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Welcome to the Nimble Youth podcast, where we provide expert insights and valuable resources for parents navigating the complexities of their children's mental health. We empower parents to nurture healthy minds in children, teens, and young adults through real conversations.
Our team of seasoned professionals, including physicians, therapists and educators, delve into pressing topics, share research-based strategies, and offer practical advice for fostering mental and emotional well-being within your family.
Welcome to the Nimble Youth podcast, where we explore the mental health challenges facing children, teens, and young adults today. I'm your host, Matt Butterman. In this episode, we're taking a close look at a condition that is often misunderstood and frequently misdiagnosed, pediatric obsessive compulsive disorder or OCD. With us is returning guest, doctor Gretchen Hoyle, a pediatrician with over twenty five years of experience helping young people and their families navigate complex mental health issues, and this is certainly one of them. While OCD is commonly associated with excessive handwashing or checking behaviors, the reality for children and adolescents is much more nuanced and often more distressing.
Consider these facts. OCD affects one to two percent of children and adolescents, yet many go undiagnosed for years due to the secretive and stigmatized nature of their symptoms. The average age of onset is between eight and 12, but symptoms can begin even earlier, and they often worsen without early intervention. And children with OCD are at higher risk for co occurring conditions, including anxiety, depression, and even suicidal thoughts, making early recognition and treatment all the more critical. In today's conversation, we'll explore what intrusive thoughts and compulsive behaviors actually look like to young people, how OCD is diagnosed, and what kinds of treatments from cognitive behavioral therapy to medications can help kids lead happier, less anxious lives.
So grab your headphones and join us as we untangle the myths and realities of pediatric OCD because understanding is the first step to healing. But before we get into it, we remind you that the content of this podcast is intended for informational purposes only and should not be construed as medical advice. While we aim to provide valuable insights on pediatric mental health, it's very important to consult with a qualified health care professional for any concerns or questions regarding your child's mental well-being. Always seek the advice of your doctor, therapist, or other health provider with any medical or mental health concerns. So doctor Hoyle, let's start with the basics, I guess.
What is OCD? Sure. So OCD is a mental health condition that has sort of two components, and it's kinda right there in the name. So there's obsessions. And obsessions, it refers to the thoughts.
Right? So folks will have intrusive, unwanted thoughts or images that may cause distress to them. And then there's also a component of the compulsions. And the compulsions are the behavior. So they are often engaging in repetitive behaviors or mental acts that are aimed at reducing their anxiety or preventing some feared event from happening.
And so this is where you'll see folks get into different compulsive ritualistic behaviors. Probably the most common one that people think about is, you know, excessive handwashing, that kind of thing. And so those are sort of the two components. And there is you know, in the pediatric world, there is a lot of variability as to how that presents depending on age group. And so for young children, a lot of times, they don't really fully understand, like, what it is that they're doing and why.
So they often have a lot of magical thinking and fear of harm to their family, and they may or may not, like, really be able to, articulate that. Like, why what their thoughts are and why they feel like these behaviors might help that. As folks get older and get into adolescence, a lot of time, they're able to have a little better insight as to what their thoughts or behaviors are, and why they're doing it. And then a lot of times, they realize that it doesn't make sense. Right?
Like, but what they're doing in order to reduce their anxiety is really not going to, you know, change the outcome that they're worried about. And so that often makes them feel like it's, you know, it's irrational, and it makes them feel, like, ashamed of it, and they try to hide their symptoms. Right. And, pediatric OCD manifests itself slightly differently among the age groups. Right?
Oh, yeah. We see different ways it affects children, adolescents, and adults. Can you talk a little bit about the differences there? Right. And so, you know, I will say a lot of times, what's happening with children is, this need for sort of persistent reassurance from adults.
And a lot of times, that's the thing that will get them in. So parents are like, you know, this kid, like, asked me over and over again, like, is everything gonna be okay? Is everything okay? And it just doesn't make any sense. Right?
And it just it's it's you know, you try to reassure them, and it that seems to, in some ways, sort of make it worse. And so, a lot of times, that's the issue that folks come in with. It can be other things, and I'll sort of give, like, a little summary of the different symptoms that folks see. Mhmm. And then for older kids, you know, they often have kinda gotten engaged in these ritual behaviors that they need to do in order to reduce their own anxiety.
And so a lot of times that involves, like, checking behaviors, and sometimes it can be things like, sort of a lot a lot of times, older kids will have themes to their OCD. And so they can have a theme that's, you know, like, the germ like, being afraid of germs is a really common theme. And so that will cause them to have to do this very specific process in washing their hands and washing things around them and keeping everything clean. And sometimes they'll have, you know, like, themes that are more about, like, moralistic stuff. Like, I'm a bad person if I think this, and I need to balance that out by thinking a good thought or something.
There's a lot of, like, moral themes to OCD. And then sometimes it's a religious thing too, where they're like, oh, well, I'm worried about, you know, I think if I have this thought, it's gonna upset God. They'll often, you know, say that that is part of their part of their symptoms. And so I thought I might go down a couple of these questions. Yeah.
Please do. Yeah. And so when I meet somebody where I think, okay. Well, this seems like you may be having some intrusive thoughts and, and then that's leading to some of these compulsive behaviors, then I will often use a questionnaire, that is called the children's obsessional compulsive inventory. And, and it's got it comes in two parts.
So the first part is actually about the behaviors. And so I will ask them a question, and then I will ask them, is this not at all, somewhat, or a lot true for you? So it kinda gives you a numerical score. So, like, the first question is sort of the classic one, which is I spend far too much time washing my hands over and over again. Okay.
So then it's like, is that not a lot? Not at all, somewhat, or a lot for you? And then I feel I must do ordinary everyday things in exactly the same way every time I do them. So parents will sometimes see kids doing things that seem like, you know, that they have a process there, that if that gets interrupted, then that makes the child anxious. And then a lot of times I have to start over.
And so then you're getting into, you know, issues with, you know, being late and not being able to get out the door because you have a sequence that you need to go through that is not functional. Right? There's also, like, I spend a lot of time every day checking things over and over and over again. I have trouble finishing things because I need to make absolutely sure that everything is exactly right. So this is a huge problem academics wise.
Right? So if you are, I have a lot of kids who are really just unable to perform academically because if their assignments aren't perfect, then they can't turn them in. So then they wind up not getting anything turned in. Does that mean you think, like, oh, that sounds really conscientious. There must be a really good student.
And you're like, well, in reality, like, that's not very practical, but it has to be perfect every time, you know, everything. And they just and so a lot of times, they just are not able to keep up because their work never meets their own, you know, very high threshold expectation of what they need to be able to turn in. And so that is a real problem, like, a big problem, like, functionally. I spend far too much time arranging things in a certain order. I need someone to tell me things are alright over and over again.
So that's that persistent asking for reassurance. This is always an interesting one. If I touch something with one hand, I feel like I need to touch the same thing with the other hand in order for it to feel even or equal. So there's a lot of balanced stuff with these folks. Like, they need, you know, both sides of their body to be involved.
I always count even when doing ordinary things. If I have a bad thought, I always have to make sure that I immediately have a good thought to cancel it out, and I am often very late because I keep repeating the same action over and over again. So those are the behaviors that go along with, like, OCD. And so, and so then I kinda want to go to the thoughts that are also in the mix. Because a lot of times, you know, with parents, they may or may not understand, like, why their child is doing these behaviors.
And then when I'm able to ask them questions about what's going on in their thinking, it makes sense to them. So a lot of things are like, a lot of the time, what they're thinking about is upsetting thoughts about an accident. So the question is, do you have situations in which you can't stop thinking upsetting thoughts about an accident, or do you have bad thoughts that make you feel like you're a terrible person? Do you have upsetting thoughts about your family being hurt that go round and round in your head and keep you from concentrating? Do you have big doubts about whether you made the right decision even about stupid little things?
So this is a big thing too. Like, you can tell, it's by the language here, that that word stupid is sort of how a lot of times these folks with OCD will conceptualize their inability to make decisions. So they're like, this shouldn't be such a big deal, but I can't get past it. And so they get frustrated with themselves. I'm like, oh, yeah.
I do that. That's just how that's exactly how I think about it. And so it's just revealing. Upsetting thoughts about death, mean thoughts about other people, bad thoughts about going crazy, frightening thoughts that something terrible is going to happen, and it will be all your fault. Mhmm.
And that is sort of in that moral, you know, version as well where you're like, okay. It's an obsession that they get stuck in, and then they will find compulsions to do to try to reduce their anxiety about it. Right. Yep. Do you see, rates of pediatric OCD perhaps higher in high achieving?
Oh, yeah. I do. Yeah. I feel like that's a big part of it that they'll get, you know, into just this there's there's a lot of challenges with just sort of this hyper perfectionistic culture that we're in already, and we've talked a little bit about we talked about the social media and sort of that portraying yourself as, you know, flawless. And so I think a lot of times that that will connect up with this academic pressure that these kids put themselves under and, you know, that all sort of makes a big loop in their brain.
Right. Yeah. And so we're seeing rates of diagnosed pediatric OCD rising. I guess a lot of that is due to the increased awareness of Yeah. Of the condition, and sort of a more functional definition of it.
Right. So let's talk a little bit about some of the diagnostic tools that you use. And we have another, addition to the list of Yeah. Alphabet soup of diagnostic tools, something called the CHOCI. Talk a little bit about that if you Yeah.
So that's the one that we talked about just now. That was the child obsessional compulsive inventory, and there's two versions of that. Well, there's a it this is the one that we're using as the revised version. And then there is a self inventory where the patient describes their own symptoms. And then there's one where the parent describes the child's symptoms.
And so, it's kinda like the scared questionnaire where you have a report from both the child and the parent. Mhmm. And then there's another one that's the Children's Yale Brown Obsessive Compulsive Scale. This one's a little bit, I think, more useful for folks who are, you know, doing research and have longer periods of time to really dig in. And then, potentially, the psychiatrists are using this as well.
And this is another one of these conditions. We're now talking about conditions that a lot of times they're being, you know, ideally managed by psychiatry, but there's often a wait. And so sometimes we will try to get a handle on things in the general pediatrics, you know, setting. You're on the front line. Correct.
Yeah. Yep. Until we can get you in with somebody who, you know, can make a potentially more definitive diagnosis or even, you know, additional, you know, comorbid diagnoses. But we can do some screening to try to get a sense as to what's happening. And a lot of times, it can be extremely revealing and helpful.
Sure. Yep. So let's talk a little bit about the functional impact of OCD, in young people. It affects many aspects of their life, probably all aspects of their lives. Right?
Definitely. So, you know, I feel like I've probably said this before, but I feel like the canary in the coal mine is school. Right? So, like, if you're, that's often the thing that we start to have trouble with and, you know, for parents who are tracking their child's grades, which I think is probably a good idea for most people, that they'll start to recognize. Usually, it's not so much that the grades and tests are going down first, but it's just that they're having a hard time getting stuff turned in.
And it's because they just can't do it without it being perfect. And then they get behind. And for some reason, I guess, in their brains, they'd rather not do it at all than to not have it perfect. And that that, of course, is just not a functional place to be in. Right?
I mean, that's true for probably all of our jobs. Like, you know, and so that's true for school too. Like, you need to make your best effort, do as well as you can, and you're gonna move on. And that is a really hard, you know, a hard thing for folks with OCD to do. Right.
Yep. Right. And so then it causes a lot of trouble at home where you've got, you know, one kid who is constantly occupying parents' attention because they're asking repetitively for, you know, reassurance. And I think we'll talk a little bit about that in the next one as well. But, that can be a problem.
And, and then you often end up getting siblings involved where they're feeling like they have to engage in this bit in order for the kid to, you know, feel comfortable. And so then it sort of disrupts what should be the typical flow of things in the family. And then, you know, a lot of times, kids who have these these compulsive behaviors and, you know, and they're being driven by these, intrusive thoughts, that can be pretty isolating for them because, you know, sometimes people will recognize what behaviors they're doing and, you know, they'll get teased for that. And most of the time, it's really just that they're so absorbed with what's going on in their brain that they just don't have as much bandwidth as they need to do social stuff. And so they tend to be pretty isolated.
Right. And they can get sometimes teased for these Oh, yeah. Unusual or weird behaviors. Absolutely. Yep.
And, you know, it can disrupt their sleep and, you know, that they, you know, they feel like they're out of step with everybody else and that's, you know, that's a problem. Right. For sure. Yep. So what are the treatment options, for pediatric OCD both, I guess, both therapy and medication wise?
Right. Right. Right. Right. So, you know, we often think of OCD as being in that sort of family of conditions that are related to anxiety.
Right? And so it does as it turns out from a medicine standpoint, the SSRIs or the selective serotonin reuptake inhibitors, which were, you know, classically called antidepressants, they're very helpful. Very, very helpful. And so that's often the first line, like medication. So those are things like Prozac and Zoloft and, potentially even Lexapro.
My experience with that has been that you have to often push the dose up, you know, maybe a little higher than you would necessarily expect if you were just treating anxiety in order to get eight eight, like, OCD symptoms under control. So I tell parents, like, sometimes what'll happen is it'll we'll be on this for a while continuing to push up, and we'll get some of the baseline anxiety better, but it'll we we need to get to a higher dose before we really start seeing a reduction in some of the compulsive behaviors and the intrusive thoughts and, you know, maybe getting them sleeping better. A lot of times this stuff interrupts sleep and stuff too. And so, that's the typical medication, like, strategy, especially in the general peds setting. And then there is, like, the cognitive behavioral therapy, which is a, you know, go to for most of these things.
We're trying to get your brain involved with what is going on with your behavior. And then exposure and response prevention. So that's another therapy. And then combining those, a lot of times, people will be doing both medicine and therapy. And then there are some really interesting emerging options.
There are some digital platforms or digital therapy platforms. There's something called parent guided ERP, which is exposure response prevention apps. And there's even, you know, some things that are under investigation called, like, transcranial magnetic stimulation or TMS. And then we had talked at one point about ketamine, which is, it has been really helpful for treatment resistant depression. And so it looks like that there's some rational use for that in OCD.
But, of course, that is something that is obviously just for adults, and it would be kinda way, way down the line. But the idea that there is, some other emerging therapies, I think, is helpful. And that's so OCD is part of, a larger category of disorders, driven by what they call ruminative thinking Right. Rumination, which includes PTSD. Right?
Mhmm. That's right. So those thoughts that we had talked about where you can get, into a pattern where you're, you know, you if that's that cognitive triad where you've got, you know, thoughts and then emotions and then behaviors. And when your thoughts are, like, negative and you're ruminating on them, then it typically brings your mood down and can cause you to have behaviors to kinda compensate for that. And so that was we touched on that a little bit in the podcast about cutting.
But some of these compulsive behaviors, or maybe in the same, you know, vein as that. Right? And so, and so working on trying to break the cycle with the thoughts, trying to get that rumination under control, trying to give the brain other options for what to think about is, you know, helpful. And it seems that the medicines that we use as SSRIs often make it a little bit easier for us to train that brain to be able to get off of that rumination and do other things. Right.
Right. So for parents who suspect their child might have OCD, what are some things that they can do, outside of, of course, bringing them into your office, early on. Right? Right. Yeah.
So, so yeah. Certainly, evaluation seeking evaluation is important. You wanna have a treatment plan. Potentially, they're gonna be using therapy and SSRIs. And you also like, it's super helpful when people come in and they've already got some, you know, understanding as to what these rituals look like, and they're able to describe those to me or to whoever they're seeing, and that can be really helpful.
And then I think we're gonna lead us nicely into our conversation about the book that we're gonna discuss and discuss. In the next episode Yeah. Having to do with accommodating rituals that the family is sometimes on with unwittingly, you know, contributing to the condition. Correct. What is the prognosis for kids who are diagnosed with pediatric OCD?
Right. So, you know, with early intervention, a lot of times we can get folks into sort of a remission looking, pattern. And, and some people will continue to have these tendencies. I think a lot of times, you'll hear people say things like, oh, I'm OCD about this or I'm OCD about that. And that's not really a great, you know, description because the condition is kind of a different thing.
It's not just like Sort of trivializes the condition as well. It makes it sound like you're just really conscientious about something. Right. And, and of course, you know, that's typically a good thing. And so I think that, you know, I think that sometimes you'll see kids where they have had sort of a series of, little nuance behaviors that just seemed like, you know, just an idiosyncrasy about that child.
And then, and then they sort of add on more of these sort of ritual behaviors, and then it sort of looks more dysfunctional. And so a lot of times what'll happen is that over time, we can, you know, control the stuff that's causing dysfunction, but they may still have, you know, certain things being very particular about their room or their clothes or, you know you know, different, like, things that they get a little bit stuck on. And sometimes those are, I think, probably there are parents who would, you know, be happy if their kid was a little more conscientious about their room, but that's a different, you know, that's like, that's kind of a different situation. Right? So, we, you know, know that everything's on a spectrum to some extent.
Like, you know, there's there is, there's an amount of attention to detail that can be really helpful for things. But with this condition, it's more than that. It's a lot of really intrusive thoughts. It tends to take up the space in your brain and your consciousness, and then the behaviors that go along with it just aren't functional. Right.
Yep. Right. And I guess some of the studies suggest that about, forty six forty to sixty percent of, pediatric patients, with OCD achieve substantial symptom reduction? Sure. Yeah.
I would say that that's, yeah, that makes sense. With, with the appropriate treatment. Right. Exactly. And about twenty to thirty percent may require ongoing therapy, or medication into adulthood.
Right. And there are certainly certain career paths that probably lend themselves well to OCD. I was just thinking, you know, I would want my airline pilot to be Right. More more on the OCD spectrum than being very laissez faire. Right?
Right. Right. Exactly. And so it's about, yeah, trying to get to a functional level of conscientious Right. You know, behavior.
It's often a thin line. Without yeah. Without yeah. Going over to the top. Right.
Exactly. So as with all the conditions that we talk about, OCD is a treatable condition. And, we keep repeating this, but early intervention is Correct. You know, results in a much better outcome Yep. Long term.
Well, thanks again, Doctor Hoyle, for your insights, and thank you to our listeners for joining us on the Nimble Youth Podcast. Next time, we're gonna talk a little bit more about a book, about OCD and the family and how that relationship can affect the treatment of OCD. Please visit our website at www.nimbleyouthpodcast.com for recordings of past episodes and show notes for each episode. Until next time, please take care of yourselves and each other.