So, I was hoping that you could tell
me and tell other parents what obsessive compulsive disorder
looks like in children and adolescents.
So,
obsessive compulsive disorder in children and adolescents, not surprisingly,
is characterized by obsessions or intrusive thoughts
or images or feelings that are unwanted.
So, children may have
like worries or fears or
thoughts that just pop into their head for no reason
that are very upsetting to them.
So, things like they're afraid of germs or
something bad happening to somebody or that they're gonna
do poorly in school or that or that something they left
the door unlocked and a burglar might come.
And compulsions
which are the behaviors that are designed to make these bad feelings go away.
So, a child that worries about germs or contamination
will wash their hands or clean things in order to make
this worry about germs are getting sick go away.
A child that's afraid of something bad happening like a robber coming or
a burglar coming to the house will make sure all the doors are locked
and that everybody is safe to make this bad concern go away.
So, some of the things you describe like worries and
fears sound like things that all kids deal with.
So, how does a parent know if their child or their adolescent
has a disorder,o s
the obsessions and the compulsions are a problem in their life?
So, parents can tell if the obsessions or compulsions are problems
if they're taken to the extreme.
So, a child that spends an inordinate amount of time
worrying about bad things happening or checking the locks
or washing their hands is a sign that these typical
kind of fears or normal concerns might be problematic.
A common symptom is children that feel they need
to rewrite, erase and rewrite their school work or their school papers
so that everything is perfect. There can't be any crooked letters
or any crooked words, and they may spend two or
three hours on one paragraph or one paper
erasing and rewriting over and over again to
the point where the paper is all messy or ripped
because they might be afraid that if there's something that's not exactly
perfect with this paper that they're gonna get a bad grade,
that they're going to flunk.
Other children with OCD that have contamination fears
or cleaning rituals or cleaning compulsions
may spend two hours in the shower—one or two or three hours in the shower.
They may spend 30 or 40 minutes brushing their teeth or brushing their hair
to make sure that everything is exactly right.
Or they may spend hours cleaning their rooms or arranging their rooms
because they need to have everything just arranged in a certain way.
So,
it sounds like, and correct me if I'm wrong, that
it's not just kids who are doing things frequently,
but children and adolescents who are really doing these behaviors to an extreme.
So, it's taking up a large part of their day, impacting their life,
their family, schooling.
Is that correct?
Yes. So, OCD really does. It either can take up a large proportion of time,
or it's something that's really gonna be interfering.
You can also have some OCD symptoms that may not take up a lot of time,
but still can be very upsetting or interfering.
So, some children with OCD have intrusive images.
They get pictures or thoughts in their head that are really scary,
like maybe doing something bad or hurting somebody or hurting themselves.
And these are thoughts that are unwanted. They don't want to do these things.
They have no intention of hurting themselves or somebody else.
But these thoughts keep coming into their head and making them very upset.
And even though the thoughts can be very brief,
they still can cause a lot of problems for the child.
So, if a family is seeing their child or their adolescent
have obsessions, have compulsions,
and they're affecting their life in a significant way,
what should they do? Whom should they speak with about their concerns?
Well, the important thing is to find
a therapist or a mental health professional
that has experience working with children and
has experience working with obsessive compulsive disorder.
This would typically be a
clinical child and adolescent psychologist
or a child and adolescent psychiatrist
or another professional that has experience in this area.
What information about
treating OCD or obsessive compulsive disorder should parents be aware of?
Well, the important thing is that there are
two treatment approaches for OCD that have been been studied and
researched very carefully and been shown to have some benefit for children,
adolescent with OCD.
The first is exposure-based cognitive behavior therapy
and the second is a specific class of medications
called the selective serotonin reuptake inhibitors or SSRIs.
Cognitive behavior therapy
is really considered the first line treatment approach.
So, the recommendation is that that in almost all cases, children with OCD
should try cognitive behavior therapy first because
it has no side effects,
and it's really been shown to have very positive effects
in many cases on children with OCD.
And importantly, also is that
once the child has been able to benefit from cognitive
behavior therapy or completed treatment with cognitive behavior therapy,
the gains tend to last.
So,
in most cases, cognitive behavior therapy would be the
preferred treatment to start with
for a number of reasons.
The first is that cognitive behavior therapy has been shown to be effective
in a large proportion of cases, probably more so than medication.
And the symptom reduction or the benefits of cognitive behavior therapy again,
have been shown to probably be better than that for medication
to some degree. The CBT,
that's short for cognitive behavior therapy,
may tend to lead to slightly better outcomes.
Also, with CBT, once treatment is finished,
the kids, children tend to maintain their gains for
somewhat longer than with medication, oftentimes with medication,
which can be associated with side effects.
Once the medication is stopped, the symptoms may come back.
So, you make reference to cognitive behavioral therapy.
How would a parent know if the treatment that
they're getting or if the therapist that they're seeing
used this cognitive behavioral therapy?
Well, the important consideration that the
most active ingredient of cognitive behavior therapy
is something called exposure plus response prevention.
So, there are many different forms of cognitive behavior therapy, and
and there are many forms of cognitive behavior therapy that
are used for children with obsessive compulsive disorder.
But only
cognitive behavior therapy that's
based on exposure plus response prevention
has been shown to be effective for OCD. So, parents,
when interviewing a therapist or trying to
find a therapist or talking to a therapist about
whether or not
that treatment is helpful to the child should really
ask if the therapist does exposure plus response prevention.
Ok. Could you give me an example of what
exposure plus response prevention
is, or what it looks like?
Well, first, let me tell you
the rationale underlying exposure plus response prevention.
In OCD when children experience unwanted thoughts
or images like the obsessions,
that can obviously be distressing or upsetting or troubling to them.
The compulsions or the ritualistic behavior like the hand washing or
the checking or the repeating or the touching over and over again
are then done to make the bad feelings or make the obsessions go away.
And the obvious example is
a child that's afraid of germs or contamination
will repeatedly wash their hands to make these germs or contamination go away.
So,
when children with obsessions or who are upset by their obsessions
engage in the rituals or the compulsions like hand washing,
what that tends to do,
it tends to reinforce or strengthen the obsessive thoughts.
So, everytime the child gives into his or her OCD by checking or washing or repeating,
that tends to make the thoughts stronger and more believable.
So,
what exposure plus response prevention does is try
to break the connection between the obsessive thoughts
and the rituals or the compulsions.
And by demonstrating to children that just because they have an obsessive
thought doesn't need to mean they need to do their ritual.
So, for example, in treatment,
the first thing that we would do is make
a list of all the child's obsessive compulsive symptoms.
And then starting with the mildest symptom or the smallest symptom,
we would trigger the child's symptom.
For example,
maybe by putting something contaminated on the child's hand to get him or her
to become more anxious feeling.
And at that point, the child would want to do their ritual,
would want to wash their hands to make the bad feeling go away.
But in treatment,
we would work with the child or encourage the child to
not wash their hands and instead wait and see what happens.
And what happens is that the bad feelings or the anxiety goes away by itself.
And by repeatedly doing this, doing the exposure or
making the child want to do a ritual, but then having them not do the ritual,
they learn that their anxiety will go away without
having to do the rituals, and that relationship
the connection between the obsession and the and the ritual is broken.
And over repeated
trials
of doing the exposure
plus response prevention, the child learns that the
thoughts they have the scary thoughts or feelings that they have
about bad things happening or about germs or contamination
or other kinds of things
really aren't that bad and that they'll go away
on their own without having to do the rituals.
So, it sounds like
exposure and response prevention is
when a child practices
in a graduated way.
So, what they're fearful of,
you don't make them do first, but they build up
to it by practicing different strategies along the way.
Do I understand that correct? Yes. Correct.
The treatment is done in a way that's very sensitive for children.
So, we always have the children start with a very kind of
an easy or very mild symptom that's easy for them to resist.
We don't have them
work
on their most difficult or most anxiety
provoking symptoms until well on into treatment.
In addition,
there's a lot of work that we do with the child in
the family before we even start working on the specific symptoms.
So, there's a lot of education about anxiety and about OCD so
that they can learn more about what's causing their problem and
why they have the symptoms that they have.
We talk a lot about methods for reducing anxiety and for helping make them stronger
in terms of their ability to handle their OCD or deal with their OCD.
In treatment,
we also work very closely with parents to
give parents the appropriate tools to help them
assist their children and help support their children in treatment
and to set up situations at home that are also going to
help the children learn how to master or overcome their OCD.
So,
parents might be part of the treatment and help their children to practice,
but they should still be
doing that in concert with a mental health professional?
Yeah, it's important that parents work with a mental health professional
to best learn how to manage or
interact with their child around his or her OCD symptoms.
What commonly happens with children with OCD is that
they will gradually involve their parents or
other family members and their symptoms.
For example, making their mother or father wash things for them
or having them avoid certain kinds of food or things at home
if the child is afraid that those might be contaminated or covered with germs.
They may ask parents to check, for example,
the doors or check the locks or check the stove
if they're afraid of a burglar or a fire.
And it really over time can really involve parents and even brothers and
sisters in ways that can be very difficult for the family to manage.
So, one of the goals of treatment is to teach parents
and brothers and sisters and other family members or
other important people in the child's life how
to disengage from the child's symptoms, to not
be so involved in the child's symptoms,
which will allow the child then to get better with treatment
and lead to kind of normal family functioning again.
But this can be a little bit tricky. So, it really should be done
working closely with the mental health
professional that is experienced in this area.
So,
parents should look for a cognitive behavioral
therapist who uses exposure and response prevention.
That sounds to be a very important thing that parents should seek. Are there other
aspects or things that parents should ask about when looking
for a therapist for their child for treating OCD?
Yeah,
it's very important that parents are
very careful and very knowledgeable when they're
looking for a therapist
to work with their child's OCD.
The therapist again, must have experience with OCD.
The therapist must do exposure plus response prevention for the OCD.
And the child must really be
knowledgeable in working with children and adolescents.
These are all important factors.
So,
are there other takeaway messages that you would want to give
to a parent whose child or adolescent has
OCD
in terms of what they should be doing as a parent?
There are a number of things that parents should think about
when their child has OCD.
One of the big misconceptions that we run into is that parents
sometimes think that the children are doing the behaviors on purpose.
When in reality, in most cases,
children with OCD are unable to control their symptoms. The anxiety
is just too strong, and when the child says
that they need to wash their hands or to check
or to repeat certain things,
it really is something that oftentimes is beyond their control.
So, before parents try to do something to
stop their children from doing these behaviors,
they really should talk to a qualified mental health professional.
Can you tell me how many children and adolescents have OCD or your best guess?
OCD is pretty common in children and
adolescents. Anywhere from about 1 to 3% of children
and adolescents in this country have obsessive compulsive disorder.
So, if you think about that, if you think of, say a child
that goes to a school with 1000 children,
maybe a medium size middle school or small high school,
there are probably anywhere from 10 to 20 children at that school that have OCD.
So, it's actually quite common,
and in milder forms, it may even be more common than that.
So, how come we don't hear about OCD a lot?
OCD has oftentimes been called the Secret Disease or
the Hidden Disease because the symptoms can be quite embarrassing.
Sometimes they do involve kind of bizarre fears or
worries that children might not want other people to know about.
So, in a lot of cases,
children or adolescents are able to hide their symptoms from friends
or from classmates or from relatives, and in some cases,
even from parents.
So, we don't tend to hear about OCD as often as other disorders, say ADHD
or some other things that get more attention.
What should parents look
for?
If
your
parent thinks, suspects that their child might have a problem with OCD,
there are a number of things to look for.
One would be avoiding situations that
the children may have used to like,
like not wanting to go to school or avoiding social situations,
maybe avoiding being away from home.
Sometimes this occurs because the children are afraid that they're gonna do
their rituals or their compulsions in public settings.
Children with OCD, oftentimes, if it's related to perfectionism
or writing or school work
may all of a sudden take much longer to do their school work. So, an assignment that may
take on average 30 minutes to complete,
may all of a sudden take like an hour or 90 minutes or two hours for a child with OCD.
Children that tend to erase and rewrite over and over again,
try to get things perfect
or really get upset when things aren't exactly right or exactly perfect,
that may also be a sign of OCD.
Finally, children that are spend excessive time,
say washing
or showering or bathing or engage in other activities,
that also may be a sign that the child has OCD.
Do we know what causes OCD?
OCD is a biological disorder. It's genetic.
So, it tends to run in families.
But there's also some kinds of environmental factors associated with OCD.
So, if a child is stressed
or tired or sick, that may make the symptoms worse.
Reactions....
If the child is in a situation where others might be reacting to the OCD
or
putting pressure on the child, that may also make OCD worse.
And although some people might say because OCD is a biological disorder,
shouldn't you treat it with medication?
That's not the case.
In fact, the cognitive behavior therapy is
the most effective treatment that we have for OCD right now.
So, would you say that
for children and adolescents who have OCD,
there's a fair amount of hope that with
CBT treatment or cognitive behavioral treatment,
things will get better?
Yeah, there is a fair amount of hope associated with treatment.
Cognitive behavior therapy,
CBT,
has been shown to be effective in a number of cases.
Not everybody benefits from it.
Not every child is able to do it.
There may be certain situations or factors
such as coexisting problems that might make it difficult for
the child to engage in cognitive behavior therapy as the first treatment.
Or in some situations, the CBT may be so severe
that the child is unable to engage in the treatment.
And in these cases,
other families might want to consider medication and talk to either
a qualified mental health professional about
medication or a referral for medication.
But between these two treatments,
there's a good chance that most children will be able to
experience significant benefit and be able to live normal lives.
Can you tell me a little bit about
what OCD looks like in the long term, or what
parents should expect for their children or adolescents who have OCD
in a longer term sense?
So, OCD is considered a chronic disorder, which means it tends not to go away by itself.
It typically starts around age in childhood.
So, maybe around the ages of 7 to 11.
And
it
in some cases will have a sudden onset. So, it'll just kind of come,
seems like almost out of the blue.
In other cases, it tends to have more of a gradual onset. So, the symptoms
tend to get worse over time and kind of a slower format.
But without treatment, in most cases for children,
most kids will just continue to experience the symptoms
overtime into adolescence and even adulthood.
In fact,
most adults with OCD had an initial
onset of their symptoms during childhood or
adolescence.
But the good news is that effective treatment can really
have a positive impact on children's long-term functioning.
So, if they're able to
benefit from cognitive behavior therapy or
even perhaps medication in addition to the therapy,
the chances are that they may have a
very good long term prognosis in the sense that they can go on and to lead,
you know, normal healthy lives.
And it sounds like, correct me if I'm wrong,
a lot of kids or adolescents will learn skills
for managing their symptoms that they can draw upon
as they age.
Yeah.
One of the benefits of cognitive behavior therapy is that children learn skills;
they learn strategies for coping with their OCD, for challenging their OCD.
And just for general problem solving and coping,
which in the long term can really be beneficial.
A lot of children that receive treatment
actually can serve to strengthen them in many
ways by increasing their confidence and their
ability to deal with other difficult situations.
One thing I know about other mental health disorders is that sometimes one mental
health disorder will co-occur at the same time with another mental health disorder.
And so kids are dealing with multiple concerns at the same time.
Does that happen with OCD? Do we see that co-occur with other disorders?
Yeah.
OCD quite commonly
cours with other disorders.
The most common other disorders are another kind
of an anxiety disorder such as generalized anxiety
or social anxiety fears or separation fears.
We also see it occur quite commonly with Tourette's or Tick Disorders and ADHD.
In adolescence or in older children or adolescents or adults,
co-incurring depression is also quite common.
In fact, most children with OCD or the majority of children
with OCD
will present for treatment or come into clinics with one other disorder
and some kids will even come in with two or more other disorders.
Ok.
So, for some parents, it sounds like they report that
they've noticed this in their children for a long period of time,
and it might get worse as they get older or stress might make it
more noticeable.
For other parents,
they might just suddenly notice that their child is experiencing
problems with obsessions or compulsions or it's impacting their life.
So,
if a parent is first noticing these problems are really coming to the
realization that it might be impacting their child or their adolescent life.
What's the first step for them?
Well, the first step,
if you suspect that your child may have OCD or another problem is to not panic
and not overreact,
especially not in front of the child because that can be very upsetting to the child.
But if a parent sees something that doesn't seem right or a change in the
child,
I think it would be important for the parent just
to talk to the child about it. Again,
not in an alarmist fashion, but maybe, you know,
I've just noticed that you seem to worry about
this or that a little bit more than you used to. Do you want to talk about it?
Can you tell me what's going on?
And try to get some information from the child.
Now,
commonly children and may not want to talk about it or may not want to
say anything either because they're embarrassed or
they don't want to upset their parents.
But if the parent continues to feel that there's something that concerns them,
it would be important to contact
again, a qualified mental health professional,
somebody that is an experienced child and
adolescent
psychologist or psychiatrist or social worker that has
experience working with OCD or
other kinds of disorders.
Do kids go through phases where they'll have obsessions or compulsions?
Meaning,
when a parent first notices it,
is that the time to contact a mental health
professional or should parents wait to see the course?
If parents see some different kind of a behavior, odd behavior in their child,
it probably makes sense to watch it for a
little bit of time and not overreact too soon.
I mean, unless the behavior is clearly problematic,
but in
if there's something that looks a little bit different and maybe
the parent isn't sure if it's something that serious or not,
maybe to watch it for a little while because
most kids go through different stages of something where they
may be a little more anxious or a little
less anxious or a little sad sometimes or have
more active or whatever that might be. And that kind of
normal in kids, but just to watch
and continue to monitor and if things don't get
better or if things look a little bit worse,
then it might be time to seek out help.
The recommendation would be that if a parent sees something
that looks like it is interfering with the child's life
in terms of school or friends or family functioning,
is distressing or disturbing to the child, or is upsetting to them,
that would be the time to
seek some kind of professional help.
Ok.
Well, thank you for your time and for answering questions.
I'm sure that many parents will be happy to review this information and
to share their concerns with the qualified
mental health professional in their area.
So, thank you again. Oh, it's my pleasure. Thank you.