Family Accommodation, Comorbid Depression, and a Reluctant Adolescent with OCD
Lena is 13 years, 8 months, with OCD (contamination and symmetry concerns), a CY-BOCS total of 28, and comorbid major depression (PHQ-A 17). For two years her mother has accommodated rituals extensively: buying extra supplies, repeated laundering, and answering reassurance more than 30 times daily. Her father dismisses the OCD as "attention-seeking" and wants her to "just stop." The family completed six weeks of supportive therapy with no change. The pediatrician suggests starting fluoxetine. Lena's school lets her leave class to wash whenever she asks. Lena says she wants "to feel normal" but fears therapy will confirm she is "crazy."
1. What treatment components would you prioritize, and in what sequence?
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This is moderate-to-severe OCD with a complicating comorbidity and high family accommodation, so first-line treatment is exposure and response prevention, with family accommodation work built in rather than added later. ERP should begin with psychoeducation framed as a strength-based, skills-focused treatment-directly addressing Lena's fear of being "crazy"-then move to a hierarchy she co-constructs. The mother's reassurance and laundering are safety behaviors that maintain the cycle; reducing them gradually, with agreed scripts and limits, is a core exposure. The father's dismissal is a barrier: I would invite him to a session to observe the functional analysis and agree on a unified response, without forcing him into a therapist role. Given CY-BOCS 28 and depression, combined ERP plus an SSRI is indicated; I would coordinate with the pediatrician rather than recommend a specific drug. School washing passes should be faded into a planned, time-limited accommodation rather than removed abruptly.
2. How would you handle the school accommodation plan and the parents' divergent views?
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I would convene the family and school separately but with consistent messaging. With the school, I would explain that unlimited washing passes function as a ritual and inadvertently reinforce OCD, then negotiate a graded plan: a fixed number of brief, scheduled washroom visits that reduce over weeks, with teacher cues and a safe adult for distress. I would emphasize this is a treatment accommodation, not a punishment, and get written agreement with review dates. With the parents, I would use the father's concern-he wants her to stop-as a bridge: the ERP plan is precisely a structured way to stop, but reassurance and criticism pull in opposite directions and both undermine it. I would set concrete behavioral agreements for both parents, rehearse responses to reassurance requests, and monitor with CY-BOCS and PHQ-A at set intervals. If the father remains obstructive, I would address it directly as a treatment-interfering factor and consider a family session focused on that impasse.