**9.3. Additional consideration for ERP in child populations**

Children are encouraged to externalize the OCD as separate from themselves [64, 65]. Therapists often describe OCD as a "bully" or "worry monster" that puts "silly worries" or "scary thoughts" into the children and "commands" or "bullies" the children to repeat certain behaviors. Children externalize their OCD by giving their OCD a name of their choice (e.g., Mr. Wrong, Meanie, Silly Sam, etc.) and "bossing back" or fighting OCD by not listening to its commands and doing the opposite of what OCD says (i.e., exposures).

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Psychoeducation can involve using examples from other areas of the child's life to build motivation for facing fears as a way of overcoming them (e.g., learning to ride a bike or swim). Depending on child's age or developmental level, therapists may measure level of anxiety in a variety of ways: a fear thermometer or using objects of different sizes that symbolize anxiety levels (e.g., three cups of different sizes). When possible and applicable, therapists can make exposure into a game (e.g., doing silly things in the presence of feared trigger, who can touch the dirty pen first, passing a pen between their toes and race with the therapist) to increase children's willingness to participate and match their developmental level. Additionally, including parents in the "game" or exposure activity may help children feel more comfortable and open to engage.
