If I hadn’t seen it with my own eyes, over and over for almost 20 years now, I’m not sure I’d believe it either. Is five years old too young to identify OCD, and too young for CBT with ERP?
October is OCD Awareness Month, and I want to share a study I'm still proud to have been part of. I don't think its message has reached enough parents yet.
Many young children love routines. A favorite cup, the same bedtime story, things done "just so" are a normal part of development.
OCD is different. The rituals are driven by fear or a strong feeling that something isn't right, they take up more and more time, and the child gets very upset when they can't do them.
Parents of young children with OCD often describe things like:
Washing hands again and again, or refusing to touch things that feel "dirty"
Asking the same question over and over and needing the same answer each time
Redoing things until they feel right, like retying shoes or rewriting letters
Bedtime or leaving-the-house routines that must be done exactly, and take longer each week
Worrying that something bad will happen to a parent unless a ritual is done
Parents are often pulled in too, answering the same question or changing family routines to prevent a meltdown. When they raise concerns, many are told it's a phase, or that their child is too young for treatment.
The Pediatric OCD Treatment Study for Young Children (POTS Jr) tested whether children this young could be helped, and what treatment components are needed to be effective. It was funded by the National Institute of Mental Health and published in JAMA Psychiatry in 2014.
Our teams at Brown, Penn, and Duke enrolled 127 children ages 5 to 8 with OCD. Each family received 12 sessions over 14 weeks: the first two with parents alone, and the rest with parent and child together.
Families were randomly assigned to one of two approaches:
Family-based CBT with exposure. Children, with the support of a parent or guardian, learn how to challenge OCD and practice facing it, one small step at a time. Parents learn to reduce accommodation.
Family-based relaxation training. Children, with the support of a parent or guardian, learn about OCD and feelings, and practice progressive muscle relaxation, deep breathing, and guided imagery.
Both approaches involved parents, and both were delivered by trained therapists with the same number of sessions. The difference was whether children practiced facing OCD.
After 14 weeks, 72% of children who received family-based CBT with exposure were much or very much improved, compared with 41% of those who received relaxation training.
OCD symptom scores in the CBT group dropped by more than half, from about 26 to about 12 on the standard OCD rating scale for children. In the relaxation group, scores dropped from about 25 to about 20.
Put simply, about one in three families who received CBT with exposure saw a meaningful improvement they would not have seen with relaxation alone.
Relaxation sounds like the gentler choice for a young child, and it does help some children feel calmer in the moment. But OCD isn't only about feeling anxious. It's a cycle: a scary thought, a ritual that brings quick relief, and a fear that comes back stronger next time.
Exposure breaks that cycle. With a therapist and a parent beside them, children practice facing what OCD tells them to avoid, starting small, and learn that the fear fades without the ritual. Young children often think of this as "bossing back" OCD.
Parents were central to this work. They learned to coach their child through practice instead of helping them around the fear.
They also learned to step back from accommodation: the reassurance, extra steps, and changed routines that families slip into to keep a child calm. Accommodation comes from love, and it's one of the hardest things for any parent to change. But it keeps OCD going, and reducing it is part of how children get better.
The data matter to me as a scientist, but they aren't the only reason I believe in this treatment. I've worked directly with children and families for almost 20 years.
I've seen very young children take back their lives from OCD. I've seen parents discover they can help their child, and feel equipped to keep supporting them long after treatment ends.
And I've had the joy of watching some of those very young children grow into confident, resilient young adults.
If you've been told to wait and see, I hope this gives you another option. An evaluation with a therapist who provides CBT with exposure for young children can be a helpful first step in deciding whether now is the right time.
When you look for a therapist, it's fair to ask:
Do you use CBT with exposure (sometimes called exposure and response prevention, or ERP) for OCD?
How much experience do you have with children under 8?
How will parents be involved in treatment?
You can find trusted resources and help finding a provider at ocdandanxietyinstitute.com.
If you'd like to bring this approach into your practice, the treatment manual is available. Family Based Treatment for Young Children With OCD: Therapist Guide (Oxford, 2008) was written by my colleagues Dr. Jennifer Freeman and Dr. Abbe Marrs Garcia, who developed this treatment protocol.
Freeman J, Sapyta J, Garcia A, Compton S, Khanna M, Flessner C, FitzGerald D, Mauro C, Dingfelder R, Benito K, Harrison J, Curry J, Foa E, March J, Moore P, Franklin M. Family-based treatment of early childhood obsessive-compulsive disorder: the Pediatric Obsessive-Compulsive Disorder Treatment Study for Young Children (POTS Jr). JAMA Psychiatry. 2014;71(6):689-698. Free full text
Freeman J, Garcia AM. Family Based Treatment for Young Children With OCD: Therapist Guide. New York: Oxford University Press; 2008.
