Anxiety disorders are the most common mental health problem in children and adolescents, and studies show that as many as 80 percent of kids who have them don’t get treatment. This is a particularly painful statistic because cognitive behavioral therapy (CBT) has been shown to be highly effective for kids struggling with obsessive-compulsive disorder (OCD) and other forms of anxiety, sometimes in combination with medication.
The drawback is that CBT usually takes 12 to 15 sessions to get substantial results. If a child is seeing a psychologist for the traditional once-a-week, one-hour session, that means three or four months. To speed that process up, and get help to kids sooner, more and more clinicians are using intensive treatment.
In intensive treatment the child has sessions that might last several hours, several days a week for 3-6 weeks. And evidence shows that just as much progress can be made on an accelerated timetable, especially when parents are part of the treatment.
The advantages of intensive treatment are obvious for children who are severely impaired, whose anxiety or OCD has taken over their lives and the lives of other family members. Often these kids are not able to go to school, participate in normal activities or see friends — sometimes they can barely leave their rooms. Intensive treatment means getting kids released from their misery in a matter of weeks rather than months.
“It’s very exciting that you can get a whole course of treatment in a really short period of time, and get kids back in control of their lives and able to go to school and do the things they care about,” explains Jerry Bubrick, PhD, the director of the Child Mind Institute’s intensive OCD program.
But intensive treatment also has advantages for kids whose anxiety is more moderate but has been resistant to treatment. And it’s useful for families who live in parts of the country without access to clinicians trained in CBT, who can travel for treatment.
How it works
Anxiety thrives when children avoid things that make them anxious or develop rituals to cope with their fears, like washing their hands or touching things in a certain order. Over time, these accommodations allow the anxiety to grow and the avoidance and rituals become more and more time-consuming.
Often kids keep their fears, and their rituals, secret, until they become too overwhelming to hide. At that point the children often enlist family members and friends to support their avoidance and rituals to keep anxiety at bay.
In CBT kids learn about how anxiety works — how avoiding it gives it more and more power — and they develop skills to tolerate it without escaping or performing rituals. This is called exposure with response prevention, and it, in turn, causes the anxiety itself to diminish. The therapist helps kids confront fears in controlled, incremental steps. At each step, with repetition and practice, they see the anxiety subside and are ready to work their way up to bigger and bigger fears.
“If you think about it like learning a language, it’s similar to taking a two-hour class every single day with homework in between,” explains Dr. Bubrick. “You’re just exposed to it over and over and over, burning it into memory through lots of experience and lots of practice.”
In CBT, kids practice not only during sessions but in between them, and evidence shows that the most change occurs as patients apply the skills they’ve learned at home. When sessions are weekly, there is a lot of distraction in between sessions, and competition for kids’ and parents’ attention.
When the family is focusing on the treatment intensively, they’re more likely to do homework consistently, and learning is accelerated. Kids start to see results quickly, which increases their commitment to treatment and motivates them to work hard.
“Treatment for OCD works best with high compliance and high motivation,” says Dr. Bubrick. “When we do intensive treatment, kids learn the skills faster and get results faster. They get more and more empowered and motivated because they see it works.”
When earlier treatment hasn’t worked
Intensive treatment is particularly helpful for children who’ve made little or no progress with their anxiety or OCD, even thought they may have seen several different mental health professionals and even received some form of CBT.
One reason treatment fails, according to Dr. Bubrick, is that they sometimes get a watered-down version of CBT. In graduate school, a psychologist may study many treatment techniques — psychodynamic, CBT, gestalt — and then use a combination in their practice that incorporates some CBT but doesn’t follow through enough to be effective, he argues.
Another obstacle can be that a clinician has CBT training, but no experience with its application to a particular condition. “Having a specialty in CBT for eating disorders or insomnia doesn’t automatically make someone an expert in OCD,” notes Dr. Bubrick.
Another common problem is that a clinician may focus on one particular trigger for anxiety and miss others. For example, take a child who’s afraid of contamination and avoids touching the floor, which he fears might make him sick. The child might successfully do exposures that involve touching the floor and picking up things from the floor, but the anxiety about getting sick could remain. “This kid will show some improvement but will still have a fair amount of powerlessness about thoughts and will get caught up in those symptoms again,” Dr. Bubrick says.
Finally, families aren’t always included in the treatment. A “drop your kid off, pick your kid up” mentality isn’t going to be as successful, Dr. Bubrick adds, as when parents are involved as “cotherapists.”
The parents’ role
Research shows that reducing family accommodation of the OCD —the role parents play in helping children isolate themselves from their anxiety — makes treatment more effective. Parents often try, understandably, to make the home and family life “safe” for a child by giving them repeated reassurance and banishing things that trigger anxiety. They’re trying to protect the child, but reinforcing the child’s unhealthy coping strategies actually feeds the anxiety.
This response also leads some parents to worry that exposure therapy is too difficult for children. “It would be understandable for someone to hear about exposures and think, ‘There’s no way my child could handle that,’” Dr. Bubrick says. However, he continues, “it’s really about slowly and systematically facing the things that prompt anxiety and learning how to overcome those things so they are not to be feared or avoided. Anxiety really does diminish.”
And knowing how it works and being involved can help the whole family that has been feeling helpless at the hands of their child’s OCD or anxiety. Learning how to help their kids push back against their fears empowers parents, too.
As Dr. Bubrick observes, “Parents usually leave here not only grateful but much more knowledgeable about how to be advocates for their kids instead of victims of the anxiety.”