Exposure and Response Prevention (ERP)

This is the gold-standard evidence-based treatment for OCD. It consists of exposure to a feared thought, feeling, or situation (e.g., touching a surface feared to be contaminated) and prevention of a compulsive response (e.g., not engaging in a hand washing ritual). In OCD our brains believe that a compulsive behavior is keeping us safe from a feared thought/ uncomfortable feeling/ bad outcome (even if it really isn’t!). The idea of ERP is essentially to prove that connection wrong by delaying or eliminating the compulsion so the person with OCD is able to experience a lack of feared outcome (e.g., not getting sick) despite exposure to the feared thought or feeling (e.g., touching a surface that the person fears is contaminated). In ERP, we create a hierarchy of challenges (i.e., feared thoughts, situations, feelings) from easiest to most difficult, and we start with something that feels a little scary but doable. The child (or adult) “levels up” as they adjust to different challenges.
Age range: 1st through 5th grade, or even younger middle schoolers.
Recommended for: This interactive workbook is best for kids and tweens with OCD who have clear compulsions (e.g., tapping, reassurance seeking, hand washing) and/or “not just right” OCD (e.g., straightening, erasing and rewriting, repeatedly changing socks) and who don’t have hoarding challenges. It could be completed chapter-by-chapter in therapy sessions, between sessions as therapy “homework,” or alongside therapy as a supplemental intervention. A caregiver with some understanding of OCD treatment might feel comfortable working through this workbook with their child without the support of therapy; however, most children with OCD will benefit most from being in therapy while completing this workbook (or soon after).
Age range: 1st through 3rd grade, or perhaps even 4th grade.
Recommended for: This book is exclusively for a child who has recently been diagnosed with OCD and is starting treatment with a therapist who is trained in Exposure and Response Prevention (ERP). The book reassures children that they aren’t “crazy” or the only ones with OCD, and it teaches about ERP and the strategy of externalizing and talking back to OCD (the boy in this book calls his OCD thoughts “Mr. Worry”). It provides children with an analogy of medication being a child’s running shoes, the therapist being the coach, and the child being the runner (ERP is the “running strategy”). The book is a bit outdated but it’s still one of the best picture book introductions to ERP that I’ve been able to find.
Age range: Best for 1st through 5th grade. It’s a bit long and wordy for younger kids.
Recommended for: A child who has recently been diagnosed with OCD and/or who is exhibiting OCD symptoms and is about to start treatment with a therapist trained in Exposure and Response Prevention (ERP). A therapist could read it with a child in an early therapy session, or parents could read it with their child prior to starting therapy.
Age range: Preschool through 2nd grade.
Recommended for: This book is a good introduction to the idea that picking/pulling at an “imperfection” (in this book, a loose thread) often makes it worse, and the more one picks/pulls, the harder it is to stop. The book ends with Rose (the stuffed bunny protagonist) realizing that instead of trying to fix her imperfection, she can practice tolerating it until she no longer notices it much at all. It’s a good fit for a child who is struggling to stop picking at imperfections in their skin, hair, or nails to the point that they’re causing sores or bald patches. It could also potentially be used to start a conversation about intrusive thoughts and/or “not just right” thoughts in OCD, but an adult would need to facilitate a child’s understanding of this metaphor.
Age range: Preschool through 1st grade.
Evidence-Based Practices: Exposure and Response Prevention (ERP)