Robert D. Friedberg, PhD, ABPP.
Head, Child and Family Emphasis Area, Core Full Professor, and Director and Research Group Advisor, Center for the Study and Treatment of Anxious Youth; Palo Alto University, Palo Alto, CA.
Dr. Friedberg has served as a consultant for Kinark Child and Family Services and Psychological Assessment Resources. Relevant financial relationships listed for the author have been mitigated.
CCPR: Welcome, Dr. Friedberg. Let’s start by talking about obsessive-compulsive disorder (OCD). Back in 2013, DSM-5 separated OCD from the other anxiety disorders. Did that make sense to you?
Dr. Friedberg: OCD is fundamentally neurobiological in origin. Anxiety disorders such as generalized, social, and separation anxieties have less neurobiological foundation; however, there is so much anxiety around the kids’ obsessions and compulsions that it’s difficult for me to separate them out from anxiety spectrum disorders.
CCPR: Help us understand the broader nature of anxiety in these conditions.
Dr. Friedberg: I am fascinated by the transdiagnostic role of intolerance of uncertainty (IU) across all these disorders. Kids with OCD, anxiety, eating disorders, and autism often have high IU or “intolerance of doubt.” In OCD, checking, re-checking, and fixing things that are out of line is about doubt—“Did I do it? Did I really lock that? Did I really get that stuff off my hands? Will I stab these people?” The inhibitory learning model used in modern exposure therapy may directly target IU (Craske MG et al, Behav Res Ther 2014;58:10–23; Jacoby RJ and Abramowitz JS, Clin Psychol Rev 2016;49:28–40).
CCPR: Tell us about exposure-based techniques with the inhibitory learning model.
Dr. Friedberg: The inhibitory learning theory of exposure is an indispensable experiential procedure that helps the patient encounter what they fear and realize that the threat they have expected from encountering that fear is not present. Additionally, they learn to tolerate the distress associated with the previously avoided situations.
CCPR: Can you give an example?
Dr. Friedberg: Kids with OCD might fear touching contaminated surfaces and becoming deathly ill. During exposure, they realize that the contact with the surface won’t kill them and they can cope with distress. For symmetry obsessions and compulsions, they learn that leaving something unaligned or asymmetrical won’t lead to dreaded consequences such as harm to themselves or others.
CCPR: So it’s not about feeling better, but tolerating distress?
Dr. Friedberg: Exactly. Until the early 2000s, the prevalent exposure model was the emotional processing theory, where the person confronts the dreaded circumstance until their distress goes down 50% during habituation sessions, and then between sessions. This model was only somewhat helpful. Around 2008, Michelle Craske and colleagues at UCLA coined the inhibitory learning model of exposure. In this model, you don’t need reduction of distress or habituation. In fact, the level of distress can remain the same. The person learns that fear doesn’t harm them. They learn that touching a toilet seat or leaving a picture crooked is okay. They have skills to tolerate the distress. Put more simply, the focus goes from fear extinction to fear tolerance.
CCPR: What does the inhibitory learning approach look like in therapy?
Dr. Friedberg: For a contamination fear, we might use graduated exposure. The child or teen makes predictions or shares their threat expectancies about contamination and then touches different surfaces they perceive as contaminated. In the beginning, they might do this while using tissues as a barrier between their skin and the surface for different amounts of time. Eventually, we phase out the tissues and they touch the surface bare-handed. The key is that the threat expectancy is violated, they tolerated the distress, and they reduced the safety behaviors like the tissues. As a result, the child might still believe the surface is contaminated, but they know they won’t die from it.
CCPR: How much better is inhibitory learning than the older extinction approach?
Dr. Friedberg: It is quite effective. In the Pediatric OCD Treatment Study (POTS) in the early 2000s, researchers compared exposure-based cognitive behavioral therapy (CBT) for OCD in kids and teens with sertraline plus CBT and with sertraline alone (POTS Team, JAMA 2004;292(16):1969–1976). CBT had a 39% remission rate, and combined CBT and sertraline was 54%. Later, Öst and colleagues found roughly statistically equivalent effect sizes for SSRI and CBT (Öst LG et al, J Anxiety Disord 2016;43:58–69). However, the response rates for CBT alone (70%) and combined CBT and SSRI (66%) were superior to SSRI alone (49%). Finally, a 2021 meta-analysis found effect sizes of CBT for OCD over 2 (Wegeland GJH et al, Clin Psychol Rev 2021;83:101918).
Dr. Friedberg: Maybe so. Many practitioners shy away from “exposure” just because of the word itself. A less scary moniker for exposure, developed by Becker-Haimes and colleagues, is Supported Approach to Feared Experiences, or “SAFE CBT.”
CCPR: In my general work with kids and families, I say: “Let’s you and me be a little bit brave today.”
Dr. Friedberg: Absolutely, a brave adventure. There’s a great parenting resource book called Freeing Your Child From Anxiety by Tamar Chansky. The first chapter is “Giving Your Child Wings and Roots” because parents of youth with OCD and anxiety disorders often either accommodate the disorder, which can lead to worsening symptoms, or are too strict, which can be overwhelming for the child. Chansky’s approach teaches them to have some balance (Editor’s note: See “Caregiver Resources for OCD in Children and Adolescents” table for more).
CCPR: How much time does it take to do inhibitory learning exposure CBT for OCD in kids?
Dr. Friedberg: It takes about 15 minutes to orient them. John March and colleagues have a great manual for this, where they talk about drawing or naming the OCD (March JS and Friesen KM. OCD in Children and Adolescents: A Cognitive Behavioral Treatment Manual. New York, NY: Guilford; 2007). Tell the child that eventually they’ll practice touching surfaces, thinking blasphemous thoughts—whatever the OCD symptom. Next, it takes about 20 minutes to teach distress tolerance skills such as cognitive structuring with the talk-back (eg, more productive self-talk, like “no one dies from touching doorknobs”). You might teach mindfulness techniques, like having the child focus on their own weight on their chair to feel more stable and safe. The time it takes for exposure will vary based on the severity of the case and the provider’s skill. Often this includes creating a hierarchy of feared circumstances—one thing the child touch might produce more anxiety than another. In the middle level of the hierarchy, you might need 20 or 30 minutes. Higher levels of distress might require 30 or 40 minutes for an exposure trial.
CCPR: Do you track symptoms with a Children’s Yale-Brown Obsessive Compulsive Scale (CY-BOCS) score?
Dr. Friedberg: You can use the CY-BOCS or create individual functional metrics based on your hierarchy.
CCPR: Does online CBT for OCD work? The Australian government has a free self-guided program (www.tinyurl.com/2bab7v9y).
Dr. Friedberg: Online programs that teach kids about OCD, basic coping skills, and talk-back strategies can be nice augmentations. But you can’t really do exposure via an online program or an app. It’s something you do together with the person. The big problem is finding a clinician—regardless of their discipline—who does exposure with kids.
CCPR: Are there listservs where you can find people who do competent CBT for OCD with kids and teens?
Dr. Friedberg: The Association for Behavior and Cognitive Therapy lets you search your geographic area and shows you whether a specific clinician does exposure. Another option is the American Psychological Division 53 website. A third one is the Beck Institute for Cognitive Behavioral Therapy and Research.
Dr. Friedberg: Marginalized populations have poor access to care for OCD, much like for other mental health conditions. The promising news is that exposure therapy for anxiety disorders, including OCD, works just as well across racial demographics and LGBTQ+ populations. You can use these techniques with any kid and expect the same kind of efficacy.
CCPR: With the shortage of CBT therapists, is it practical for prescribing clinicians to learn to do CBT for OCD in children and adolescents?
Dr. Friedberg: I would love to see prescribers learn how to do it if they have the time to employ it with patients. But if you are seeing folks for 10–20 minutes, it’s difficult to treat OCD with exposure techniques. There might also be reimbursement constraints.
CCPR: If prescribers want to learn to do inhibitory learning exposure CBT for OCD for child and adolescent patients, how should they go about it?
Dr. Friedberg: Don’t just rely on a book or a journal article to learn how to do it. You need to see it, try it out, and get feedback. Here are three good ways: 1) Jonathan Abramowitz out of North Carolina has a website. He has books and articles, but his videos in particular are great. You can get coaching from him too. 2) Eric Storch and colleagues have two recent sets of great books. One is Exposure Therapy for Children With Anxiety and OCD: Clinician’s Guide to Integrated Treatment. It’s a great backup to the videos and individual consultations you might get from somebody like Abramowitz. Each chapter has a different slice with the different vicissitudes of working with OCD. He also has a training book and does coaching. 3) The Beck Institute offers a curriculum where you go through some didactics on how to treat OCD and get 10 individual consultations where you do video consultation with your case and get feedback. (Editor’s note: See “Clinician Training and Treatment Resources for OCD” table for more information.)
CCPR: Any final thoughts about the process of delivering CBT for OCD to kids and teens?
Dr. Friedberg: Behavior therapists lament that we have this powerful intervention and it’s just not used enough outside of academic or training clinics. People have a lot of myths and fears about trying to do it. But if you get the training and the supervision or consultation, I think exposure work is the most rewarding thing that I have done as a clinician.
CCPR: Thank you for your time, Dr. Friedberg.
PO Box 626, Newburyport MA 01950