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Developmental Considerations for OCD in Kids, Teens, and Adults

Presented by Jacquelyn Gola, Psy.D.

View the webinar’s corresponding slides here        View the Webinar

Although OCD is diagnosed using one set of criteria, it manifests differently across the lifespan. This presentation will explore OCD across different age groups. Webinar attendees will learn how OCD presents in children, adolescents, and adults and how Exposure and Response Prevention therapy (ERP) could be adapted for each age group.

Dr. Gola provides psychological treatment of children, adolescents, and adults with a wide range of psychological disorders using evidence-based cognitive behavioral therapy (CBT), including Exposure and Response Prevention (ERP/ExRP), Comprehensive Model for Behavioral Treatment (ComB), Prolonged Exposure (PE), Acceptance and Commitment Therapy (ACT), and Parent Management Training (PMT). She also conducts psychological evaluations for pre-operative bariatric surgery candidates, as well as psychological and psychoeducational testing for children and adolescents to assess attention issues, executive functioning difficulties, learning disabilities, and other psychological disorders. Dr. Gola has extensive expertise in evidenced-based treatments for OCD, anxiety disorders, specific phobias, PTSD, and trichotillomania. She obtained her formative experiences and training at the Center for the Treatment and Study of Anxiety (CTSA) and the Child and Adolescent OCD, Tic, Trich, and Anxiety Group (COTTAGe) at the University of Pennsylvania.

Comments(24)

  1. CLoggins says

    Advise please on how best to convey to a high school teacher your son’s OCD and Tics that he hides incredibly well at school but let’s loose once home.

    • Jacquelyn S Gola says

      Can this question be clarified, please? What wold you like to convey to the teacher about his OCD and tics and what would you hope to gain from that?

  2. CSingh says

    What kind of medications are used for OCD?

    • Jacquelyn S Gola says

      The types of medication that research has shown to be most effective for OCD are a type of drug called a Serotonin Reuptake Inhibitor (SRI), which are traditionally used as an antidepressants, but also help to address OCD symptoms. The SSRI’s have been found to work well to treat OCD symptoms: fluvoxamine (Luvox®), fluoxetine (Prozac®), sertraline (Zoloft®, paroxetine (Paxil®), citalopram (Celexa®)*, clomipramine (Anafranil®), escitalopram (Lexapro®), venlafaxine (Effexor®)

  3. FMotiar says

    What if a child/teen refuse to participate in treatment?

    • Jacquelyn S Gola says

      Trying to force treatment for the child or teen may result in them digging in their heels even more and likely, lack of progress. I would suggest first educating the child/teen on OCD. This can be done with a couple to a few sessions with an experienced psychologist or with the help of books on OCD at home. If the child still does not want to participate in the treatment, therapy can resume with parents-only sessions, in which the focus can be eliminating parents accommodations and participation in rituals plus further support and education. This should be fully transparent to the child/teen so they are aware that the parents may be changing how they respond to OCD in order to help. A reward system could be discussed and put in place for the child/teen when they are able and willing to fight OCD rituals. If OCD symptoms are moderate to severe, a referral for a psychiatrist for medication may be provided. Furthermore, I would encourage the parents and family to attend support groups for OCD or perhaps attend a SPACE treatment group (Supportive Parenting for Anxious Childhood Emotions), which we can provide at the Center for Emotional Health in NJ. Finally, although a child may not be ready for ERP treatment, they may be more open to this in the future, especially if OCD starts to interfere in things that they care about.

  4. GBusch says

    How to distinguish labeling thoughts as “OCD thoughts” from this turning into a compulsion?

    • Jacquelyn S Gola says

      Labeling thoughts as “OCD thoughts” can be helpful to learn to better identify obsessions (which we don’t need to respond to and are not important). This can help the person recognize earlier when their OCD is in play and use strategies to refrain from engaging in compulsions. However, this strategy could turn into a compulsion if the function of labeling thoughts becomes providing reassurance (over and over) that the thoughts are not true. For example, a person could respond to the thoughts “Does this feeling mean that I am gay?” by telling themselves this is an “OCD thought” so it means it is untrue and they are not gay. The function here is not helpful, as it serves a purpose of attempting to getting certainty, which is not possible and the opposite of the goal of ERP to better tolerate uncertainty. A better response may be “This thought is probably my OCD talking but I am not going to get caught up in figuring this out or analyzing this since this is what my OCD wants.”

  5. Dosantos.g says

    What is the best way to do exposures?

    • Jacquelyn S Gola says

      While there is no “best” way to do exposures, many patients do well with gradual exposure within a hierarchy that they design with their therapists. They collaboratively identify exposures that would go from least to most difficult and work up from the “easier” exposures. However, there is some research that suggests varying the intensity of exposures is best for optimizing long-term outcomes because it maximizes the opportunity for surprise; that is, a greater discrepancy between fear-based predictions and what actually occurs. Like I mentioned previously, exposures work well when they violate the person’s expectations about the outcome. It is important that exposures to feared situations are at a greater level of intensity, duration, or frequency than the person believes would be “safe” or “tolerable” to help solidify learned safety (inhibitory learning). It is also highly effective to combine fear cues if possible during exposures. For example, the person could engaged in the feared behavior (in vivo exposure) while bringing on the obsessional thoughts and images (imaginal exposure). For a person with a fear that they will sexually molest children, they might be asked to hug a child while purposefully bringing on thoughts and images that they are inappropriate touching him/her. It is also optimal to conduct exposures in a variety of contexts, stimuli, interpersonal contexts, and emotional conditions. Finally, exposures should be done repeatedly, daily, and part of the person’s “ERP lifestyle” not just part of therapy sessions.

  6. MartinB says

    We know that TS is more common in boys. Did I understand you that OCD is more prevalent in boys as well? Or is that just the early onset in boys? Do you know of any research between the severity of OCD & TS with boys vs girls?

    • Jacquelyn S Gola says

      Research suggests that OCD is more prevalent in boys only for early onset OCD. It levels out between girls and boys after that. Regarding gender differences, a literature review from 2011 found that males with OCD present with greater social impairment and greater co-morbidity of tic disorders and substance use disorders. Female patients had greater comorbidity with eating and impulse-control disorders. I am not aware of research that suggests tic or OCD symptom severity is greater in one gender versus another.

  7. IWeaver says

    Rage incidents in a child with TS/OCD is mainly OCD driven. Would exposure response prevention be the appropriate treatment?

    • Jacquelyn S Gola says

      I would want to know more about the “ABC”s of these range incidents. What are the antecedents (the event that immediately precedes the problem behavior), the behavior (what exactly does the rage incidents entail) and consequences (or event that immediately follows a response). Is the child engaging in the “rage incidents” because he or she cannot complete the ritual? What makes it OCD driven? If the child is at risk of harming herself or others during the rage or if this risk is possible if it escalates, I would likely recommend starting with addressing those behaviors first. I love “The Explosive Child” by Dr. Ross Green for parents that have children who have difficultly with managing emotions. Before addressing the OCD, it could be beneficial focus on teaching the child skills of frustration tolerance, problem solving, and flexibility and helping parents better cope with these situations. Granted, ERP would still be an appropriate treatment to address the OCD. If the child is not cooperative with the treatment, sessions can start with parents only. Please see my response to the question above if a child refuses to participate in treatment.

  8. GEngel says

    Regarding the cartoon example that you showed where the child says that her parents will die if she doesn’t do something a certain number of times: does that number ever change or does the object of the obsession/compulsion, in this case the parents ever change to be someone else?

    • Jacquelyn S Gola says

      Yes, this number can easily change to another number if OCD deems that a new number is “lucky” or OCD becomes “unsatisfied” with the number of times that the child completes the compulsion. Often times, they feel that they have to do the compulsion over and over even if that hit that number because it might still not feel right or their OCD is doubting that they did the compulsion right so some may not “count.” As far as the object that the OCD latches on to, this can expand to include siblings, themselves, or other friends or family members. OCD can even latch on to another theme altogether. OCD might “let up” the target of one if situations change (e.g. parent is no longer sick) or another theme becomes more urgent but there is usually no logical track.

  9. ESneffel says

    If a teen age girl has a counting obsession focusing on how many steps she takes walking to the car, the bus, around the mall etc. I’m concerned that this might be leading to an eating disorder. She does not seem particularly concerned about her self-image. In your experience have you seen that kind of transfer from one OCD issue to another?

    • Jacquelyn S Gola says

      I would want to find out what obsession(s) the counting compulsions are tied to. Is this related to having good luck or avoiding bad luck? Or is the counting steps related to body image or weight? Or something else? Patients with eating disorders are primarily driven by concerns of physical appearance, and consequently alter their eating patterns in order to lose weight accordingly. Some people with OCD may be restricting their eating for reasons very different than body image concerns. For instance, if this is not related to body image concerns, this could show up with eating if she start to count the number of mouthfuls chewed or pieces of food in a meal according to some fixed or magical number that is “correct” or “just right.” I certainty have seen OCD transfer to new situations and the person starts having to do more compulsions that she did not need to do previously, especially if they are yielding completely to the OCD. However, it is difficult to predict what this may look like. I recommend this link for more information on OCD and eating disorders: https://iocdf.org/expert-opinions/expert-opinion-eating-disorders-and-ocd/

  10. DAngelo says

    If I understand you correctly Touretteic OCD is different from TS with a co-occurring disorder of OCD. More information please.

    • Jacquelyn S Gola says

      When an individual meets criteria for both TS and OCD, they may be diagnosed with both disorders and present with symptoms that may or may not overlap. So in other words, the TS symptoms could be related or unrelated to OCD symptoms. For example, a person may present with vocal and motor tics (performed in response to unpleasant internal sensory phenomena) and they also may present with a separate set of compulsions (performed to relieve thoughts/feelings of anxiety or discomfort). Or, a person might present with a hybrid of both disorders in which the repetitive behaviors the person is doing can look like both a complex tic or a compulsion (e.g. repeating actions a certain number of times or until it feels right). “Tourettic OCD” is not a diagnoses in the DSM-5 but a conceptual framework that helps in the understanding and treatment of that symptom presentation.

  11. BForest says

    Please explain disconfirmmatory evidence and how it’s used in the treatment of OCD.

    • Jacquelyn S Gola says

      What I mean by using discomfirmatory evidence is using ERP and processing after exposures to disconfirm what the person’s OCD is telling them. For instance, their OCD may say do engage in checking compulsions and exaggerate the risk of something bad occurring if they do not engage in excessive checking. If the person continues to practice response prevention (limiting checking to one time), it provides evidence that the thing they think will happen, didn’t happen, is less likely to happen, or they can tolerate the anxiety or discomfort better then expected. They likely “know” this rationally but it “feels” real and true to them. ERP provides new learning that overrides old leaning through disconfirmatory evidence.

  12. M.Y. Phoebe says

    The current medical crisis is stressful for families. Any advice on navigating the worry for those with germ phobias?

    • Jacquelyn S Gola says

      It is definitely a stressful time for all. Those with germ phobias, health, or contamination OCD may experience an increase in anxiety and uncertainty during this current crisis. Although these feelings are normal, strategies to manage worrying can be used to keep worrying in control and avoid contributing to to feelings of hopelessness, depression, or panic. Worrying in itself might feel productive, but it is almost always not productive and often means repetitive, catastrophic thinking about the future. When we worry, we overestimate how the likelihood of something bad occurring or underestimate how well we can tolerate it if it does come true. I recommend using mindfulness-based strategies of noting you are having a thought or feeling, sitting with thoughts/feeling without reacting to the thought as if it were true (I feel contaminated, therefore I must wash), and returning to the present moment. (There are many free resources on mindfulness and mindfulness-based strategies to cope with anxiety!) Also, It is important to watch out for behaviors we might engage in only to decrease or avoid anxiety. This includes washing/cleaning compulsions that are excessive and only have a purpose to relieve anxiety. (Use current CDC guidelines). This also may mean avoidance of activities we usually enjoy. Finally, it is important to find ways to practice relaxation, such as progressive muscle relaxation, breathing techniques, mindfulness meditation, ect., and to limit how much access we give ourselves to coronavirus news to avoid getting overwhelmed and to times when anxiety is lower.

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