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

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 to decline naturally. For example, a child who worries about contracting a serious illness and engages in excessive handwashing and avoidance of germs would not only touch objects that are associated with germs but also refrain from handwashing for the exposure exercise.
