenging beliefs that thinking something bad will make something
bad happen); her overvalued sense of responsibility (e.g., not doing a compulsion doesn’t make
it my fault if something bad happens); and beliefs about controlling of her thoughts (e.g., I can’t
control my thoughts, but I can control me!). Furthermore, Sarah and the therapist discussed
and practiced powerful thinking strategies she could use to increase her strength and gain more
control over OCD, which was termed “bossing back OCD.” Sarah made a list of bossing back
thoughts she could use to change her cognitive response to the occurrence of intrusive thoughts
and contamination triggers, such as “go away OCD, you’re just playing tricks on me again” and
“icky, sticky dirt and germs, I can cope with you on my terms!” Sarah was encouraged to write
her bossing back self-talk on cards that she could place around the house to remind her to fight
OCD.
The focus of Sarah’s treatment began with targeting her most pervasive OCD symptoms (fear
of becoming contaminated and vomiting); however, for her to experience early success and gain
confidence in continuing with facing and fighting OCD, her first exposures were developed to
target symptoms she perceived to be the most manageable to work on. The intensive treatment
approach philosophy that was shared with Sarah was to “creep up on OCD” by starting very
small and very slow, and then with some wins, “go, go, go!” In our experience, we find that if
children have multiple small successes during the first couple of hours of their session 1 intensive,
then they are more likely to engage in more substantive and regular practice over the week after
this session. It is equally important that parents are encouraged to look for early small ERP
successes and discouraged from placing pressure on their children to fight all of their OCD from
the outset. Both the child and parents are often reminded of the old fable of “the tortoise and
the hare.”
Upon engaging in ERP, Sarah and the therapist collaboratively agreed upon specific tasks and,
before completing them, Sarah was encouraged to predict her anxiety ratings during the task as
well as what OCD might make her fearful of happening. The purpose was to encourage Sarah
to discover new information about the stimuli and herself that would challenge her obsessional
beliefs and dysfunctional expectancies for danger as well as her ability to cope. Each ERP
was developed to ultimately involve complete response prevention (no ritualizing afterwards);
however, in some cases when this was too difficult, Sarah was encouraged to “mess with OCD,”
which involved either delaying the compulsion or doing it differently, such as shortening the
compulsion, or doing it in a silly way (e.g., say it backwards, do the habit with your eyes closed).
For example, Sarah found her mental ritual for cancer (i.e., “mum won’t get cancer”) the most
difficult compulsion to prevent. Therefore, she was initially encouraged to do it in a silly way (e.g.,
singing it to herself, or saying it like Yoda, “cancer, she will not get”) until she was eventually able
to say something that conflicted with the mental ritual, such as “maybe mum will get cancer–oh
well.”
During each ERP task, subjective units of distress (SUDs, on a scale 0 to 10) ratings were
monitored at both the start of the task and regular time intervals throughout the task. Sarah
was also taught the importance of staying in each exposure task until her anxiety levels reduced
by at least half in order for habituation to occur. For each ERP task that Sarah completed, she
was surprised to learn that her actual anxiety was often lower in intensity and reduced much
quicker than she had predicted and, further, that she could indeed tolerate the anxiety which
would always subside. Sarah also learned through ERP that her feared outcomes did not occur
and that she was able to tolerate the uncertainty of not knowing whether or not something bad
might happen.
Once Sarah had experienced considerable success addressing her contamination fears through
exposure hierarchies (which she chose to work on first), she and the therapist collaboratively
developed a hierarchy to expose her to the content of her obsessional fears related to cancer.
Given that she had achieved greater confidence in facing and fighting OCD and gained a
sound awareness and understanding of the cognitive strategies she could use to address her
1184 Journal of Clinical Psychology: In Session, November 2016

Table 3
Example Exposure Hierarchy for Intensive ERP Session 1 (Not All ERP Steps Listed)

Pre-SUDs Post-SUDs
ERP steps Exposure task Response prevented 0–10 0–10

Hour 2 Clinic
Steps 1–2 Eat biscuit snack that had Asking mum, “Will I be ok 4 0
been on the therapy room after eating that?”
floor for 5 seconds
Step 3 Follow a trail of biscuit Asking mum, “Will I be ok 5 0
snacks from the therapy after eating that?”
room to outside the clinic
and eat them on the way
Step 4 Put a biscuit snack on the Asking mum, “Will I be ok 6 0
handrail of the escalator after eating that?”
and eat it once it reached
her at the bottom of the
escalator
Steps 5–6 Eat a sandwich that had Asking mum, “Will I be ok 6 1
been on the ground for 30 after eating that?”
seconds outside the clinic No rinsing mouth out
afterwards
Step 7 Eat a sticky lollipop that Asking mum, “Will I be ok 8 1
had been touched by the after eating that?”
therapist and put on the No rinsing mouth out
ground for 30 seconds afterwards
outside the clinic
Hour 3 Clinic
Step 1 Go over to hospital and sit Asking mum, “Will I catch 4 0
on seats in waiting area something from sitting on
where people with this seat?”
illnesses or disabilities
had sat
Step 2 Sit next to someone in Asking mum, “Will I catch 5 1
waiting area at hospital something from sitting
who may be sick next to this person?”
Steps 3–5 Sit in-between two people in Asking mum, “Will I catch 6 1
waiting area at hospital something from sitting
who may be sick next to these people?”
Step 6 Rub hands on seats in Asking mum, “Will I catch 7 2
waiting area at hospital something from licking
and then lick hands this seat?”
No washing hands or
rinsing mouth out

Note. ERP = exposure and response prevention; SUDs = subjective units of distress.

dysfunctional beliefs, she felt more confident and capable of addressing her most distressing
obsession.
Once the least distressing steps in Sarah’s hierarchy for exposure to the obsessional content
of cancer had been achieved, the final step involved writing a detailed script about her worst
conceivable fears of her mother dying from cancer. As a home practice ERP task, Sarah made
a voice recording of herself reading the script and listened to it on a continuous loop every day
until her SUDs decreased to a 1 or a 2. While this was a distressing task for Sarah to engage in
at first, she habituated to the anxiety and eventually the strength of her OCD declined such that
she became bored with the script and was no longer afraid of OCD-related words. Tables 3, 4,
and 5 present an overview of the ERP tasks that Sarah engaged in during her intensive sessions.
 Intensive Treatment of Pediatric OCD
Table 4
Example Exposure Hierarchy for Intensive ERP Session 2 (Not All ERP Steps Listed)
ERP steps Exposure task
Hour 1 Home
Step 1 Touch dad’s dirty work
clothes with one hand for
30 seconds
Step 2 Touch dad’s dirty work
clothes with two hands
for 30 seconds
Step 3 Take dad’s dirty work
clothes from his bedroom
to the laundry
Steps 4–5 Touch dad’s work boots and
bring them inside at the
front door
Step 6 Hug dad for 1 minute while
he’s wearing his dirty
work clothes
Hour 2 Home
Steps 1–3 Shine torch light into eyes
for 2 seconds increasing
the brightness each time
Steps 3–6 Listen to favorite song at
increasing volume levels
Step 7 Have a fake disco in
darkened bedroom with
loud music and bright
torch light being
intermittently shone into
eyes
Hour 3 Home
Steps 1–3 Write worry script about not
waking up in the morning
if I don’t believe in God
Step 4 Lie down on bed in
darkened bedroom with
eyes closed and have
worry script read by
therapist
Step 5 Lie down on bed in
darkened bedroom with
eyes closed and have
worry script read by mum
Step 6 Read worry script herself
out loud
Note. ERP = exposure and response prevention; SUDs = subjective units of distress.
1185
Pre-SUDs Post-SUDs
Response prevented 0–10 0–10
Washing hands 2 0
Asking mum, “Will I catch
something or get sick from
touching dad’s clothes?”
Washing hands 4 0
Asking mum, “Will I catch
something or get sick from
touching dad’s clothes?”
Washing hands 4 0
Asking mum, “Will I catch
something or get sick from
touching dad’s clothes?”
Washing hands 5 1
Asking mum, “Will I catch
something or get sick from
touching dad’s clothes?”
Washing hands 7 2
Asking mum, “Will I catch
something or get sick from
touching dad’s clothes?”
Asking mum, “Will I go deaf 4 0
and blind?”
Asking mum, “Will I go deaf 4 0
and blind?”
Asking mum, “Will I go deaf 7 0
and blind?”
Asking mum, “Will I wake up 4 0
in the morning if I don’t
believe in God?”
Asking mum, “Will I wake up 5 0
in the morning if I don’t
believe in God?”
Asking mum, “Will I wake up 6 1
in the morning if I don’t
believe in God?”
Asking mum, “Will I wake up 7 1
in the morning if I don’t
believe in God?”
1186 Journal of Clinical Psychology: In Session, November 2016

Table 5
Example Exposure Steps for Intensive ERP Session 3 (Not All ERP Steps Listed)

ERP Response Pre-SUDs Post-SUDs

steps Exposure task prevented 0–10 0–10

Hour 1 Clinic
Step 1 Write a sentence with two Don’t rub out and rewrite 3 0
letters touching Don’t perform mental ritual for
cancer
No reassurance seeking from mum
Steps 4–5 Write the sentence, “I might Don’t rub out and rewrite 5 1
get cancer” with all letters Don’t perform mental ritual for
touching cancer
No reassurance seeking from mum
Step 6 Write the sentence, ‘My mum Don’t rub out and rewrite 6 2
will get cancer’ with all Don’t perform mental ritual for
letters touching cancer
No reassurance seeking from mum
Hour 2 Clinic
Step 1 Write down numbers 12, 17, Don’t rub out 3 0
and 21 Don’t perform mental ritual for
cancer
No reassurance seeking from mum
Step 2 Do math problems involving Don’t rub out 3 0
feared numbers Don’t perform mental ritual for
cancer
No reassurance seeking from mum
Steps 5–6 Write down “mum will get Don’t rub out 6 1
cancer” on pages 12, 17, Don’t perform mental ritual for
and 21 in various books cancer
owned by Sarah and read No reassurance seeking from mum
these every day
Hour 3 Clinic
Step 1 Write down list of words Don’t perform mental ritual for 3 0
associated with cancer cancer/No reassurance seeking
from mum
Steps 3–4 Write a detailed script about Don’t perform mental ritual for 6 1
her mother dying from cancer
cancer and say aloud No reassurance seeking from mum
Steps 5–6 Make a recording of the Don’t perform mental ritual for 6 2
script for her mother cancer
getting cancer No reassurance seeking from mum
Steps 7–8 Listen to loop recording of Don’t perform mental ritual for 8 2
script every day until cancer
SUDs reduces to 1 or 2 No reassurance seeking from mum

Note. ERP = exposure and response prevention; SUDs = subjective units of distress.

Intensive ERP Session 1

The first hour of intensive ERP session 1 was spent reviewing Sarah’s progress over the previous
week, reviewing the psychoeducation information and rationale for ERP that was presented in
the previous session, and providing an overview of the OCD thinking traps, which also involved
having Sarah create her own bossing back OCD thoughts. When commencing intensive ERP,
it is important for the therapist to maintain a confident and strong approach, additionally
providing the child with lots of positive reinforcement when conducting exposure tasks to
 Intensive Treatment of Pediatric OCD 1187

elicit motivation and encourage a fighting spirit (all the while being careful not to provide
reassurance).

Intensive ERP Session 2

At the start of intensive ERP session 2, Sarah’s homework was reviewed with the therapist.
Sarah demonstrated through the completion of her homework tasks that she was able to cope
with more than she had anticipated and had gained a greater level of confidence to attack some
more challenging tasks during the home visit. Given Sarah’s increased confidence and success in
facing and fighting OCD thus far, she and the therapist agreed to tackle slightly more challenging
tasks during ERP session 2. While tasks completed were more challenging, Sarah felt a greater
sense of achievement after learning that she could indeed complete the tasks she had previously
thought would be too hard for her.

Intensive ERP Session 3

On the basis of Sarah’s successes and mastery of ERP tasks during prior sessions, intensive ERP
session 3 focused predominantly on exceeding the limits or “overlearning,” whereby Sarah was
encouraged to go beyond what would be deemed normal exposure to feared stimuli. Taking
an overlearning approach helps ensure longer term retention of positive gains made during
therapy, puts their uncertainty beliefs to the test, and teaches children that they can tolerate
significant discomfort. In addition to conducting tasks to exceed the limits in-session, Sarah was
encouraged to take an overlearning approach to homework tasks at this point. For example,
Sarah decided to let her dad sleep in her bed with her for the night–in his work clothes!

Relapse Prevention
Relapse prevention occurred toward the end of intensive session 3, and involved informing Sarah
and her mother that setbacks can occur and teaching them approaches for managing relapse
prevention. The therapist discussed with Sarah the many faces of OCD (OCD in disguise) and
taught her how to recognize the onset of different OCD symptoms. Sarah and her mother
also collaboratively generated alternative exposure hierarchies to practice skills in developing
different hierarchies.
After this, Sarah was encouraged to identify stressful situations that may put her at higher
risk for OCD setbacks, such as returning to school after being on school holidays. Sarah and the
therapist collaboratively discussed strategies she would use if setbacks occurred. These involved
using her “strong team” or “OCD army” for support; acting early; noticing the “nervous” and
“uncomfortable” feelings that OCD causes; facing and fighting OCD; and identifying stressful
situations that may make OCD more likely to reappear. Given that Sarah had more time
available to her now that she wasn’t spending hours engaging in obsessions and compulsions, the
remainder of the final session was spent discussing “life without OCD.” Sarah was encouraged
to identify “healthy habits” that she could put to use, such as spending more time with friends,
making posters, and spending more one-on-one time with mum or dad.
Concluding the final session, the therapist and Sarah outlined a plan for home practice ERP
tasks over the course of 3 weeks after intensive ERP session 3. The therapist also arranged with
Sarah and her family to make weekly 15 minute calls to check on Sarah’s progress and address
any issues or challenges that might arise during home practice.

Outcome and Prognosis

A systematic assessment that occurred 1 month after the third session (allowing time for Sarah
to continue practicing ERP at home) revealed that Sarah’s OCD symptoms had significantly
declined after treatment. Her CYBOCS score was 4, indicating OCD within the normal range.
In addition, Sarah no longer met criteria for OCD, on the basis of the ADIS-P interview, or
for SAD and GAD. Sarah’s three most distressing target thoughts and behaviors also showed
1188 Journal of Clinical Psychology: In Session, November 2016

8
7
6
5
4
3 Fear of Geng
2 Cancer
1
0

Figure 2. Sarah’s ratings for her target obsession of getting cancer from pre- to posttreatment and 3-week
follow-up calls.

systematic improvement: At posttreatment Sarah rated her distress at 0 (out of 8) for each.
Figure 2 shows Sarah’s ratings from pre- to posttreatment and 3-week follow-up calls for her
most distressing obsessional fear of getting cancer.

Clinical Practice and Summary

This case describes a concentrated, time-limited approach to CBT for pediatric OCD, which
involved ERP over three sessions. The outcomes offer promise for more efficient models of
treatment delivery and accessibility and, importantly, more rapid improvements for children
who are often chronically and severely impaired. In particular, this approach may provide a
more efficient and cost-effective means for patients to access specialist clinic-based treatment.
While Sarah’s treatment was delivered weekly, this approach could occur over 3 days at a
specialist center, reducing both time away from school and work and accommodation costs for
families who need to travel to seek treatment.
Although the majority of therapists endorse a CBT orientation and use of CBT techniques,
exposure therapy is rarely endorsed in routine clinical practice for childhood anxiety disorders
(Whiteside, Deacon, Benito, & Stewart, 2016). This case study and the associated program of
studies from which this intensive treatment approach to childhood OCD has been developed (e.g.,
Farrell et al., 2016) suggest that exposure therapy is indeed critical to successful outcomes and in
fact suggest that therapists should be using even longer and more frequent sessions of exposure
therapy with children who have OCD. Such work has implications for graduate clinical training
programs and challenges common misperceptions about exposure therapy. Furthermore, this
approach encourages therapists to think flexibly about therapy location; acquire the skills and
confidence in delivering exposure therapy within clinic, home, and community contexts; and
make use of e-therapy applications such as Skype to conduct booster and follow-up sessions as
required.
Finally, through fewer sessions of longer duration exposure therapy, this intensive approach
to treating childhood OCD may also be more effective in targeting key mechanisms proposed in
contemporary learning models, such as the acquisition of new learning and distress tolerance,
than traditional approaches involving more sessions of shorter duration (Abramowitz, 2013;
Craske et al., 2008). Such work encourages further studies on the benefits and cost-effectiveness
of intensive treatment approaches for childhood OCD.

Conclusion
In conclusion, we highlight a number of important clinical considerations.
First, given that the idea of exposure therapy is often distressing for children and their parents,
it is essential in a time-limited framework such as this to provide a very clear rationale for the
 Intensive Treatment of Pediatric OCD 1189

approach early on. This can be achieved by providing psychoeducation on the nature of OCD
and the treatment of OCD as early as possible, such as at the end of the assessment session. By
doing this, the therapist begins socializing the child and parents to the approach from the outset.
Second, to be effective and enhance motivation and compliance, it is essential that the therapist
be focussed on building alliance and rapport with the child and parents from the very initial
contact with the family.
Third, the intensive sessions should be booked no more than a week apart, to maximize
compliance and engagement–larger time intervals between sessions may facilitate avoidance of
committing to the intensive nature of both within-session and between-session exposure practice.
Finally, the intensive approach should be viewed as a kick-start to therapy; as such, therapists
are encouraged to make plans with clients for regular, albeit brief, check-ins with the family
to ensure compliance with exposure practice after the concentrated treatment. Furthermore,
booster sessions, spaced monthly, then 3-monthly and 6-monthly, may facilitate generalization
of gains and prevent relapse.

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1190 Journal of Clinical Psychology: In Session, November 2016

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