Family-Based Treatment For Young Children With OCD Workbook

Family-Based Treatment for Young Children With OCD
EDITORS-IN-CHIEF
Anne Marie Albano, PhD
David H. Barlow, PhD
SCIENTIFIC
ADVISORY BOARD
Gillian Butler, PhD
David M. Clark, PhD
Edna B. Foa, PhD
Paul J. Frick, PhD
Jack M. Gorman, MD
Kirk Heilbrun, PhD
Robert J. McMahon, PhD
Peter E. Nathan, PhD
Christine Maguth Nezu, PhD
Matthew K. Nock, PhD
Paul Salkovskis, PhD
Bonnie Spring, PhD
Gail Steketee, PhD
John R. Weisz, PhD
G. Terence Wilson, PhD

Family-Based
Treatment for Young
Children With OCD
W o r k b o o k
Jennifer B. Freeman • Abbe Marrs Garcia
1
2009
1
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About ProgramsThatWork TM
One of the most difficult problems confronting the parents of children with
various emotional and behavioral disorders is finding the best help available.
Everyone is aware of friends or family members who have sought treatment
from a reputable practitioner, only to find out later from another doctor that the
original diagnosis was wrong or the treatments prescribed were inappropriate or
ineffective. Spending time in a therapy that does not work can prolong the child’s
distress and prevent certain developmental milestones from being met. Most par-
ents or family members address their quest for finding effective treatments by
reading everything they can about their children’s symptoms, seeking out infor-
mation on the Internet, or aggressively “asking around” to tap knowledge from
friends and acquaintances. Governments and healthcare policymakers are also
aware that people in need do not always get the best treatments—something they
refer to as “variability in healthcare practices.”
Increasingly, healthcare providers and policy makers are attempting to correct this
variability by promoting “evidence-based practices” for the treatment of emo-
tional and behavioral disorders. From a public health perspective, it is in every-
one’s interest that patients of all ages get the most up-to-date and effective care
for a particular problem. By offering a children or adolescents the best possible
chance for overcoming their difficulties and returning to optimal health, kids may
then spend more time in productive and healthy activities. In turn, the child or
adolescent is then able to meet key developmental milestones, such as advancing
in school or making and keeping friends, which then result in an overall healthier
quality of life. Healthcare policymakers have also recognized that it is very useful
to give consumers of mental health services as much information as possible about
the potential benefits of various treatment approaches. This enables the consumer
to make intelligent, informed decisions with their providers on which course of
treatment to undertake. Much like in medicine, providers of psychological inter-
ventions can now assist their patients in deciding on treatment options based on
scientific evidence. This series, Programs ThatWorkTM , is designed to accomplish
just that for children suffering from behavioral health problems. Only the latest
v
and most effective interventions for particular problems are described in user-
friendly language. To be included in this series, each treatment program must
pass the highest standards of evidence available, as determined by a Scientific
Advisory Board. Thus, when parents with children suffering from these problems
or their family members seek out an expert clinician who is familiar with these
interventions and decide that they are appropriate, they will have confidence that
they are receiving the best care available. Of course, only you and your healthcare
professional can decide on the right mix of treatments for your child.
This workbook accompanies a family-based treatment program for obsessive-

compulsive disorder (OCD) in young children (ages 5–8). The program is most
effective when carried out in collaboration with a trained therapist. You and your
child will learn “tools” to better understand, manage, and reduce OCD symp-
toms. In every session, your child will learn to face feared situations without
avoidance or rituals, and to stay in the situation until anxiety decreases. A reward
plan will help motivate your child to practice at home. This workbook is for your
family to use to review and apply the skills learned in therapy. It includes forms
for parent use, as well as pages for your child to complete. It is important for you
and your child to work together in the fight against OCD.
Anne Marie Albano, Editor-in-Chief
David H. Barlow, Editor-in-Chief
ProgramsThatWorkTM
vi
Contents
Chapter 1 Introduction to the Treatment Program 1

Chapter 2 Parent Tools 9
Chapter 3 Child Tools 29
Chapter 4 Exposure With Response Prevention 43

Chapter 5 Therapy Process Issues 51
Chapter 6 Relapse Prevention 57

Session Homework Sheets for Parent Tools 63
Reward Charts 75
Monitoring Forms 85
Daily Practice Records 95
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Chapter 1 Introduction to the Treatment Program
Goals
■ To assess overall impact of obsessive-compulsive disorder (OCD) and

related behaviors on family functioning
■ To learn about OCD
■ To differentiate between OCD behaviors and non-OCD behaviors

■ To understand what the program involves
Overview
This chapter includes information to help prepare your family to begin therapy.
Before treatment of your child begins, you will have a chance to meet with the
therapist alone and ask questions. Throughout treatment, you can use this work-
book to review what was learned in session. Instructions and forms are provided
to help you apply new tools in your family’s fight against OCD.
Assessment of Impact on Family Functioning
Troublesome Behaviors
One of the first steps is to identify your child’s troublesome behaviors. Answer
the following questions:
1. What does your child do that is causing the most concern at home or for the
family?
1
2. How do your child’s specific obsessions or compulsions disrupt your family?
Besides OCD-related behaviors, you may have other concerns about your child.
Be sure to bring these to your therapist’s attention as well.
Family Involvement in OCD-Related Behaviors
In response to your child’s OCD symptoms, you may find that you reassure your
child, tolerate or engage in the rituals, or modify your own routines. The fol-
lowing questions can help you think about your involvement in your child’s
OCD-related behaviors.
1. What are the ways in which you accommodate your child’s OCD behavior?
2. What are the results of your accommodations?
3. What happens if the OCD behavior is not accommodated?
Your child’s OCD-related behavior and your accommodations can have an

impact on the family’s overall functioning. Both parents and siblings may be
affected. You may also notice that accommodation has short-term benefits, but
ends up reinforcing OCD behaviors in the long term. In this program, your
family will learn how to gradually disengage from your child’s OCD symptoms.
2
About OCD
OCD is a biological disorder and genetic factors may contribute to its develop-
ment. Research shows that OCD runs in families, especially when young children
have symptoms. It is important to remember that it is not your child’s fault, or
yours, that he has OCD. There is nothing that you have or your child has “done”
to make him have OCD. If you have feelings of blame, it may help to think about
whether you would feel differently if your child were diagnosed with diabetes or
another chronic medical condition.
OCD as a Neurobehavioral Disorder
One way to think of OCD is that the “wiring” in your child’s brain is different
from that of a child without OCD. People with OCD receive messages differently
than people without OCD due to this difference in brain “wiring.” Researchers
have found that serotonin, one of the chemicals in the brain that sends messages
to other parts of the brain, is linked to OCD. Medications that work on serotonin
can be used to manage OCD symptoms, but their safety and effectiveness with
young children have yet to be fully established. However, these biological differ-
ences have been shown to respond to behavioral treatments like the one used in
this program.
Obsessions and Compulsions
OCD stands for obsessive-compulsive disorder. People with OCD can have
obsessions and/or compulsions.
■ Obsessions are persistent impulses, ideas, images, or thoughts that intrude

into a person’s thinking and cause excessive worry and anxiety.
■ Compulsions are mental acts or repetitive behaviors performed in
response to obsessions to relieve or prevent worry and/or anxiety.
It is not uncommon for young children to have only compulsions (rituals). To be

diagnosed with OCD, the symptoms must take up at least 1 hr per day and cause
significant interference in daily life (e.g., get in the way of functioning at home
or at school). The rituals or obsessions cannot be developmentally appropriate or
expected (to be discussed later).
Obsessions and compulsions are most commonly related to some general cate-
gories (fear of harm coming to self or others, fear of illness, washing, hoarding,
3
ordering, etc). Keep in mind, however, these may look very different depending
on the child and are often different in younger children. Begin making a list of
your child’s obsessions and compulsions in the chart provided.
Obsessions Compulsions
Development and Course of OCD
Prevalence
About one or two kids out of every hundred have OCD. In a school of 1000 kids
that means maybe 10–20 kids have OCD. Remember your child and family are
not alone!
Onset
OCD typically has a gradual onset. You may have noticed your child becoming
more rigid about certain things. Your child probably started to become more
upset when a ritual was disrupted or more “worried” by obsessive thoughts.
Some cases of OCD appear following a stressful life event or a medical illness
and the symptoms have a more rapid onset. For example, recent research shows
that OCD symptoms may appear following a strep throat infection. If relevant
to your child, you and your therapist will discuss PANDAS (Pediatric Autoim-
mune Neuropsychiatric Disorders Associated with Streptococcal infections) in
more detail.
Obsessive-Compulsive Spectrum Disorders and Comorbidity
OCD often occurs along with other disorders and can complicate the diagnosis
of OCD. Tic disorders, anxiety disorders, behavioral problems, and learning dis-
orders are especially common in young children with OCD. If relevant to your
4
child, you and your therapist may discuss this further and begin to identify which
particular symptoms will be the focus of this treatment.
OCD Versus Non-OCD Behaviors
In this program, you and your therapist will be discussing the difference between
■ compulsions and obsessions that are common to most kids,
■ compulsions and obsessions that are excessive and indicative of OCD,

and
■ non-OCD related behaviors (e.g., other anxiety disorders, normal child
misbehavior, and aggressive/oppositional behaviors).
Remember it is not an easy task to tell the difference between these behaviors.
Most children exhibit ritualistic or superstitious behaviors at some point during
development. Also, these behaviors sometimes worsen at times of transition or
stress (e.g., going to school, birth of a sibling).
Normal Developmental Rituals
The following list outlines normal developmental rituals at different ages1 :
■ Around age 2, children are often very rigid about eating, bathing, and
bedtime routines.
■ Between ages 3 and 5, children often repeat the same activity again and
again during play (e.g., building a tower and knocking it down).
■ From ages 5 to 6, children are often very attuned to rules associated with
games and may become distressed if these rules are changed.
■ Children between the ages of 6 and 11 often engage in superstitious

behavior to prevent bad things from happening, and they may show
increased interest in keeping a collection of objects (e.g., baseball cards).
■ At age 12 and older, children may be very absorbed in particular

activities (e.g., video games) or with particular people (e.g., movie stars);
they may also show superstitious behavior in relation to making good
things happen (e.g., performance in sports).
1 Listadapted from Francis, G., & Gragg, R. A. (1996). Childhood obsessive compulsive disorder. In A. E. Kazdin
(Ed.), Developmental clinical psychology and psychiatry (Vol. 35). Thousands Oaks: Sage Publications.
5
It is important to determine that your child’s ritualistic behavior is different from
that of other children his age. Children with OCD are more rigid about rituals
than children who do not have OCD. Young children with OCD become very
upset if a ritual is disrupted, while children without OCD are not as greatly
affected by disruptions to routines. Children with OCD also feel anxious if they
are prevented from completing a ritual and are more difficult to distract from a
ritual or an obsessive thought. OCD rituals are often more elaborate or dramatic
than the rituals of children the same age who do not have OCD.
Other Kinds of Anxieties and Misbehavior
It is also important to recognize that OCD is different from other kinds of

anxieties that your child may have—for example, general anxiety or a phobia.
It can also be difficult to separate OCD symptoms from other kinds of mis-
behavior. Some forms of acting out or oppositional behavior may be confused
with OCD.
My Child’s OCD Versus Non-OCD Behaviors
You may want to think about the following questions.

1. What are the differences between OCD and non-OCD behaviors in my
child?
2. Is it clear which behaviors are related to OCD?
3. What other anxieties does my child have that are different from OCD?
6
4. What misbehavior of my child might be confused with OCD?
Overview of the Treatment Program
As you might imagine, treating OCD in young children is very different than
treating OCD in adolescents or adults or even older children. Because your child
is so young, much of this treatment program is focused on helping you as a parent
find the tools you need to help your child. Your family will learn and practice
specific techniques that other families have found helpful in dealing with similar
kinds of problems. These include techniques for parents to use and techniques
for children to use. Over the course of treatment, you will discuss all of these tools
in more detail with your therapist, practice them in session, and practice them at
home with your child.
You are probably familiar with some of these ideas already—just like you might
have many tools in your tool box at home with a basic idea of how they work
(some more than others). The interesting thing about tools, though, is that some
tools can be used in many different ways, and sometimes one tool is more effective
than another for a certain task. In other words, you already know how to use a
hammer, but this program wants you to use it like a carpenter. The goal is to
work together to make the best use of these “tools” in the group effort to reduce
the impact of OCD on your family.
Child’s Toolbox
In this treatment program, your child will practice the following tools:
■ Identifying and monitoring OCD symptoms

■ Learning how to externalize (“boss back”) OCD
■ Using a feelings thermometer to rate anxiety
■ Working with parents to develop a symptom hierarchy and implement

exposure with response prevention(E/RP)
7
Parent’s Toolbox
As a parent, you will encourage and support practice outside of sessions. You will
learn the following parenting tools:
■ Differential attention: using attention to change a child’s behavior
■ Modeling: becoming aware of how parent behavior influences child

behavior
■ Scaffolding: working alongside a child to change his emotional response

to a certain event or situation and ultimately help him to respond in
more adaptive and independent ways
Other Goals
Besides reducing your child’s OCD symptoms, other goals for this program
include the following:
■ To promote positive family problem solving related to OCD (e.g.,
reduce family accommodation of OCD symptoms and reduce criticism
or hostility related to OCD)
■ To understand how your own fears and anxieties interact with your
child’s behavior
Importance of Teamwork
For your child to succeed with this treatment, it is essential for your family to
work together as a team. In this program, it is expected that all primary care-
takers will attend all scheduled sessions and that they will complete homework
assignments with the child. If you foresee any issues with attendance, homework,
etc., discuss these with your therapist.
8
Chapter 2 Parent Tools
Goals
■ To learn about differential attention, specifically tangible rewards
■ To use a reward plan
■ To use praise and encouragement (another form of differential attention)

■ To use removal of attention (another form of differential attention)
■ To use modeling to encourage coping behavior
■ To use scaffolding or coaching steps

■ To be consistent in using tools to cope with OCD
■ To evaluate disengagement efforts
■ To extend strategies to other caregivers
Overview
This chapter covers all the parent tools you will be learning throughout the ses-
sions. After each session, you may review the relevant section of this chapter. You
may also find it helpful to refer back to this chapter as you continue to practice
each of the parent tools.
Differential Attention (1): Tangible Rewards
The first parent tool to be discussed is differential attention. The basic idea is
that you can use your attention to change your child’s behaviors. That is, you will
give attention to the behaviors you want to see and withhold attention from the
behaviors you do not want to see. Another way to think about this is that when
you reward a behavior, it increases in frequency and when you do not reward it,
it decreases.
9
Your child has probably learned to act in a way that gets your attention. Your
child may experience this attention as rewarding whether it is positive (e.g., saying
“good job”) or negative (saying “I told you to stop doing that!”). If you are much
more likely to comment on “bad” behavior than “good” behavior, your child may
act in ways you do not like to get immediate attention.
Positive Reinforcement
There are different kinds of positive reinforcers:

1. tangible rewards such as giving a child a piece of candy or a small toy
2. privileges such as allowing a child extra computer time or a later bedtime

3. praise and encouragement such as saying “great job” or giving a child a hug
(positive attention)
You will first practice using tangible rewards by using a reward plan as described
next.
Introduction to Reward Plan
In session, you will be introduced to the reward plan as one of the ways to put
parenting tools into action in this treatment. Rewards are a form of positive rein-
forcement that is very effective in increasing behaviors you want to see more of.
Everyone needs rewards to do things that are challenging (e.g., most of us would
not go to work every day unless we received a paycheck). A positive reward plan
will be an important motivator to help your child face OCD.
The following questions will help you prepare to use a reward plan with your
child:
1. Can you think of some ways that you or others reward your child for doing
things that are hard?
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2. What do you think about using rewards in general?
3. What do you think about using rewards to get kids to do things?
4. Have you ever tried using a reward plan before with your child? If so, how
did it work?
There are different types of rewards that can be used and you will decide with
your therapist on some appropriate ones for your family. In fact, some of the
things you do already may have a reward component to them without you even
being aware of it.
Rewards Versus Bribery
Rewards sometimes sounds like bribing a child to behave, but these rewards are
actually very different from bribery. The major difference is that these types of
rewards are planned and proactive. Rewards are connected to specific behav-
iors, both of which have been determined ahead of time. The rewards are set
up beforehand to help a child stay motivated to control her behavior and to
make good behavioral choices. This is very different than offering rewards out
of desperation—for example, giving a toy to a child who is throwing a tantrum
to quiet her down or telling a child who won’t stop a compulsion that if she
gets in the car now she will get something she really wants. In these situations,
rewards are being used to get quick control of a child who is misbehaving or
having great difficulty with an anxiety-provoking situation. In this program’s
reward plan, you will reward your child for practicing therapy skills and facing
her fears—appropriate behaviors you might reward anyway.
11
Key Components of Successful Reward Programs
When designing a reward program for your child, keep the following key compo-
nents in mind:
■ The plan should be simple and easy to follow—ideally targeting specific,

easy to observe behaviors.
■ Rewards should be delivered promptly following desired behaviors.
■ Rewards should be frequent enough that the child will be encouraged to

work toward them.
■ Rewards should be something the child enjoys and that the parents are
going to feel okay about if children do not get it (e.g., stickers, playing a
game, spending time with someone special, food, or a small toy).
■ Rewards have to be delivered consistently.
Situations in Which to Reward the Child
There are several different situations in which it is appropriate to reward a

child.
Completing Homework
At the end of each session, your child will be assigned “homework.” These assign-
ments will be exercises that she should be working on at home to help her keep
track of OCD symptoms or practice “bossing back” OCD. The treatment reward
plan uses daily rewards at home for completing homework tasks. At the begin-
ning, these tasks will be short and you should give rewards for every step toward
positive progress.
On-Task Behavior
Rewards can also be used in and between sessions to encourage the child to do
the things required for learning new skills (e.g., listening and following directions)
or to actually “boss back” OCD. If necessary, you and your therapist can work
together to devise a plan to target behaviors that help your child stay on task as
they become apparent during and between sessions.
12
Specific Rewards
Stickers can be used as small rewards that are delivered immediately after your
child does something positive. These small rewards can then be cashed in for
larger rewards at certain intervals. For example, you can give your child a sticker
each day of the week that she completes an assigned task. Your child will then
receive a weekly reward in-session for earning a certain number of stickers at
home during the week (all rewards for the week will be decided in the previous
session). If stickers are not enough to motivate your child to practice at home,
discuss with the therapist other rewards that could be used with your child. Use
the space provided to record ideas for possible rewards.
Ideas for Possible Rewards:
When in session with your child, as a family you will brainstorm ideas for rewards
(e.g., stickers, special meals, or family outings). Your therapist will help you come
up with reasonable ideas that your family will be able to carry out. You will pick
rewards for daily, weekly, and in-session (if appropriate) completion of assign-
ments. You, the therapist, and the child should all be in agreement on the reward
terms.
Reward: Terms:
13
How to Use Rewards
Each week your child will have different things to work on after she goes home
from session. You will keep track of how she does and give her a chance to earn
rewards. The child will earn daily rewards at home for doing her assignments. If
she does her homework a certain number of days (to be decided on together),
then she can earn another reward when she comes to therapy.
Note: Another option is to use rewards, provided weekly by the therapist, as a
motivator for the child to actively participate in session (e.g., perform in-session
exposure) later in treatment.
You can use a Reward Chart to keep track of rewards. See Figure 2.1 for a com-
pleted example. A blank form is provided in this chapter; additional copies are
included in an appendix. You may photocopy this form as needed.
14
Week of 3/17-3/23
Homework Mon Tue Wed Thurs Fri Sat Sun

Tell parent when OCD Before Before Before Before Before Before Before
happens (reward for each school school school school school lunch lunch
instance) ★ ★ ★ ★ ★ ★
Tell parent when OCD After After After After After After After
happens (reward for each school school school school school lunch lunch
instance) ★ ★ ★ ★ ★ ★
Tell parent when OCD After After After After After After After
happens (reward for each dinner dinner dinner dinner dinner dinner dinner
instance) ★ ★ ★ ★ ★
Misc notes/bonus rewards Ate muffin

without
complaint or
checking;
gave extra
TV time
Figure 2.1
Example of Completed Reward Chart
15
16
REWARD CHART
Week of
Homework Mon Tue Wed Thu Fri Sat Sun

Differential Attention (2): Praise and Encouragement
Throughout treatment, you will continue to use positive attention to increase

the desirable things that your child does. This could involve praising your child’s
successful attempts to take control of OCD, including monitoring symptoms,
reporting symptoms, and completing homework assignments. Eventually this
positive attention will include praise for your child’s attempts to “boss back”
OCD. Additionally, you should be praising or paying attention to the things
that your child does or enjoys doing that are not related to OCD. Remember,
you do not want your child to feel that the only attention she receives is because
of her OCD.
Praise and OCD
Praise is something that probably happens less often in relation to OCD because
the symptoms are often confusing and frustrating. Parents often respond by trying
to reassure and redirect the child, or by setting limits with the child to try to stop
the struggle. When the symptoms are less severe (or absent), parents are often
happy to “let sleeping dogs lie.” That is, they may not refer to it for fear that
saying something could make things worse. But OCD is a constant struggle and
when symptoms are less severe may be times when the child is more successful at
managing her obsessions or compulsions.
Think about paying attention to and praising your child for courageous behavior
in which she is fighting back against OCD. For example, you could praise your
child for going to a friend’s house rather than praise lack of time spent wash-
ing hands. Sometimes, children with OCD feel as if they cannot do anything
“good,” so it is important for them to get positive attention for doing well in
certain situations. To start, be sure to give positive attention (specifically praise,
encouragement, and hugs) when your child completes the assigned homework
tasks. Over time, you will be working on paying attention to your child’s brave,
nonanxious behavior you want to see more of.
Differential Attention (3): Removal of Attention
By this point, you have learned about using praise, encouragement, and other
kinds of rewards (such as prizes and stickers). Next, you will learn about the flip
side of this idea—not paying attention to (or not rewarding) behavior that you
17
do not want your child to be doing. In this way, you will try to reduce the amount
of attention these behaviors get and make them less likely to occur. Over time,
you will work on reducing reassurances, questions, and confrontations when your
child is engaging in OCD symptoms.
Note: The number one rule of removing attention is to never ignore a child if she
is a danger to herself or anyone else. When removing attention, be sure to pick a
behavior that does not have the possibility of being dangerous.
Remember that removal of attention means all of the following:
■ You cannot speak to your child
■ You cannot touch your child
■ You cannot make eye contact with your child

Once you remove attention from a behavior, you have to continue to ignore it
until she stops doing it. It will not be helpful if you remove attention at first, and
then pay attention to it once it has been going on for a while. Continue, however,
to praise your child for good behavior.
Modeling
Goals or key concepts for this section include the following:
■ Children can learn both positive and negative behaviors by observing

others (especially parents)
■ Parents can model anxious behaviors or coping behaviors in reference to

OCD
Parents can model all different kinds of behaviors for their children. There are
probably many times when you are able to positively influence your child’s behav-
ior by modeling courageous or coping actions. For example, if your child is afraid
of doing something (e.g., petting a large dog), you do it first, showing her that it
is safe and saying positive things such as, “I know this dog looks big, but we know
he is friendly because he is our neighbor’s dog and I have petted him before.” This
may help your child to feel better about the situation.
On the flip side, parents’ own anxieties can affect their child. For example, a child
who is concerned about germs is about to enter a public restroom. A parent may
then heighten the child’s anxiety by warning the child to be careful while using
18
the restroom. The child may also pick up on behaviors of the parent regarding the
cleanliness of the restroom. If the parent says something like “Even though this
might not be the cleanest bathroom ever, we can use it anyway” in response to
the child’s worries or uses the bathroom herself without displaying concern, the
parent is modeling that we go forward even if we are anxious.
Consider what you teach your child by answering the following questions:
1. When you are at your best, what does your child learn from watching you?
2. When you are at your worst in a difficult situation (particularly an anxiety

provoking one), what does your child learn?
Sometimes parents do things, even unknowingly, which can add to a child’s

OCD behaviors or feelings. One of the goals of this treatment is for you to
decrease unhelpful kinds of modeling and increase helpful kinds of modeling.
You will help your child by modeling ways to “talk back” or “boss back” OCD
(see Chapter 3 for more information on “bossing back”).
Introduction to Scaffolding or Coaching
Scaffolding is a technique that parents can use to help an anxious child take
more responsibility for her symptom management. This tool also helps decrease
parental involvement in the process of symptom management. Scaffolding is par-
ticularly helpful for situations in which parents’ instinct would be to “rescue”
their child because she is feeling anxious (e.g., giving the child permission to
avoid doing an E/RP task, allowing the child to avoid a particular situation).
Scaffolding can also be useful in general to help children change their emotional
response and act more independently.
19
By encouraging your child to take some responsibility for her behaviors, you
are actually demonstrating that you have the confidence she will be able to
“boss back” the OCD. Think about how you can show support and encour-
agement, while expecting more from your child. Remember, scaffolding will
provide a way for you to limit your involvement without making your child feel
abandoned.
You will use scaffolding during exposure assignments (see Chapter 4). As you
practice the following steps, keep in mind the goal is to encourage your child to
approach rather than avoid the situation.
Scaffolding Steps (1): E/RP Assignments
Step 1: Find out how the child feels (e.g., afraid, angry, or sad) and
empathize with the child.
■ Help your child to identify her feelings and thoughts.

■ Listen to what your child is saying and let her know that she has been
heard.
■ Help your child use the feelings thermometer to identify the level of
distress that she is experiencing.
Step 2: Brainstorm with the child how to approach rather than avoid the
situation.
■ As a parent, you will be in charge of activating the child to do the E/RP
task. Generate ideas about how to approach the situation.
■ Talk with your child about her concerns and provide a rationale for
doing E/RP (“Avoiding the OCD doesn’t make it go away”).
■ Offer some reasons why doing E/RP would be a good thing versus a bad
thing (“You’ll be in charge, not the OCD,” “the OCD wants you to
believe that you can’t do it”) or, if possible, prompt the child to generate
some of these ideas.
■ Help reinforce the importance of E/RP—it is necessary to feel some
anxiety in order to practice being the boss of OCD.
Note: It is important to meet kids where they are in this process (cognitively,
emotionally). Praise your child for generating ideas and/or for listening to you.
Decide on which tools you and your child can use to accomplish the task.
20
Step 3: Choose one of the options from Step 2 and act on it.
■ Pick from the ideas generated on how to approach rather than avoid the
situation.
■ Follow through on the exposure task.
Step 4: Evaluate and reward.

■ Review how the plan worked (or didn’t work).
■ Try to learn from mistakes.
■ Reward your child for trying, no matter how it turned out.
Note: In addition to the anxious feelings that can be evoked by the E/RP task,
young children can be very sensitive about their performance when trying new
things. Therefore, you should anticipate resistance to practicing and/or
frustration when the practice doesn’t go quite as planned. Try to remind your
child that this is a skill that she is learning, similar to riding a bicycle, and that it
will take some time to get “good” at it. What is most important is to try to
practice regularly, to be honest about how it went, and to reward your child for
making an effort to practice regardless of the outcome.
Scaffolding Steps (2): Other Situations
After you have practiced using scaffolding with a specific E/RP task, you can
expand this tool to other situations. You might try scaffolding when your child
gets anxious about an OCD-related concern when out of the house or not doing
a planned E/RP task—for example, when using a public bathroom. Remember
the goal is to encourage approach rather than avoidance in your child. See the
following instructions for adjusting the scaffolding steps to situations other than
planned E/RP tasks.
Step 1: Find out how the child feels (e.g., afraid, angry, or sad) and
empathize with the child.
The difference in this step from planned E/RP tasks is that you must work with
the child to identify the level of difficulty in the situation. It is important to have
a conversation with your child and determine whether or not this situation is a
task she will be able to approach. Depending on where your child is at with her
treatment, she may not be ready to approach the situation.
21
Step 2: Brainstorm with the child how to approach rather than avoid the
situation.
Talk with your child about her concerns and help provide a rationale for doing
E/RP (“Avoiding the OCD doesn’t make it go away”). Offer some reasons why
doing E/RP would be a good thing versus a bad thing (“You’ll be in charge, not
the OCD,” “the OCD wants you to believe that you can’t do it”) or, if possible,
prompt the child to generate some of these ideas. Help reinforce the importance
of E/RP—it is necessary to feel some anxiety in order to be the boss of OCD.
Note: It is important to meet kids where they are in this process (cognitively,
emotionally). Praise your child for generating ideas and/or for listening to you.
Decide on which tools you and your child can use to accomplish the task.
Again, the difference from before is that you had not planned a specific E/RP
task. After deciding whether this is a task your child will be able to approach,
you still may need to come up with modifications so that it is appropriate with
regard to level of difficulty (e.g., touching something else that touched the
public toilet). You and your child will need to balance a number of issues (e.g.,
being in a hurry or being in public where others may be around) while
attempting to boss back OCD. It may be important for you and your child to
develop a signal or sign to use with each other that means “this is a time to try
and boss back OCD” so that this does not always need to be said out loud (e.g.,
in front of friends).
Step 3: Choose one of the options from Step 2 and act on it.
After you have picked an option, follow through on the exposure task. Because
you may be doing this in a situation that is not conducive to taking frequent
ratings, be flexible in how closely you adhere to the process of doing the
exposure. However, as with planned exposures, it is important to avoid
premature bailing out. Therefore, if at all possible, stick with the situation until
your child’s anxiety has gone down significantly.
Step 4: Evaluate and reward.

Review how the plan worked (or didn’t work), and reward your child for trying.
Remember, the experience of doing E/RP “on the fly” (i.e., when the child is not
expecting it) may be difficult for some children. Sometimes these difficulties will
look like anxiety, and other times may present more like oppositional behavior.
Therefore, listen carefully for your child’s feelings associated with being taken off
22
guard by being asked to do E/RP “out of the blue.” Empathize with these
feelings, noting how what your child has just tried is different from what she’s
done in session and for homework so far. Emphasize that doing E/RP “in real
life” is very important for being in charge of OCD. Reward your child for her
efforts.
If the exposure task did not work because of the difference in being out in public
versus at home, you should work with your child to problem solve and
brainstorm other approaches.
Being Consistent
It is very important to be consistent in coping with your child’s OCD in all

situations. Consistency is sometimes a problem when symptoms happen away
from home. All of the parent tools and child tools in this program should be
pretty portable and good for use in other situations.
The following questions may be helpful in evaluating consistency:
1. Can you think of times when you were able to be consistent away from
home?
2. Can you think of times when there have been problems?
3. Have the scaffolding steps been helpful?
23
4. Are there places other than home where OCD sometimes acts up (e.g.,
relative’s homes, stores, school, or place of worship)?
5. How could you use parent tools in these situations?
Evaluating Disengagement Efforts
Your family will be gradually disengaging from your child’s OCD symptoms dur-
ing this treatment. These efforts will be guided by whatever symptoms are chosen
for homework and many of the session homework sheets ask about your disen-
gagement efforts. As you near the end of treatment, the following questions may
help you evaluate your progress:
1. How have things been working in terms of staying out of your child’s OCD
symptoms?
2. In what situations were you able to disengage yourself?
24
3. What was this like for everyone involved? Were there any difficulties?
4. What are the remaining areas of family accommodation?
5. How can you continue to work on these areas?
Extending Strategies
You can not only use parent tools in other situations but also extend these
strategies to other caretakers (e.g., relatives and teachers). There needs to be con-
sistency in handling OCD situations even when the child is in someone else’s
care. Although most children tend to give their parents a harder time than other
caretakers, it is important to develop strategies that others can use while caring
for your child if problems arise with OCD.
The following questions may be helpful as you prepare to extend these strategies
to others:
1. What situations might be most applicable to your family?
25
2. How have you tried to manage these kinds of situations in the past?
3. Has this changed since you started treatment?
4. Do others have more difficulty coping with your child’s OCD symptoms or
other behavior problems?
5. How do you feel about sharing your own and your child’s experience with
OCD with others outside of the immediate family?
6. How could this disclosure be handled to make it most pleasant and

productive?
Your therapist will help you develop a specific program for extending strategies
depending on the particular situation of your family. For example, it may include
a daily report card for school or daycare, education for caretakers, or reward plans
that relatives can use with your child.
26
Homework
At the end of each session, you will be assigned homework along with your
child. See the session homework sheets for parent tools provided in an appendix.
Assignments for parents may include:
✎ Monitor your child’s symptoms and parents’ involvement.

✎ Continue disengagement from your child’s OCD symptoms as
appropriate.
✎ Use praise, encouragement, sticker chart, and specific rewards for
homework completion.
✎ Use removal of attention for complaints or refusals to do homework.

✎ Pay attention to your own modeling in relation to your child’s OCD.
✎ Practice modeling coping skills in relation to a specific OCD symptom if
possible.
✎ Use scaffolding strategy for child E/RP tasks as appropriate (see Chapter
4 for detailed instruction).
✎ Apply scaffolding to an OCD situation other than a planned E/RP
practice if possible (see Chapter 4 for detailed instruction).
✎ Apply parent tools to OCD situations outside of home (if appropriate).

✎ Teach other caregivers how to manage OCD, if appropriate.
27
Chapter 3 Child Tools
Goals
■ To introduce the child to the treatment program
■ To have the child use the feelings thermometer
■ To create an initial hierarchy of OCD symptoms

■ To monitor symptoms
■ To help the child “boss back” OCD
Overview
Last chapter outlined parent tools; this chapter discusses tools for the child to
use. All of these tools will be taught to your child in session, but information is
provided here for your reference. You may review some of this material with your
child. Forms are also provided for family use.
Introduction of Treatment Program to Child
Before the first session that your child will attend with you, you can tell your
child that you are all going to talk about OCD (or the term that your family
uses). Explain that the therapist will work with your family to help make it so
that OCD does not cause so many problems.
Reducing Blame
It is important for your child to understand that it is not his or your fault that he
has OCD. There is nothing that you or he has “done” to make him have OCD.
Let your child know that it is normal to feel like the only one to have OCD, but
that actually, there are lots of kids who have OCD.
29
Naming the Child’s OCD
If your child does not already have a name for his OCD, it may be helpful to
create one. This name should be used throughout the sessions. It may also be
appropriate for your child to draw a picture of his OCD. Your child can use the
“My OCD” page in this chapter.
30
MY OCD
Name of my OCD:
Picture of OCD:
31
What the Program Involves
You, your child, and the therapist will all be working together as a team to fight
against OCD. This might sound hard and seem scary to your child. It is impor-
tant for your child to know that he will work on easier things first and will work
at his own pace. The only goal is to always be making some progress.
Depending on the age of your child, it may be appropriate to provide some infor-
mation about OCD as a neurobiological illness (see Chapter 1). The important
thing for your child to understand is that many other kids have the same kinds
of worries and behaviors and have gotten better by fighting back against them.
Feelings Thermometer
The feelings thermometer (Figure 3.1) is used to measure the child’s level of anxi-
ety regarding specific situations. The feelings thermometer is also useful for E/RP
tasks. Using the list of OCD behaviors generated in session, your therapist will
get ratings of each item, if possible. It is likely that you will play a crucial role in
helping your child to make ratings.
The therapist may use the following dialogue to introduce the feelings thermome-
ter and you may want to repeat it to your child at home, modifying it as needed
depending on your child’s age and developmental level.
Do you know what a thermometer is? What are some things that we use thermometers for?
That’s right, we use them to measure temperature, which helps us figure things out, like
whether you have a fever and need to take medicine, or how cold it is outside and whether
we need to wear a coat. A feelings thermometer is just like other thermometers, only it
measures feelings instead of temperature. Knowing how you feel or how much you feel
something will help us work together in this treatment.
Here is a picture of a feelings thermometer. At the top of the picture next to the frowning face
is the number 10. If you rated something with a frowning face and a 10, that would mean
that you felt really bad or anxious about the situation you were rating. At the bottom of the
picture is a smiling face and the number 0. If you rated something with a smiling face and a
0 that would mean that you didn’t feel anxious or bad about the situation you were rating.
In the middle is a picture with neither a smile nor a frown and the number 5. What should
we call this kind of face? (If child doesn’t offer an option, suggest calling it medium face.)
This means that you feel some anxiety or bad feelings about the situation you are rating. Can
you give me some examples of things that you would rate with a smiley face? a medium face?
and a frowning face? We will use the Feelings Thermometer to rate your OCD symptoms
from the least upsetting to the most upsetting.
32
Figure 3.1
Feelings Thermometer
33
If your child is younger, the feelings thermometer may need to be made simpler.
For example, the 0–10 scale could be ignored and ratings of high/medium/low or
smiley/medium/frowning faces could be used instead. Modify the feelings ther-
mometer (Figure 3.1) accordingly or have your child draw his own on the “My
Feelings Thermometer” page.
34
My Feelings Thermometer
35
Initial Hierarchy of OCD Symptoms
A hierarchy of OCD symptoms will be created in session. Using the feelings

thermometer, the symptoms will be ranked from most to least bothersome.
This hierarchy will be modified throughout the subsequent sessions, adding new
symptoms and reevaluating old symptoms as needed. Record your child’s initial
symptoms and feelings thermometer ratings on the blank hierarchy form pro-
vided in this chapter. Additional copies are included in an appendix; you may
photocopy this form as needed.
36
Initial Hierarchy
Ranking Description of Symptom Label Rating Notes
37
Self-Monitoring
Your family will monitor one or two OCD symptoms every day. Your child will
have a specific monitoring task which will depend on his age, cognitive level, etc.
Depending on your child’s age and developmental level, you may or may not play
an active role in monitoring. Your therapist will work with you to develop a plan
or chart that makes sense for your family. You may use the Monitoring Form—
see Figure 3.2 for a completed example. A blank Monitoring Form is provided in
this chapter; additional copies are included in an appendix. You may photocopy
this form as needed.
38
Instructions: Please keep a daily record of TWO of your child’s OCD symptoms. In the space provided below (feel free to use additional space if necessary)
record the date, the specific symptom, the amount of time your child spent engaging in that symptom, and how parents are involved in the symptom. Try to
involve your child in some aspect of monitoring and recording symptoms. Reward child for participation in this process.
Date OCD Symptom Time Spent Parents’ Involvement Child Involved in

Monitoring/Recording (Y/N)
T 3/24 Worried about Lysol in bathroom 10 min Answered questions, then got angry Y
W 3/25 Refused to eat bagel 10 min Yelled at him N
W 3/25 Worried about Windex 1 min Answered questions Y
W 3/25 Refused to eat dinner roll 1 min Reassured not moldy Y
Th 3/26 Worried about Lysol in bathroom 2 min Answered questions Y
Th 3/26 Inspected toast for mold 1 min Ignored Y
Th 3/26 Worried about Windex 5 min Answered questions Y
Th 3/26 Worried about swallowing paper clip 5 min Reassured Y
Th 3/26 Checked roll for mold 1 min Ignored Y
Th 3/26 Worried about Lysol in bathroom 5 min Reassured Y
F 3/27 Worried about Lysol in bathroom 1 min Ignored Y
F 3/27 Worried about swallowing Windex 10 min Reassured Y
F 3/27 Worried about chemical smell 10 min Reassured Y
Su 3/29 Checked roll for mold 1 min Answered questions Y
Figure 3.2
Example of Completed Monitoring Form
39
40
Monitoring Form
record the date, the specific symptom, the amount of time your child spent engaging in that symptom, and how parents are involved in the symptom. Try to
Date OCD Symptom Time Spent Parents’ Involvement Child Involved in

Monitoring/Recording
“Bossing Back”
Your child will learn several cognitive strategies that will help with exposure, in
particular, “bossing back” and positive self-talk. The key concepts for your child
to understand are the following:
■ What it means to be the boss or be in charge

■ Therapist and parents are going to help the child be the boss of OCD
■ Being the boss of OCD is hard work but we know the child can do it
Along with the therapist, you may need to explain “bossing back” to your child.
You may want to adapt the following dialogue to a level appropriate for your
child.
Bossing back means talking back to OCD and telling it who is in charge. Sometimes, this
just means telling OCD that you know it is trying to control you (e.g., “I see what you’re
trying to do OCD, and I’m not going to fall for it.”) Sometimes it means telling OCD that
you don’t believe what it is telling you. It can also mean telling OCD that you believe the
opposite of what it is telling you. For example, if OCD told you that you would get sick if
you touch the sink in the bathroom, you could tell OCD that you know you wouldn’t get sick
from touching the sink. Bossing OCD can be hard because OCD can be very sneaky.
Sometimes when you start bossing it back, OCD might try new things to convince you that
it’s in charge. When this happens, it is a good idea to use more general ways of talking back
to OCD. For example, instead of telling OCD that you won’t get sick if you touch the sink
you could tell OCD, “Back off, I’m the boss of me; you can’t tell me what to do
anymore.”
Another thing that will help you boss back OCD is keeping good thoughts about yourself in
your head. When people think things like “I know I can’t do this” or “What if I mess this
up?” it is easier for OCD to keep bossing them around. But, when people think things like “I
know it will be hard to face my fears, but I think I can; I will use my tools to help me; I can
do this one step at a time,” then they feel stronger and this helps them beat OCD. This kind
of positive self-talk helps before, during, and after an exposure task.
It is also important for you to learn how to use bossing back and positive self-
talk because these strategies will help you support your child’s efforts. It is also
helpful because parents and other people in a child’s life are often bossed around
by OCD too.
41
Homework
After each session, your child will be assigned homework. These assignments may
include the following:
✎ Have child draw a picture of OCD and come up with a name for OCD,
if appropriate.
✎ Have child color the feelings thermometer, if appropriate.
✎ Have child participate in monitoring OCD symptoms (how much of a
role your child can play will be determined in session). You may use the
Monitoring Forms provided in an appendix and photocopy as needed.
✎ Have child use feelings thermometer and “bossing back” during E/RP
tasks (see Chapter 4 for instructions).
42
Chapter 4 Exposure With Response Prevention
Goals
■ To continue developing hierarchy of OCD symptoms
■ To complete exposures
■ To use scaffolding during planned E/RP tasks

■ To extend scaffolding to other situations
Overview
The main component of treatment is doing exposures both in session and for
homework. These exposure tasks are designed to help your child fight back
against OCD symptoms. Based on the hierarchy of OCD symptoms, tasks of
increasing difficulty will be chosen each week. You will use the parent tool of
scaffolding to help your child complete both planned and unplanned exposures.
Your child will use the feelings thermometer and “bossing back” strategies during
exposures.
Continued Hierarchy Development
Throughout the sessions, you, your child, and the therapist will continue to
review and develop the hierarchy of OCD symptoms. Ratings using the feel-
ings thermometer will be revised as needed. In preparation for E/RP tasks, these
ratings should correspond to the level of difficulty or fear your child anticipates
when trying to alter or eliminate the ritual. It is possible that the level of general
distress or fear associated with a certain symptom is not the same as the distress or
fear associated with trying to resist that ritual. For example, a child may rate the
distress/fear associated with doing her handwashing ritual as a “4,” but may rate
the distress or fear associated with not doing (or resisting) this ritual as an “8.”
43
Your therapist will also be gathering as many details about your child’s OCD and
associated triggers as possible for hierarchy development. For example, specific
objects, people, and places may be associated with especially high levels of anxi-
ety for your child. Your child may avoid these “triggers” to control that anxiety.
It is also important to learn about situations in which the child is less anxious
or more willing to take risks. The success of E/RP rests on the foundation of a
detailed symptom hierarchy. See Figure 4.1 for an example of a completed hier-
archy form. A blank hierarchy form for connecting specific triggers, obsessions,
and compulsions is also included in this chapter.
In-Session Exposure
The first exposure task will be attempted in session, if possible. Your therapist
will help pick an item with a low temperature rating from the list to try bossing
back. Before doing the task, your therapist will talk you and your child through
the steps involved and give specific directions about resisting ritualizing. During
the task, your child will be asked to make ratings every minute using the feelings
thermometer. The exposure task will continue until the thermometer rating has
gone down to 0 or 1 or your child is reporting a big decrease in anxiety.
The therapist may “coach” your child during the task by “talking back to OCD”
for her. You should observe and give your child positive reinforcement. If your
child is younger, your therapist may instruct you to assist more actively with the
exposure task. It may be difficult to see your child anxious during E/RP tasks,
but remember, your encouragement and positive reaction are important to your
child’s progress.
44
Trigger Obsession Compulsion Rating
Smelling cleaner, seeing the bottle, Worries about being poisoned by Avoiding eating off recently 10
or seeing shiny or wet surfaces in household cleaners cleaned surfaces
the kitchen
Smelling cleaner, seeing the bottle, Worries about being poisoned by Repeated questioning parents about 9
or seeing shiny or wet surfaces in household cleaners use of cleaners (verbal checking)
the kitchen
Worries about mold on food Examination of food for mold (self) 8
Worries about mold on food Asking family member to examine 8

food for mold
Worries about mold on food Avoiding eating foods that are 8

likely to be moldy (e.g., bread,
muffins)
Worries about whether she had Repeatedly asking parents if she 8

swallowed objects (e.g., paper clip) swallowed objects
Worries about touching dirt on the Avoiding certain objects on the 5

floor floor
Figure 4.1
45
Example of Completed Hierarchy Form

46
Hierarchy Form
Trigger Obsession Compulsion Rating

Homework Exposures
Exposures will also be done for homework each week. Your therapist will assign
an E/RP task with an appropriate level of difficulty for your child at that point
in treatment. Depending on your child’s developmental level and progress, you
may help your child complete the E/RP task. For example, you may take feelings
thermometer ratings from your child every minute during the task. Or you may
“coach” your child during the task by “talking back to OCD” for your child.
Exposures should continue until the thermometer rating has gone down to 0 or 1
or your child experiences a big decrease in anxiety. This is important because pre-
mature bailing out of exposures ends up reinforcing OCD. You should watch
your child for signs of ritualizing—both subtle and obvious. This ritualizing
could cause anxiety levels to drop more quickly than would be expected, without
being indicative of real improvement in the long run.
Exposure Tasks With Scaffolding
In session, you will also learn how to use scaffolding during exposure tasks. You
can then apply the techniques to E/RP homework assignments (see Chapter 2 for
detailed scaffolding steps). Use the following directions as a guide for what needs
to be accomplished.
Choosing the Task
Elicit child feedback about her feelings and thoughts about doing the proposed
task (Step 1: Find out how the child feels).
Preparing for the Task
Before doing the task talk through the steps involved with your child, and give
specific directions about resisting ritualizing and using “bossing back” and pos-
itive self-talk. It is frequently helpful to overtly model the exposure task, for
example touching a “contaminated” object.
This discussion promotes doing the exposure and concrete ideas about how the
situation will be approached (Step 2: Brainstorm with the child how to approach
rather than avoid the situation).
47
If your child resists doing exposure, try to increase your child’s motivation by
telling her about other children her age who have been successful with similar
tasks. If this is not successful, modify the task to make it possible for your child
to participate.
Completing the Task
Use the feelings thermometer to make ratings every minute during the task. Con-
tinue exposure until thermometer rating has gone down to 0 or 1 or your child
is reporting a big decrease in anxiety. You may “coach” your child during the task
by “talking back to OCD” for her. If your child is younger, you may need to
assist more actively with the exposure task. Doing the exposure task accomplishes
the third scaffolding step (Step 3: Choose one of the options from Step 2 and act
on it).
Complete scaffolding (Step 4: Evaluate and reward) by postprocessing how the
E/RP task went. Provide praise (and possibly a tangible reward if one has been
agreed upon before the task) for effort. Also note concrete things that could be
done differently next time.
Homework
Once exposures begin in session, the therapist will assign an E/RP task for home-
work each week. The goal is to move up to the top of the hierarchy of OCD
symptoms.
✎ Have child complete the E/RP task each day, with parental help as
appropriate (as treatment progresses this may involve decreased parent
accommodation and/or scaffolding techniques).
✎ Remind child to make thermometer ratings and use cognitive strategies

(“bossing back and positive self-talk) during exposure.
✎ Record each task on the Daily Practice Record (see blank form at end of
chapter; additional copies are provided in an appendix).
48
Daily Practice Record
Task Description:
Reminder of Specific Strategies to Use:
Thermometer Ratings
Date What Was Attempted Pre-task 1 min 2 min 5 min 10 min 15 min 20 min
49
Reward (describe what can be earned and what are the criteria for earning it):
Chapter 5 Therapy Process Issues
Goals
■ To identify and address misperceptions about OCD
■ To track family’s response to OCD
■ To assess family well-being
■ To problem solve obstacles to homework completion
Overview
This chapter covers many issues that are important to the therapy process. Your
therapist will discuss these issues with you as they arise. The questions provided in
this chapter are intended to help you become aware of these issues, your feelings
about them, and address them as needed.
Identifying and Addressing Misperceptions
During therapy, you may begin to identify negative or distorted assumptions

and attitudes about OCD and/or your child. You and your therapist may also
discuss the family’s expectations for treatment and whether these expectations
are realistic. The following questions may be helpful to think about as you work
through these issues.
1. What are your thoughts/worries about how your child developed OCD?
51
2. How much do you feel your child can control his OCD symptoms and
behaviors?
3. What kinds of things seem to affect your child’s ability to control OCD?
4. How do you usually react to your child’s OCD? What kinds of things seem
to change your reactions?
5. How do your child’s siblings respond to his OCD? What is their

understanding of OCD? Does OCD cause conflict between siblings at
home?
Tracking Family Response to OCD
Everyone in the family can have different responses to OCD, sometimes being
supportive about the symptoms and sometimes not. As part of the treatment, you
will be tracking your family’s response to OCD. After you have begun tracking,
you may want to answer the following questions.
52
1. Think about how you feel when your child is struggling with OCD and
circle the feelings below that apply.
HELPLESSNESS
FRUSTRATION
RESENTMENT
JEALOUSY
DISAPPOINTMENT
It is normal to have negative thoughts and feelings about your child’s OCD.
This program will help you process these negative feelings and take a more
positive approach.
2. How does everyone at your house respond to the child’s OCD?
3. What did you notice when you tracked your accommodation of your child’s
symptoms?
4. How would it feel to be less involved in your child’s symptoms?
Assessing Family Well-Being
A chronic problem such as OCD can have a negative impact on the well-being
of everyone in the family. It is important to be aware of the needs of individual
family members, including yourself. Answer the following questions:
53
1. Are you taking time for yourself?
2. Do you think that you are getting enough outside support?
3. Are there any interests, hobbies, or pastimes that you have given up as a
result of your child’s OCD or other behavior problems?
4. Do you have your own negative reactions or distress related to the

symptoms? Has this distress changed over time?
5. Similarly, how have you been managing your own anxiety and/or distress and
the way this may affect your child’s thoughts about certain OCD symptoms?
Remember, in order to fully support their children, parents need to have time for
themselves and support from others. In fact, this is a crucial part of family treat-
ment. In addition, it is good for children to see parents taking care of themselves
because it gives children permission to do the same.
54
Problem Solving Obstacles to Homework
Another extremely important area for problem solving is homework. Homework

is a critical component to this treatment. What you “put in” in terms of home-
work will likely determine what you will “get out” of treatment over time. Even
the best intentions for accomplishing homework can sometimes be difficult to
meet. Obstacles may include time or scheduling problems, interference from
siblings, resistance from the child, etc.
1. What are some obstacles that could arise in trying to practice the skills
learned in sessions?
2. What are some ways of managing these obstacles?
Your therapist can help you problem solve around these obstacles. Depending
on your particular family situation, solutions may include sharing responsibility
between parents, using a consistent time for CBT practice when distractions are
at a minimum, ignoring off-task behavior, etc. Also, remember to use the reward
plan and positive attention to increase motivation for homework compliance and
reinforce on-task behavior.
55
Chapter 6 Relapse Prevention
Goals
■ To review parent tools

■ To review child tools
■ To prepare for handling future OCD symptoms
■ To remember important points about OCD relapse
■ To learn how to deal with symptom reappearance

■ To celebrate!
Overview
This chapter reviews all the tools learned in therapy in preparation for the end
of treatment. It also gives tips for dealing with OCD in the future, as it is likely
your child will continue to have symptoms from time to time. Finally, as this pro-
gram comes to a close, it is important to recognize your family’s and your child’s
achievements.
Review of Parent Tools
Toward the end of the treatment, you will want to review all of the parent tools
you have learned and think about how to make them your own:
■ Differential attention: using attention to change a child’s behavior

1. Tangible rewards (reward program)
2. Praise and encouragement
3. Removal of attention
■ Modeling: becoming aware of how parent behavior influences child

behavior
57
■ Scaffolding: working alongside a child to change her emotional response
to a certain event or situation and ultimately help her to respond in
more adaptive and independent ways
Answer the following questions:
1. How can you make the tools most helpful for your family?
2. What have you noticed about how and when you are using the tools?
Review of Child Tools
The following are the tools that you will want to encourage your child to continue
to use:
■ Identifying and monitoring OCD symptoms
■ Learning how to externalize (“boss back”) OCD

■ Using a feelings thermometer to rate anxiety
■ Working with parents to develop a hierarchy and implement E/RP

Consider the following questions:
1. How well does your child know how to use all of the child tools?
58
2. What progress has your child made?
Handling Future OCD Symptoms
You cannot avoid dealing with future problems, but you will have a number of
skills to help you when issues arise. The following questions may help you prepare
for handling future OCD symptoms:
1. What do you think are the most effective strategies you have learned to date?
2. Can you think of problems that might occur in the future?
3. How do you think you would handle these problems?
Points to Remember About Relapse
OCD is a chronic disorder, and it is important to remember that OCD symptoms

may return at some point. This is particularly true during stressful life events or
other stressful periods of development. Given your child’s young age, it is likely
59
that some OCD symptoms may reappear. These may look identical to previous
symptoms or may look somewhat different.
The following are some important points to remember:
■ Watch more carefully for a return of OCD symptoms during stressful
periods.
■ Do not overprotect your child from stress.
■ Use strategies learned in treatment to cope with symptoms (i.e., parent

tools, child tools).
■ Provide your child with significant support and encouragement during a
period of symptom exacerbation.
■ Remember that dealing with these symptoms early on may prevent them
from becoming worse.
Dealing With Symptom Reappearance
If your child’s symptoms do reappear, you can do the following:

1. Try to figure out whether the child is aware of the symptoms.
2. Work with the child on exposure.

3. Provide support and encouragement to the child and use other parent tools.
4. Consider a booster treatment session or a follow-up phone call with the
therapist to determine whether more intensive intervention is necessary.
Conclusion
Congratulations to your family on completing treatment! You have all worked

hard to reduce OCD symptoms and improve life for the whole family. Make
sure that you acknowledge and celebrate your child’s progress. A certificate of
achievement for your child is included at the end of this chapter.
60
This certificate is presented to:
for doing a great job in treatment!
61
Session Homework Sheets for Parent Tools
63
SESSION 1 PARENT TOOLS HOMEWORK
Daily Record
Instructions: Please keep a daily record of your child’s OCD symptoms and problem behaviors. In the space pro-
vided below (feel free to use additional space if necessary), record the date, the specific symptom, and the amount of
time your child spent engaging in that symptom.
Date OCD Symptom Time Spent
64
Daily Record of OCD Symptoms
record the date, the specific symptom, the amount of time your child spent engaging in that symptom, how much disturbance it causes in the family, and
how the parents are involved in the symptom.
Date OCD Symptom Time Spent Family Disturbance Parents’ Involvement

65
Responses to OCD Symptoms (1)
At this point in treatment, we do not want you to change your responses to your child’s symptoms in any dramatic
way. Your goal at this point is to help your child accurately identify when behaviors may be related to OCD. Therefore,
when you observe such a behavior label it for your child or ask your child about it. Use the space below to make
notes during the week about how this process goes.
Description of Behavior: Label: Parent Response: Notes:
66
Responses to OCD Symptoms (2)
At this point in treatment, we still do not want you to change your responses to your child’s symptoms in any
dramatic way. Your goal is still to help your child accurately identify when behaviors may be related to OCD. As you
did last week, we want you to use positive attention and rewards to encourage homework completion (daily E/RP
task). This week we also want you to ignore (remove attention from) any complaints or refusals to do homework
assignments.
Use the space below to make notes about how these elements work/don’t work for you and your family.
Identification of OCD Behaviors:
Positive Attention and Rewards:
Ignore/Remove Attention:
67
Disengagement and Modeling
1. As you did last week, we want you to use positive attention and rewards to encourage homework completion
(daily E/RP task), and ignore (remove attention from) any complaints or refusals to do homework assignments.
How is this going?
2. The task assigned to your child this week may involve helping you disengage yourself from one of the OCD
symptoms. How does the process of disengagement feel to you? Does it seem to be helping? If there have been
difficulties, what do you think they are related to?
3. This week in session we talked about paying attention to your own behavior as a model for your child’s
behavior. Use the space below to make notes about times this week when you notice that you are modeling (in
a positive or negative way) something that could relate to your child’s OCD.
68
Scaffolding Steps
1. This week in session we talked about four “Scaffolding Steps” that you can use to help your child with the daily
E/RP task. Use the space below to make notes about how these steps work (or don’t work) for you and your
child and ideas about how you could improve upon them.
2. Continue to use positive attention and rewards to encourage homework completion (daily E/RP task), and
ignore (remove attention from) any complaints or refusals to do homework assignments. How is this going?
Are you able to deliver the rewards promptly and consistently?
69
Scaffolding (2) & Review
1. This week in session we talked about using the Scaffolding Steps in unplanned, real-life situations. Use the
space below to make notes about how these steps work (or don’t work) in these new circumstances. Write when
you tried them and makes notes about how you could improve upon them.
2. Which parent tools have been most helpful to you and why?
70
Taking Time for Yourself & Review
1. This week in session we talked about the importance of parents taking time for themselves and their own
needs. Make notes here about actions you have taken or plans you have to take time for yourself (e.g., pursue
interests/hobbies or seek emotional support).
2. Use the space below to make notes about how the scaffolding steps are going. Write when you tried them and
make notes about how you could improve upon them.
71
Teaching Tools to Others and Review
1. This week in session we talked about the importance of consistency in handling OCD across situations, even
when your child is in someone else’s care (e.g., spouse, other relative, babysitter, or teacher). Write below ideas
you have for how to make plans with other caregivers for managing OCD. Include notes about any concerns
you have or problems you anticipate.
2. Use the space below to make notes about how the scaffolding steps are going. Write when you tried them and
make notes about how you could improve upon them.
72
Design Your Own Tool Kit
Now that you have had a chance to use all of the parent tools for several weeks (positive attention and rewards,
ignoring/removing attention, disengagement from OCD, and scaffolding steps), we want you to make the tools your
own. Write below about the parenting strategies that you are currently using to help your child. These strategies may
be the ones that have been taught in this program or they may be ones that you have come to on your own. Include
notes about times when these strategies do not seem as effective.
Strategy: Notes About Effectiveness:
73
Handling Future OCD-Related Issues
We began to talk in session about how to use the tools you have learned to manage OCD-related situations that
could arise in the future. Are there additional situations that we did not discuss in session? If so, write about how
you could handle them.
Situation: Tools to Use:
74
Reward Charts
75
76
REWARD CHART
Week of

REWARD CHART
Week of

77
78
REWARD CHART
Week of

REWARD CHART
Week of

79
80
REWARD CHART
Week of

REWARD CHART
Week of

81
82
REWARD CHART
Week of

REWARD CHART
Week of

83
84
REWARD CHART
Week of

Monitoring Forms
85
86
Monitoring Form
record the date, the specific symptom, the amount time your child spent engaging in that symptom, and how parent(s) are involved in the symptom. Try to
Date OCD Symptom Time Spent Parent’s Involvement Child Involved in

Monitoring Form

87
88
Monitoring Form

Monitoring Form

89
90
Monitoring Form

Monitoring Form

91
92
Monitoring Form

Monitoring Form

93
94
Monitoring Form

Daily Practice Records
95
96
Task Description:
Thermometer Ratings
Reward (describe what can be earned and what are the criteria are for earning it):
Task Description:
Thermometer Ratings
97
98
Task Description:
Thermometer Ratings
Task Description:
Thermometer Ratings
99
100
Task Description:
Thermometer Ratings
Task Description:
Thermometer Ratings
101
102
Task Description:
Thermometer Ratings
Task Description:
Thermometer Ratings
103
104
Task Description:
Thermometer Ratings

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Family-Based Treatment for Young Children With OCD

Anne Marie Albano, PhD

David H. Barlow, PhD

Gillian Butler, PhD

David M. Clark, PhD

Edna B. Foa, PhD

Paul J. Frick, PhD

Kirk Heilbrun, PhD

Robert J. McMahon, PhD

Peter E. Nathan, PhD

Christine Maguth Nezu, PhD

Matthew K. Nock, PhD

Paul Salkovskis, PhD

Bonnie Spring, PhD

Gail Steketee, PhD

John R. Weisz, PhD

G. Terence Wilson, PhD

Jennifer B. Freeman • Abbe Marrs Garcia

Oxford New York

Published by Oxford University Press, Inc.

Oxford is a registered trademark of Oxford University Press

All rights reserved. No part of this publication may be reproduced,

Printed in the United States of America

This workbook accompanies a family-based treatment program for obsessive-

Chapter 1 Introduction to the Treatment Program 1

Chapter 4 Exposure With Response Prevention 43

Chapter 6 Relapse Prevention 57

Daily Practice Records 95

■ To assess overall impact of obsessive-compulsive disorder (OCD) and

■ To learn about OCD

■ To differentiate between OCD behaviors and non-OCD behaviors

Assessment of Impact on Family Functioning

Family Involvement in OCD-Related Behaviors

2. What are the results of your accommodations?

3. What happens if the OCD behavior is not accommodated?

Your child’s OCD-related behavior and your accommodations can have an

OCD as a Neurobehavioral Disorder

Obsessions and Compulsions

■ Obsessions are persistent impulses, ideas, images, or thoughts that intrude

It is not uncommon for young children to have only compulsions (rituals). To be

Development and Course of OCD

Obsessive-Compulsive Spectrum Disorders and Comorbidity

OCD Versus Non-OCD Behaviors

■ compulsions and obsessions that are common to most kids,

■ compulsions and obsessions that are excessive and indicative of OCD,

Normal Developmental Rituals

The following list outlines normal developmental rituals at different ages1 :

■ Children between the ages of 6 and 11 often engage in superstitious

■ At age 12 and older, children may be very absorbed in particular

Other Kinds of Anxieties and Misbehavior

It is also important to recognize that OCD is different from other kinds of

My Child’s OCD Versus Non-OCD Behaviors

You may want to think about the following questions.

2. Is it clear which behaviors are related to OCD?

Overview of the Treatment Program

■ Identifying and monitoring OCD symptoms

■ Using a feelings thermometer to rate anxiety

■ Working with parents to develop a symptom hierarchy and implement

■ Differential attention: using attention to change a child’s behavior

■ Modeling: becoming aware of how parent behavior inﬂuences child

■ Scaffolding: working alongside a child to change his emotional response

■ To learn about differential attention, speciﬁcally tangible rewards

■ To use a reward plan