The Clinician's Guide to Cognitive-Behavioral Therapy for Childhood Obsessive-Compulsive Disorder

By Dean McKay

The Clinician's Guide to Cognitive-Behavioral Therapy for Childhood Obsessive-Compulsive Disorder brings together a wealth of experts on pediatric and adolescent OCD, providing novel cognitive behavioral strategies and considerations that therapists can immediately put into practice. The book provides case studies and example metaphors on how to explain exposure models to children in a developmentally appropriate manner. The book also instructs clinicians on how to use symptom information and rating scales to develop an appropriate exposure hierarchy. The book is arranged into two major sections: assessment and treatment of childhood OCD and special considerations in treating childhood OCD.

Each chapter is structured to include relevant background and empirical support for the topic at hand, practical discussion of the nature and implementation of the core component (such as exposure and response prevention, cognitive therapy, psychoeducation and more), and a case illustration that highlights the use of a particular technique.

• Provides the strong theoretical foundation required to successfully implement treatment
• Highlights the use of particular intervention techniques through case studies
• Provides CBT strategies for anxiety, tic disorders, trichotillomania, ADHD and disruptive behaviors
• Includes strategies for treatment of patients who are initially non-responsive to CBT
• Encourages individualization of evidence-based and clinically-informed principles for each patient
• Reviews what to do if/when OCD remits and/or returns
• Provides details on differentiation OCD symptoms from anxiety and other psychopathology

• Language: English
• Publisher: Academic Press
• Release date: Jan 2, 2018
• ISBN: 9780128114285

Book preview

Kingdom

Chapter 1

Introduction

Eric A. Storch⁎; Joseph F. McGuire†,‡; Dean McKay§    ⁎ University of South Florida, St. Petersburg, FL, United States

† Johns Hopkins University, Baltimore, MD, United States

‡ University of California, Los Angeles, CA, United States

§ Fordham University, New York, NY, United States

Abstract

This chapter provides an overview of the book in terms of content, use, and purpose.

Keywords

Obsessive-compulsive disorder; Children; Treatment; Cognitive behavioral therapy; Assessment; Family

Pediatric obsessive-compulsive disorder is a debilitating condition that affects approximately 1% of children worldwide at any time (Zohar, 1999). This condition confers great impairment across home, social and family domains (Piacentini, Bergman, Keller, & McCracken, 2003), and negatively impacts quality of life (Lack et al., 2009). Without intervention, symptoms tend to persist over time and escalate in severity (Bloch et al., 2009), often presenting with other cooccurring problems (Storch et al., 2008). Fortunately, there are two effective treatments that have been widely studied: cognitive behavioral therapy (CBT) that involves exposure and response prevention, and medication management with serotonin reuptake inhibitors (SRI). Although both interventions are effective, evidence suggests that CBT alone or together with SRI medications is the most effective treatment approach (Franklin et al., 2015; McGuire et al., 2015) with the specific approach depending on the severity of the child's condition as well as other clinical factors (AACAP, 2012).

Despite the strong efficacy of CBT, dissemination and access to treatment is a particular problem. Many children do not receive this form of psychotherapy at all or have to wait long periods until proper diagnosis and treatment is provided (Marques et al., 2010). Even when CBT is available, there may be considerable variability in its implementation due to the knowledge base and experience of the available providers. To address this critical dissemination gap, substantial efforts have been made. Training institutes (e.g., International OCD Foundation's Behavior Therapy Training Institute) have been designed with the goal of broadening the base of providers with expertise in CBT for childhood OCD. A second approach has involved developing treatment manuals that are published and made widely available. In this regard, several manuals have been published building on the initial seminal work by March and Mulle (1998), Freeman and Reinecke (1993), Piacentini, Langley, and Roblek (2007). These manuals provide structured, evidence-based treatment approaches for helping children with OCD and their families overcome the condition. While the linear nature of these texts is a strength and therapeutic concepts well described, it may be difficult for texts of this nature to go into great detail about a particular topic. For example, what are the exact words that one can say when providing education to a child and their family? Or, how exactly does one create a detailed hierarchy for the multitude of problems a child experiences? And, how might one contend with the myriad of clinical complexities that so often occur in this population (e.g., resistance, comorbidity)? With this in mind, we sought to compile a group of leading experts in the field of childhood OCD to write about—in a practical, how to fashion—conducting many of the skills essential to treating children with OCD.

We have divided the book into two overall sections: (1) assessment and treatment of childhood OCD and (2) special considerations in working with this population. The first section starts with chapters dealing with diagnosing OCD and comorbid problems, as well assessing the presence and severity of obsessive-compulsive and comorbid symptoms using evidence-based assessment instruments. Next, a chapter on psychoeducation for children and their family members details how to discuss with families theoretical models of OCD, the treatment model, and nature of treatment. Clear examples are given as to how to convey this information in a ready-to-use format. Following this, the core of the CBT treatment approach is described across two chapters. There is an in-depth discussion on how to create an exposure hierarchy with multiple examples detailing this approach for varied symptoms. The chapter after discusses designing and implementing successful exposures for a variety of symptom presentations. Real-world examples are given as well as tips for implementing creative, child-oriented exposure, and response prevention tasks. Following this, a chapter discusses cognitive therapeutic approaches to complement exposure work. Detailed examples are provided to facilitate this treatment approach and integrate it within an exposure-based treatment model. The next chapter focuses on working with families in the context treatment. Earlier models of treatment seem to isolate the child with more limited family involvement. Our belief, in contrast, is that family should be intimately involved in treatment with a default position of including the parents in sessions as clinically appropriate so that they can learn how to implement therapeutic skills (Storch et al., 2007). We have found this to be not only very effective but also widely acceptable to family members who often typically want to be readily engaged in their child's care and understand how to best help them. To this end, this chapter discusses methods of integrating family members into treatment. There is a special focus on targeting family accommodation, which is a ubiquitous construct when working with children with OCD (Caporino et al., 2012), as well as how to enhance compliance with treatment. A chapter on relapse prevention strategies is included in which a clear relapse prevention plan is articulated to optimize the chance therapeutic gains are maintained. Importantly, this chapter also addresses the sensitive topic what to do if the child that you are working with experiences relapse. A clear, well laid out plan is included for implementation. Finally, a chapter on medication management for childhood OCD is included given the efficacy of this approach. This chapter highlights evidence-based pharmacotherapy practice as well as when to consider medication management combined with CBT.

The second section of the book has a variety of chapters that go into further detail necessary for the complexity of working with this population. The purpose of this section is to spend time discussing critical features related to working with children with OCD. The section starts with discussing common myths and misconceptions in treating childhood OCD including misperceptions about exposure therapy, symptom return, and multiple other aspects. Next, a chapter focused on understanding OCD within school settings and how to manage it within school is provided. This chapter provides clear examples for ensuring that the child is ultimately successful in school, and the more severe cases are able to return to school effectively. The next chapter focuses on addressing significant family accommodation. As noted, virtually all families engage in some level of accommodation of the child's symptoms. This chapter talks about addressing accommodation, especially when such behaviors are entrenched and significant. This chapter is also unique in presenting a treatment model for what to do when a child is unwilling to engage in addressing their symptoms (Lebowitz, Omer, Hermes, & Scahill, 2014). Two chapters are included to discuss working with challenging patients and families. The focus of these chapters addresses increasing motivation through reinforcement systems and working with family member issues such as parental anxiety. The second chapter describes how to manage the most commonly cooccurring conditions such as comorbid anxiety, disruptive behavior, and attentional problems to name several. Following this chapter, a chapter on working with young children with OCD is included given the frequency with which symptoms onset in early childhood. The core treatment components of exposure and response prevention remain the same, but the application of this and other therapeutic concepts can differ in many ways. This chapter focuses on describing how to work with a young child and her/his family in addressing OCD. The final chapter presents an algorithm for managing the patient's care should they not be responsive to the initial trial of CBT and/or a first-line medication.

We anticipate that this book could be used in many ways. For practitioners who are newer to treating childhood OCD, this book can serve as a practical, how to manual for addressing symptoms in an affected child. We believe that the core of treatment includes exposure and response prevention; after conducting a thorough assessment over one to two sessions followed by providing psychoeducation over a session, the bulk of treatment will consist of exposure and response prevention. Studies have suggested that 12–14 sessions of exposure and response prevention may not be sufficient to gain an optimal response and that additional sessions may help optimize outcome (Skarphedinsson et al., 2015); it is reasonable to expect that some children will get better in a relatively short period of time but that others will need a significantly longer course. In the present approach, cognitive therapy is a complementary technique to exposure and response prevention; we believe that the majority of treatment should focus on exposure therapy. As the child progresses in treatment, it would follow that sessions are tapered and a relapse prevention plan is set in place. For clinicians who are more experienced, this text may provide more detailed information on core treatment components or addressing clinical complexities.

In closing, it is our hope that this book contributes by providing individuals who are interested in conducting CBT for childhood OCD with a practical framework and resource for implementing the core elements of this intervention. Further, we hope that this book can be useful for parents of an affected child; perhaps as a complement to ongoing treatment, or as a reference to ensure that appropriate treatment is being provided. Ultimately, it is our central goal that CBT for childhood OCD becomes available to all children who are affected with this problem to improve their quality of life and happiness as well as that of their family.

References

AACAP. Practice parameter for the assessment and treatment of children and adolescents with obsessive-compulsive disorder. Journal of the American Academy of Child and Adolescent Psychiatry. 2012;51(1):98–113. doi:10.1016/j.jaac.2011.09.019.

Bloch M.H., Craiglow B.G., Landeros-Weisenberger A., Dombrowski P.A., Panza K.E., Peterson B.S., et al. Predictors of early adult outcomes in pediatric-onset obsessive-compulsive disorder. Pediatrics. 2009;124(4):1085–1093.

Caporino N.E., Morgan J., Beckstead J., Phares V., Murphy T.K., Storch E.A. A structural equation analysis of family accommodation in pediatric obsessive-compulsive disorder. Journal of Abnormal Child Psychology. 2012;40(1):133–143.

Franklin M.E., Kratz H.E., Freeman J.B., Ivarsson T., Heyman I., Sookman D., et al. Cognitive-behavioral therapy for pediatric obsessive-compulsive disorder: Empirical review and clinical recommendations. Psychiatry Research. 2015;227(1):78–92.

Freeman A., Reinecke M.A. Cognitive therapy of suicidal behavior: A manual for treatment. New York, NY: Springer Publishing Co; 1993.

Lack C.W., Storch E.A., Keeley M.L., Geffken G.R., Ricketts E.D., Murphy T.K., et al. Quality of life in children and adolescents with obsessive-compulsive disorder: Base rates, parent–child agreement, and clinical correlates. Social Psychiatry and Psychiatric Epidemiology. 2009;44(11):935–942.

Lebowitz E.R., Omer H., Hermes H., Scahill L. Parent training for childhood anxiety disorders: The SPACE program. Cognitive and Behavioral Practice. 2014;21(4):456–469.

March J.S., Mulle K. OCD in children and adolescents: A cognitive-behavioral treatment manual. New York: Guilford Press; 1998.

Marques L., LeBlanc N.J., Weingarden H.M., Timpano K.R., Jenike M., Wilhelm S. Barriers to treatment and service utilization in an internet sample of individuals with obsessive–compulsive symptoms. Depression and Anxiety. 2010;27(5):470–475.

McGuire J.F., Piacentini J., Lewin A.B., Brennan E.A., Murphy T.K., Storch E.A. A meta-analysis of cognitive behavior therapy and medication for child obsessive–compulsive disorder: Moderators of treatment efficacy, response, and remission. Depression and Anxiety. 2015;32(8):580–593.

Piacentini J., Bergman R.L., Keller M., McCracken J. Functional impairment in children and adolescents with obsessive-compulsive disorder. Journal of Child and Adolescent Psychopharmacology. 2003;13(2, Suppl. 1):61–69.

Piacentini J., Langley A., Roblek T. Cognitive behavioral treatment of childhood OCD: It's only a false alarm therapist guide. New York, NY: Oxford University Press; 2007.

Skarphedinsson G., Weidle B., Thomsen P.H., Dahl K., Torp N.C., Nissen J.B., et al. Continued cognitive-behavior therapy versus sertraline for children and adolescents with obsessive–compulsive disorder that were non-responders to cognitive-behavior therapy: A randomized controlled trial. European Child & Adolescent Psychiatry. 2015;24(5):591–602.

Storch E.A., Geffken G.R., Merlo L.J., Mann G., Duke D., Munson M., et al. Family-based cognitive-behavioral therapy for pediatric obsessive-compulsive disorder: Comparison of intensive and weekly approaches. Journal of the American Academy of Child and Adolescent Psychiatry. 2007;46(4):469–478.

Storch E.A., Larson M.J., Merlo L.J., Keeley M.L., Jacob M.L., Geffken G.R., et al. Comorbidity of pediatric obsessive–compulsive disorder and anxiety disorders: Impact on symptom severity and impairment. Journal of Psychopathology and Behavioral Assessment. 2008;30(2):111–120.

Zohar A.H. The epidemiology of obsessive-compulsive disorder in children and adolescents. Child and Adolescent Psychiatric Clinics of North America. 1999;8:445–460.

Chapter 2

Diagnosing Childhood OCD

Ella L. Oar*; Carly Johnco*; Cynthia M. Turner†    * Macquarie University, Sydney, NSW, Australia

† University of Queensland, Brisbane, QLD, Australia

Abstract

Careful diagnosis and case conceptualization are central to effective treatment planning. However, diagnosis can be complicated when working with children and families. In addition to knowledge about diagnostic criteria, diagnosis relies heavily on clinicians’ ability to identify, conceptualize, and differentiate a range of symptoms in order to generate a successful treatment plan. There are a number of important considerations when diagnosing and differentiating obsessive-compulsive disorder (OCD) in children and youth. This chapter will discuss four key areas and skills that are central to a developmentally sensitive assessment of OCD. This chapter will (1) outline how to apply the diagnostic criteria for OCD to youth, including how to differentiate age-normative and pathological rituals; (2) review common OCD symptom presentations in youth; (3) provide clinical guidance on how to conceptualize and differentiate OCD symptoms from symptoms of anxiety and other psychopathology, particularly in the context of overlapping symptoms; and (4) highlight complicating factors to consider when assessing and diagnosing OCD in children and adolescents.

Keywords

OCD; Child; Adolescent; Diagnosis; Differential diagnosis; Comorbidity

The Diagnostic and Statistical Manual of Mental Disorders 5th Edition (DSM-5) criteria for obsessive-compulsive disorder (OCD) requires the presence of obsessions and/or compulsions (APA, 2013). Obsessions are characterized by recurrent and persistent thoughts, urges, or images that are experienced (at some time) as intrusive and unwanted. These cognitive intrusions cause marked anxiety or distress for most individuals. Youth (particularly younger children) may lack the insight and/or verbal ability to communicate their obsessional experiences, sometimes simply describing a need to do something until it feels just right. Hence, for children and adolescents it can be particularly helpful to use a symptom checklist measure (e.g., Children's Yale-Brown Obsessive-Compulsive Scale [CY-BOCS]; Scahill et al., 1997) that provides prompts for a range of common obsessional symptoms and content areas when conducting an initial assessment (e.g., Are you concerned about contamination [or getting germs on you] from touching animal/insects; Are you concerned that you will get/make others ill by spreading contaminants/germs). Clinician prompting facilitates diagnosis in three key ways. First, prompting maximizes the potential for youth to endorse symptoms by helping them to articulate their internal experiences. Second, youth often show limited insight into the excessive nature of their symptoms, and as such, do not spontaneously report these symptoms. Prompting may also help to identify symptoms that the child does not recognize as problematic. Finally, prompting has the potential to help to reduce shame or embarrassment about particular symptoms by validating them as common to OCD, rather than the symptom being a sign that the young person is weird, defiant, or abnormal.

The CY-BOCS provides prompts to help assess duration (i.e., persistence), interference, distress, resistance, and control over obsessions (e.g., How much time do you spend thinking about these things/what is the longest amount of time each day that you are not bothered by these thoughts? How much do these thoughts bother or upset you? How hard do you try to stop the thoughts or ignore them? Are you able to control the thoughts? Goodman et al., 1989). Assessing these clinical features of intrusive thoughts is important to help with differential diagnosis.

Compulsions are characterized by repetitive behaviors (e.g., hand washing, ordering, checking) or mental acts (e.g., praying, counting, repeating words silently) that the child feels driven to perform in response to an obsession or according to rules that must be applied rigidly (APA, 2013). The goal of these behaviors is to prevent or reduce distress, to be rid of the intrusive thoughts, and/or to prevent some negative outcome from occurring. However, these behaviors are clearly excessive compared to the objective level of threat, or they may not be connected in a realistic way with what they are designed to neutralize or prevent (APA, 2013). Compulsions are not performed for pleasure, although some individuals do experience emotional relief from feelings of anxiety, distress, discomfort, or incompleteness. The DSM-5 includes a developmental specifier for young children, noting that they may not be able to articulate the goals of these behaviors or mental acts; however, this is also a common clinical experience in older children. Although missing from the DSM-5, the previous diagnostic manual (DSM-IV-TR) noted that in addition to difficulty communicating the function of their compulsions, youth also commonly fail to recognize the excessive nature of their compulsive behaviors (APA, 2000). Even when youth do have sufficient insight, their compulsive behaviors often become habitual over time, and as a result they may fail to report certain symptoms. Similar to obsessions, it can be useful to use a structured measure like the CY-BOCS to assess compulsive behaviors to ensure adequate assessment of common compulsive phenotypes.

Criterion B for OCD specifies that obsessions or compulsions need to be time consuming (e.g., take more than 1 h per day) or cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. Intrusions are a common phenomenon, with almost all people experiencing at least the occasional intrusive thought (Crye, Laskey, & Cartwright-Hatton, 2010). These criteria help to differentiate occasional and normative intrusive thoughts from clinically significant intrusive thoughts. Although a time-based minimum of 1 h is noted in the diagnostic criteria, the frequency and duration of OCD symptoms can vary between youth. Symptom duration of 1–3 h per day is generally considered mild to moderate severity, although some individuals may experience almost constant symptom presence (more than 8 h per day).

Diagnosis can be challenging when, even in the context of severe OCD pathology, families or children report that their symptoms occupy less than 1 h per day. This is especially common in circumstances where a young person is avoiding particular items/situations that may trigger their obsessions, or when families are accommodating the child's OCD symptoms. Common accommodating behaviors that family members may engage in include providing excessive reassurance; participating in rituals (e.g., facilitating the child completing a compulsion; completing or avoiding a particular behavior at the request of the child); providing the child with items needed to complete their compulsions (e.g., decontaminants); allowing the child to avoid situations that may trigger their OCD; completing tasks or chores for the child (e.g., dressing, making the child's bed) to avoid triggering OCD; and altering family functioning (e.g., avoiding certain activities, allowing the child to dictate the arrangement of furniture in the house) (Calvocoressi et al., 1995; Wu et al., 2016). Families engage in these behaviors to prevent the child's OCD symptoms from being triggered or to reduce the child's distress. When diagnosing OCD, it is important to consider how OCD may be impacting on family members, as family accommodation may be reducing other clinically relevant factors (e.g., time spent, distress).

Youth with OCD can present with limited insight into the excessive or dysfunctional nature of their beliefs (Adelman & Lebowitz, 2012). It is not unusual for a child to endorse symptoms as normal, when these are actually behavioral excesses or obsessional in nature. For example, children may report feeling strongly that certain clothing be worn on specific days. Parents may report that this belief is firmly held, but the child may report it as a highly desired preference. Clinicians can struggle to determine whether this constitutes merely a preference or a behavioral problem. Therefore clinical knowledge of the phenomenology of OCD (e.g., that individuals may display an inflated sense of responsibility for preventing harm, magical thinking about the capacity for special actions to prevent negative outcomes, excessive concern with controlling thoughts, or perceiving that having a thought is equivalent to acting on it, etc.) can aid diagnosis. Diagnostic specifiers can be used to note the level of insight displayed by the young person (e.g., with good or fair insight, with poor insight, and with absent insight/delusional beliefs). Regardless of the child's level of insight clinicians should routinely consult with parents during the assessment process, as this will greatly aid in determining whether behaviors are dysfunctional or excessive. Given the high level of comorbidity with tic disorders (Leckman et al., 2010), and the potentially different pattern of comorbidity, course, and familial history of youth with comorbid OCD and tics (APA, 2013), a tic-related specifier may also be given when youth have a current or lifetime diagnosis of a tic disorder. Finally, as with most mental health concerns, symptoms need to be differentiated from the effects of a substance or medical condition, and cannot be better explained by another mental disorder (refer to Differential Diagnosis and Comorbidity section).

Developmental Considerations

Children often display a number of ritualistic and/or repetitive behaviors that can appear compulsive in nature. Differentiating between normative and pathological rituals is relevant when diagnosing OCD. By the age of 2, around 60% of children display some form of ritualistic behavior, with strong attachment to a favorite object commonly emerging around 14 months; bedtime routines around 16–17 months; being very concerned with dirt, cleanliness or neatness around 22 months; and lining up objects around 24 months (Evans et al., 1997). Although many of these rituals subside over time as children become more flexible, others (e.g., bedtime rituals) often remain, and superstitious beliefs can emerge in later childhood. Leonard, Goldberger, Rapoport, Cheslow, and Swedo (1990) describe a number of common age-normative rituals and beliefs during childhood. For example, children often play a game of jinx where one child can be silenced if two children speak the same word simultaneously; young children may fear being contaminated by cooties if touched by a child of the opposite sex; common childhood hobbies may be focused around acquiring (or hoarding) large quantities of figurines, stamps, coins, or memorabilia related to popular culture; and children often play games where they avoid stepping on surface cracks (step on a crack and break your mother's back). It is normal for children to believe in more magical and mythical constructs (e.g., the tooth fairy, Santa), while adolescents typically do not. Although onset of OCD commonly occurs during childhood, it is important to consider whether the child's beliefs and behaviors are normative given their age and stage of development. The clinical dimensions of duration, interference, distress, resistance, and level of control related to the thoughts and behaviors being assessed aid in diagnosis.

Common OCD Symptom Presentations

Although core symptom features (obsessions and/or compulsions) remain similar across individuals, the clinical presentation of OCD can vary widely. There are a number of well-recognized OCD symptom subtypes or dimensions that youth can present with, with many individuals presenting with symptoms in more than one symptom cluster (Mataix-Cols, Nakatani, Micali, & Heyman, 2008).

Contamination (Contamination Obsessions and Cleaning Compulsions)

Youth with contamination OCD are typically preoccupied with fears of illness or death as a result of exposure to germ or chemical contamination. These obsessions often drive compulsive washing or cleaning behaviors (e.g., prolonged or excessive hand washing or showering; sterilization of objects, surfaces, and people). They also typically lead to avoidance of particular surfaces (e.g., door handles, trash cans), objects (e.g., crockery, cutlery, pens, toys), people (e.g., siblings), food (e.g., sushi), and situations (e.g., public transport, movie theaters). The dominant emotions in contamination-based OCD are fear and disgust.

Symmetry (Symmetry Obsessions and Repeating, Ordering and Counting Compulsions)

The symmetry symptom dimension is characterized by a preoccupation with evenness and symmetry. Symptoms can present in different ways. For example, arranging possessions in a particular order or pattern, or needing body parts to feel even if touched or when touching surfaces (e.g., feet on floor). Repetitive compulsions fall within this dimension and can include verbal repetition (e.g., words, phrases) or repeated activities (e.g., reading and rereading, writing and rewriting, retracing steps, turning handles or switches repetitively). Counting compulsions are also common. Unlike other symptom dimensions, individuals with these symptoms do not tend to report a fear of negative outcomes occurring from a lack of order or symmetry. Rather, there can be a strong urge for uniformity, perfectionism, feeling right or even, and these symptoms have been termed not just right experiences (Coles, Frost, Heimberg, & Rhéaume, 2003; Schubert, Ravid, & Coles, 2016).

Forbidden or Taboo Thoughts (Aggressive, Sexual, or Religious Obsessions and Related Compulsions)

Unacceptable or repugnant obsessions typically refer to obsessions that contain aggression, harm, sexual, or religious content. Aggressive (or harm) obsessions involve distressing, unwanted thoughts, or images about purposefully or unintentionally causing harm to oneself or others (e.g., Moulding, Aardema, & O'Connor, 2014). For example, images, thoughts, or urges to push a friend off a balcony, stab a sibling, or step in front of a car. While compulsions may involve avoidance strategies (e.g., of objects, people, or environments) in order to prevent the child from engaging in the behavior, checking compulsions (e.g., recurrent calling or texting), and/or other ritualized behaviors aimed at undoing or preventing the risk of harm.

Sexual obsessions refer to unwanted sexual thoughts, often focused on family members, friends, or other children. These obsessions can include violent or homosexual acts, or bestiality. Similar to harm obsessions, behavioral responses tend to involve avoidance and/or engaging in compulsive rituals that either un-do or compensate and make up for their obsession (Fernández de la Cruz et al., 2013). These obsessions are often highly shameful and children may be reluctant to disclose such symptoms. There is no evidence to suggest that the experience of sexual obsessions is linked to the child sexual abuse.

Religious obsessions (referred to as scrupulosity) tend to involve preoccupations with blasphemy, death, (unwarranted) fears of having sinned, and religious or moral judgment focused on narrow/insignificant aspect of religious doctrines or moral standards (Miller & Hedges, 2008). Compulsions often involve ritualized, repetitive, and excessive use of religious behaviors (e.g., prayer, confession, self-punishment) or excessive use of behaviors that are perceived to un-do or make up for their sin (e.g., volunteer, donate, help others).

Hoarding

Although compulsive hoarding has historically been considered a symptom cluster within OCD, Hoarding disorder is now categorized separately (APA, 2013). However, many individuals with OCD may still display hoarding symptoms, despite not meeting criteria for hoarding disorder comorbidity (Morris, Jaffee, Goodwin, & Franklin, 2016; Pertusa et al., 2008). Hoarding behavior refers to a pattern of saving or acquiring items, with persistent difficulty discarding them, regardless of their actual value. Hoarding behavior may be limited or moderated by adults, given young people typically live with parents/adult caregivers. Youth may refuse to discard old toys, clothes, or items of no value (e.g., packaging, string, rubber bands), often with a belief focused on the potential need for the item at a later time, sentimentality related to the object (e.g., the item reminds the child of a particular event or experience), anthropomorphism, or a concern about waste. In the context of OCD, hoarding is usually the direct consequence of obsessions or compulsions. Feelings on incompleteness and needing to preserve memories and meaning are the most common OCD symptom associated with hoarding, although acquisition may also be the result of avoiding other OCD-related triggers (e.g., not discarding to avoid washing or checking).

Other Miscellaneous Symptoms

There are several other common OCD symptoms that do not fit neatly within the symptom dimensions discussed earlier. These can include obsessional doubting (i.e., worries of having done something wrong) that usually relate to compulsive reassurance seeking or confessing (i.e., a need to tell or report all activities, thoughts, or perceived wrongdoings), superstitious fears (e.g., fears of certain numbers or colors, stepping on a crack); fear of losing things that can relate to obsessional checking or list making; transformation obsessions (e.g., fears of morphing or acquiring negative characteristics), and intrusive (nonviolent) images, songs, or music (e.g., theme songs).

Differential Diagnosis and Comorbidity

In addition to high levels of comorbidity between OCD and other disorders, symptoms of OCD can overlap with some of these conditions. Assessments should incorporate multiple methods (e.g., clinical/diagnostic interview, behavioral observation, self-, and parent-report questionnaires) and multiple informants (e.g., child, parent, and teacher) to gain a complete picture of the youth across contexts and settings. Chapter 4 provides a comprehensive review of evidence-based assessment measures for OCD and differential/comorbid diagnoses. Therefore the focus here is on clinical guidance related to differentiating symptoms of OCD from other disorders that share commonalities in their clinical presentation. Table 1 provides an overview of the common features of these disorders, along with relevant clinical features that may help to differentiate symptoms.

Table 1

Shared and Differential Features Between OCD and Its Common Cooccurring Disorders

Generalized Anxiety Disorder

Perhaps not surprisingly, a high degree of overlap exists between OCD and the anxiety disorders. Anxiety disorders are one of the most common comorbid conditions in childhood OCD, with 26%–75% of youth meeting criteria for a cooccurring anxiety disorder diagnosis (Langley, Lewin, Bergman, Lee, & Piacentini, 2010). Differential diagnosis between generalized anxiety disorder (GAD) and OCD is often the most complex given similarities in the phenotypic presentation of the disorders. GAD is characterized by excessive and uncontrollable worry about a range of events and/or activities (e.g., school, performance, health, family, and world events; APA, 2013). To meet diagnostic criteria, children and adolescents must worry most days, for at least 6 months, and worry must be associated with at least one physiological symptom (e.g., restlessness, fatigue, difficulty concentrating, irritability, tense muscles, and sleep disturbance).

OCD and GAD share a number of common symptoms such as repetitive and persistent thoughts that focus upon future events, in addition to other cognitive processes (e.g., perfectionism, intolerance of uncertainty, cognitive avoidance). There are also a number of shared safety-seeking behaviors (e.g., mental rituals, reassurance seeking, checking; Comer, Kendall, Franklin, Hudson, & Pimentel, 2004). One of the most common sources of diagnostic confusion between OCD and GAD is the overlap between obsessions and worries. To assist with differential diagnosis, clinicians can probe for further information relating to the content of the cognitions. Generalized worry tends to focus on more everyday concerns, such as parental health or well-being (Weems, Silverman, & La Greca, 2000). Obsessions are often more unusual or bizarre in nature, or the child may believe she or he has a pivotal role in preventing the feared outcome from occurring, such as fearing a parent may die if a child touches their food without washing his or her hands. Examining the form of the cognitions may also help clinicians to distinguish between the disorders. GAD has been found to be associated with thoughts that are more verbal in nature, whereas obsessions can also be image based or urge related (Langlois, Freeston, & Ladouceur, 2000).

Beliefs related to the meaning and significance of intrusive thoughts may also differentiate OCD and GAD, as research suggests that people with OCD are more likely to misinterpret the meaning of their thoughts (Purdon, 2004). For example, thought-action fusion (TAF) has been found to successfully discriminate between obsessive features and worry in adults, with TAF most strongly related to obsessions (Coles, Mennin, & Heimberg, 2001). TAF involves either a morality bias, where the individual believes that thinking about immoral behavior (e.g., harming a loved one) is morally equivalent to engaging in the behavior, and/or a likelihood bias whereby the individual believes that thinking about an aversive event (e.g., a loved one being in a car accident) actually increases the chance of that event occurring.

Ritualized or repetitive behaviors may be present in both GAD and OCD. For example, children with GAD may repeatedly check they have packed everything for school, rewrite/erase work, or seek reassurance from family members. Some authors have suggested that worry in GAD may be analogs to mental rituals in OCD, in that it is negatively reinforcing, provides relief from distress and regulates emotions (Vrana, Cuthbert, & Lang, 1986). Repetitive behaviors in OCD and GAD have been proposed to be distinguishable based upon the following key factors: (1) incidence—youth with OCD engage in compulsive behaviors more frequently than those with GAD; (2) flexibility—youth with OCD tend to be more rigid in the performance of their behaviors (i.e., OCD rituals are highly rule-bound, and often repeated unless done in exactly the right way); and (3) nature—the logic that connects the performance of the behavior to the thought in youth with OCD may be tenuous or magical (e.g., if I avoid stepping on cracks nothing bad will happen; Comer et al., 2004). These proposed differences in compulsive behaviors between GAD and OCD have not yet been empirically examined; however, they provide a heuristic for clinical decision-making.

Illness/Health-Related Anxiety and Emetophobia

There are several areas of symptom overlap between OCD and both illness/health anxiety and emetophobia. While the rates of comorbidity between the disorders are unknown in children and adolescents, comorbidity in adults is high, with 8.2%–15% of adults with OCD presenting with comorbid hypochondriasis, and 13% of adults with emetophobia presenting with comorbid OCD (du Toit, van Kradenburg, Niehaus, & Stein, 2001; Sykes, Boschen, & Conlon, 2016). Illness/health anxiety is a broad term that relates to anxiety associated with a fear of developing a serious illness (Asmundson, Abramowitz, Richter, & Whedon, 2010). In comparison, emetophobia is a type of specific phobia that is characterized by an extreme fear of vomiting (Boschen,