Melanie Cole, MS (Host): There's no handbook for your child's health, but we do have a podcast featuring world-class clinical and research physicians covering everything from your child's allergies to zinc levels. Welcome to Kids Health Cast by Weill Cornell Medicine. I'm Melanie Cole.

And today, we are highlighting OCD in children. Joining me is Dr. Lauren Webb. She's a psychologist at New-York Presbyterian Hospital, Weill Cornell Medical Center, and an Assistant Professor of Psychology in Clinical Psychiatry at Weill Cornell Medical College - Cornell University. Dr. Webb, thank you so much for joining us today. Can you give us to begin with a little working definition of OCD or obsessive compulsive disorder? What is it? What are we looking at here?

Lauren Webb, MD: Thank you for having me today. And OCD, I'd like to define it using the three words that are in the title, obsessive compulsive disorder. So, it's really characterized by having obsessions, which we think about these as intrusive thoughts, images, urges, or feelings that come up again and again and again, and they're really hard to get rid of. And then, compulsions are things that we do or things that we think in our head to try to get some relief from these obsessions. The disorder part comes in when these obsessions and these compulsions start to actually get in the way of our lives, and how we want to live our lives. And I should add the caveat that maybe it's not so much getting in the way of our lives, but getting in the way of how a family is functioning together.

Melanie Cole, MS: So then, let's talk about the symptoms and when this typically is something that we notice in our kids. But what is it that we're looking for? What are some of those red flags?

Lauren Webb, MD: Yeah. It's a good question, because OCD is so complex and can come in so many different shapes and sizes. I think in pop culture, we probably talk the most about OCD when it comes to contamination or having a fear of germs or getting sick or getting other people sick. But it can look really different from that.

So, I would say, in general, the key things to try to look for are is your child getting stuck on something? They're talking about having these thoughts, these images, these urges come up again and again that they really can't move past. And you're maybe noticing them either do something to try to move past it or think something or ask you for reassurance to try to move past it.

So, some other examples might look like we might see kids having this real fear of someone harming them or harm coming to the people that they love or care about. You might see kids getting really stuck on religion or some type of moral scrupulosity. You might see kids having a lot of health concerns that go just even beyond germs. It really can range so much.

Melanie Cole, MS: Do we know what causes this? Is there a genetic component? Because it seems to me like it sometimes does run in families. Tell us a little bit about what we know. Is it a chemical imbalance? What do we know about it?

Lauren Webb, MD: So, on one hand, we have learned a lot in the past few decades. And on the other hand, we don't have kind of this magic bullet of this is exactly what causes it. The way we look at it with OCD is we think about it from this multiple pathways approach, meaning that there are a lot of different factors that come together. I like to call it basically the perfect storm of factors that come together to actually cause it. So, we certainly look at the biological piece where often there is a family history of OCD or even anxiety disorders. Sometimes families will come in and say, "But there's no OCD." But then, when you look a little more closely, there are maybe some OCD tendencies or kind of some subclinical OCD in the family history. So, we definitely see that.

We do know that there's definitely a biological component as well. Kids and adults with OCD, their brains are working a little bit differently. We know that certain chemicals are involved, pathways in the brain. So, there's definitely that biological piece. There might be a neurodevelopmental piece that comes into play, and then a number of environmental factors or stressors. And like I said, it kind of all comes together to become this perfect storm and this breeding ground for OCD.

Melanie Cole, MS: Dr. Webb, some kids, I mean, mine were organizers. My son used to line up his crayons by color or line up his cars to roll cars across the table. And I got a little concerned at the time. But what age do we typically see this and what are some of the things that parents would notice as far as the little things. You've given us some of the symptoms already and you know, you told us about those. But when we see them doing things like the organization, that's not necessarily OCD, right? It's just some kids just want to see things in order.

Lauren Webb, MD: Yeah. I mean, you bring up a really good point, especially with orderliness. And again, we also see that in pop culture. We see people say, "Oh, I'm so OCD. I like this organized a certain way." And that isn't OCD. We also know with little kids, they very often go through a phase of really like things in a particular way, liking order, wanting to line things up. And these can be symptoms or they can just be normal little kid behavior of kind of standing their ground and learning how to set their own boundaries.

So, we do see two peaks of onset. The first peak that we see is basically from the ages of eight to twelve. That's when we see kind of the first wave of OCD emerge in kids. And then, the second peak is towards later adolescents, early 20s. We do know that OCD, the onset is-- according to research-- a little bit earlier in boys than it is in girls. But again, still, we often see that eight to 12 range for kids.

I have a lot of parents who come in and, you know, when we look at their history, they say in retrospect, "Yeah, my kid had some of these like cute little quirks, and we thought they were cute at the time of wanting their socks rolled perfectly, or collecting things and having a hard time throwing them out." And that is true, especially when someone is in my office and they have OCD, we can say, "Okay, this was maybe an early sign of it." But little kids also have those things, and it doesn't always have to be an early sign. You can also try to avoid that pathway to OCD. it's complicated, I guess, is the answer here.

Melanie Cole, MS: Well, it certainly is. So if this is something that we notice, parents, caregivers, even teachers at school, what is then the next step? Dr. Webb, can you speak a little bit about treatment options, whether it's behavioral therapy, medicational? What do we do for these kids that are living with OCD?

Lauren Webb, MD: Yeah. I think, first and foremost, I always tell families you don't have to wait for things to get really bad. If you suspect something might be going awry or things are just not headed down a great path. You can always come in for an evaluation. You can always try to seek care. And that's really good, early intervention is great.

That being said, in general, the best treatment, the gold standard treatment for OCD is what we call exposure and response prevention or ERP. This falls under the branch or umbrella, I should say, of cognitive behavioral therapy or CBT. The whole idea with exposure therapy is that it's kind of as it sounds, you approach your fears in a slow, gradual way while also not doing the compulsion or trying to delay the compulsion with it. That would be the response prevention part. So, we know that that's the best type of behavioral therapy and therapy in general that works for OCD. We also know from research that, for people with more moderate to severe OCD, the best way to approach it is to combine exposure and response prevention with medication therapy, which typically means some type of selective serotonin reuptake inhibitor or an SSRI.

Melanie Cole, MS: What have you seen as far as outcomes when children do these types of therapy and maybe with or without medication? As they grow into adults, do you see the OCDs changing, changing the form that they take? Or I'm not going to say go away altogether, but lessening in their severity or intrusive thoughts, that sort of thing. What have you seen, Dr. Webb?

Lauren Webb, MD: OCD. It is a shapeshifter, which can be very annoying in that way. So, OCD can certainly look different age to age if someone has it. Even just in the course of having OCD, let's say, there isn't even a break from symptoms. It still shape shifts. We sometimes call it or say it's like whack-a-mole, where one thing we kind of are able to treat that, then one other thing pops up, which I know a lot of people hear that and think, "Oh my gosh, it's never going away. It'll never get better." And it really does get better with treatment. Exposure therapy is really, really effective, especially with that combination of medication. And I see many, many kids and teenagers heal from OCD. And it does not have to mean that you are destined to a life of OCD either.

To your point, kids are really young, they have long lives ahead of them. They will have many high highs, low lows. For some kids, if OCD is at, say, eight years old, this is happening before their bodies have changed, before they've hit puberty, their brains will change. There is this misnomer of we say at the end of treatment, we always try to do something called relapse prevention planning. I like to phrase it to kids of, sure, this is relapse prevention, but it's also trying to figure out and help you understand what are the signs that OCD might be flaring up again, so that you never have to be in a place where OCD is as bad as it once was when you came here. We can look for the warning signs. You can come in for booster sessions. This doesn't have to mean that you're destined to a life of OCD being really rampant and controlling you.

Melanie Cole, MS: I think that's a good point you just made about controlling your life and that it's something that can, if left untreated, take control and limit the things that a child or an adult will want to do or be able to do, Because sometimes it's about that ability. But as we look at family and friends, and one of the things I've noticed over the years, Dr. Webb, is that people are a little intolerant of the OCD behavior. "Oh, just stop it. Just stop washing your hands" or "You're not going to get sick. Just don't even worry about it. Carry sanitizer." Whatever form the OCD takes, it can be frustrating for loved ones who just say, "Come on, get over it. What would you like to say to family and friends of someone that they love that does live with OCD, and how they can help or harm the situation?

Lauren Webb, MD: It's a really good question because OCD is unique in that it really sucks everyone in. So, OCD is something that certainly, it's so painful for the person who is directly affected by it, but it's also incredibly painful for parents, for siblings, for extended family, teachers. It's really hard to watch someone go through OCD. And to your point, there can be a lot of different reactions to it. There can be a lot of frustration. I have a lot of parents come in and say, "I just totally lost my patience. There can also be a lot of-- and we see this often-- a lot of accommodation of symptoms too of "My child is in so much pain, how can I not help them? How can I not provide, for example, a lot of hand sanitizer? How can I say no when they're asking me for reassurance? How do I just not respond?"

And to help someone with OCD, we do have to, one, kind of take a hard line and really try not to accommodate the OCD. That is really, really important. I never say let's take all of the accommodation all away at once. It wouldn't be fair. It would be, really, really hard for the kiddo. But we do want to gradually start to understand how are we accommodating OCD and how can we start to peel that back? And you might notice too, I'm kind of personifying OCD a bit and really referring to it as essentially this other person in the room. And that's a really critical thing that we do right away with treatment. We try to help kids and families externalize OCD. For little ones or even big kids, we'll have them name OCD, so for example, Bob, so that they can actually talk to it and the families can say, "Okay, it sounds like Bob is really being a bully right now. It sounds like Bob is in charge right now. How can we turn the volume down on Bob? How can we fight Bob together?" And that can also take the heat out of the situation and help parents really start to change their language and understand that it's not your child wanting to do these things. It's OCD, essentially bullying them into doing these things.

Melanie Cole, MS: Wow. That is so interesting. I have never heard it put like that, and naming the thing. Because, wow, you know, when you name a thing, then you can at least look to it and provide a map. What a great idea, Dr. Webb. You've given us a lot to think about and so much great information. Wrap it up with your best advice for families who have a child that is maybe starting to exhibit some of these symptoms and red flags that you pointed out, and maybe they are living with OCD. What would you like them to know about treatment options out there and hope that this is something that can be tackled?

Lauren Webb, MD: Yeah. I think first and foremost there are treatment options out there, and we know what treatments work. OCD is something where we're actually really confident in how to treat it. I encourage everyone to seek treatment as soon as you feel like something might be wrong. And otherwise my number one piece of advice, if you are noticing any of these little kind of creeping in OCD symptoms, really work hard to try to not accommodate them. That's essentially what exposure therapy is. We work to not accommodate OCD, not do what OCD is telling us to do. So if you can cheerlead your child into pushing back, doing what they want to do and having them be in charge, that's a great first place to start.

Melanie Cole, MS: Dr. Webb, what programs are available or out there to help families with the situation.

Lauren Webb, MD: There are a number of programs out there. Specifically at Weill Cornell, I work for a program called the Pediatric OCD, anxiety and Tick Disorder Program, or the POCAT program. Under POCAT, we have a few different branches, all of which really focus on treating kids with OCD and anxiety, other related disorders. But when it comes to OCD. We have our kind of regular private pay options, but we also have an insurance-based track within our NYP Weill Cornell Clinic, which is really rare I know, to be able to get insurance-based care. That's specialty care for OCD.

We also have an adolescent partial hospitalization program where you can seek more intensive treatment. And there, we have a specific OCD track that teenagers can participate in. And then, we also have an intensive treatment program that's more outpatient-based. But again, it's for kids who really are in need of more intensive OCD or anxiety treatment.

Melanie Cole, MS: Thank you so much, Dr. Webb, for joining us today and sharing your incredible expertise with this often frustrating situation. But gosh, you've given us so much great information. Thank you again.

And Weill Cornell Medicine continues to see our patients in person as well as through video visits, and you can be confident of the safety of your appointment at Weill Cornell Medicine. That concludes today's episode of Kids Health Cast. We'd like to invite our audience to download, subscribe, rate, and review Kids Health Cast on Apple Podcast, Spotify, iHeart, and Pandora. For more health tips, go to weillcornell.org and search podcast. We have so many great ones on there. Thank you so much for joining us. I'm Melanie Cole.

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