**9.1. Family involvement in treatment**

Routine screening of obsessions and compulsions is recommended during all psychiatric evaluations of children and adolescents, regardless of whether OCD is part of the presenting complaint. Screening can be conducted via several brief questions such as "Do you have worries that just won't go away or get stuck" and "Do you do things over and over or have habits you can't stop?" [17]. For individuals who exhibit OCD symptoms and meet DSM criteria for the disorder, a comprehensive evaluation of possible comorbid psychiatric disorders is recommended as well as a thorough medical, developmental, family, and school history [17]. As discussed in comorbidity section above, children are likely to present with multiple diagnoses, which may impact their treatment needs and ability to participate effectively in OCD treatment. With regard to family history, inquiries should focus on family mental health history, activities of daily living, general family dynamics, and lifestyle factors. Medical history questions may also provide helpful information regarding differential diagnosis of PANDAS/ PANS. Additionally, gathering information about a child's academic performance over time also allows for an understanding of functional impairment and symptom severity outside of

Evidence-based treatment modalities for pediatric obsessive compulsive disorder comprise cognitive behavior therapy (CBT), specifically exposure and response prevention (ERP), as well as psychiatric medication (selective serotonin reuptake inhibitors, SSRIs) [17, 45, 60, 61]. CBT is recommended as the first-line treatment for mild-to-moderate cases of OCD in children [17]. A combination of psychotropic medication and CBT is recommended for moderate-to-severe OCD in children, with serotonin reuptake inhibitors considered the first-line medication [62]. Additionally, medication can be helpful in cases where children are having difficulties engaging in treatment or have co-occurring disorders that cause additional functional impairment. Medication augmentation may also be considered for individuals with treatment resistance (i.e., nonresponsive to empirically based interventions) who experience persistent OCD symp-

Exposure and response prevention (ERP) involves prolonged, repeated contact with feared stimuli that trigger obsessions (exposure) without engagement in compulsive or avoidant behaviors (ritual prevention) [63, 64]. Treatment will usually start with psychoeducation to orient the child and family to the cognitive behavioral model and expectations for therapy. The therapist, child, and often family members will then collaborate to create a list of situations that trigger anxiety and rate them from lowest to highest intensity (i.e., treatment hierarchy). Exposures will typically begin with situations that trigger mild anxiety and proceed in a graded fashion as the child habituates (experiences a reduction in anxiety) and/or increases their willingness to remain in the situations despite anxiety. Simultaneously, the child does not engage in rituals before, during, or after exposure to block negative reinforcement and to allow the anxiety

the child's home [17].

**8. Treatment practice guidelines**

76 Anxiety Disorders - From Childhood to Adulthood

toms despite adequate treatment interventions.

**9. Cognitive behavioral therapy for pediatric OCD**

Family-based CBT programs have been recommended for early childhood OCD (approximately ages 5–8) and have demonstrated success in randomized control trials [45, 61]. Parent participation is particularly important for younger children who have unique developmental needs and rely heavily on their caretakers. The Pediatric Obsessive-Compulsive Disorder Treatment Study for Young Children (POTS JR) evaluated the efficacy of a family-based CBT protocol (FB-CBT) for young children who addressed cognitive, socioemotional, and family factors compared to a family-based relaxation training protocol [45]. This 14-week randomized clinical trial involved 127 pediatric outpatients with OCD aged 5–8 years at three academic medical centers. Results revealed that the FB-CBT led to significant reductions in OCD symptoms and functional impairment; young children with OCD were able to benefit from exposure and response prevention with parental support [45].

Family-based CBT incorporates parent tools such as behavior management skills training; parents are trained in behavioral strategies such as implementing reward systems, modeling, and ignoring behaviors that are reinforced by attention [45]. As children may lack insight into their symptoms and/or resist voluntary contact with triggers, they may be more likely to participate in treatment with the addition of external reinforcers. Additionally, parents can be actively involved during in-session and home-based exposure exercises and provide helpful support to their child. Therapists teach parents how to act as a coach between sessions, which ensures increased likelihood of children practicing and adhering to CBT principles between sessions [45]. Parents who are included in the treatment process are less likely to accommodate their child's OCD, which can greatly enhance treatment outcomes [14].
