Under Pressure

Under Pressure

Lisa’s second New York Times best seller is a celebrated, urgently needed guide to addressing the alarming increase in anxiety and stress in girls from elementary school through college.

Untangled

Untangled

Lisa’s award-winning New York Times best seller–now available in eighteen languages–is a sane, informed, and engaging guide for parents of teenage girls.

Episode 58

Does My Child Have OCD?

How do you know if your child has Obsessive-Compulsive Disorder (OCD)? A parent writes in worried about her daughter’s compulsive behavior and anxiety around germs. Dr. Lisa describes OCD, how it takes hold, when it's time to worry, and what parents should do if they are concerned that their child might suffer from it. Reena asks about the power of rituals and what parents can do to help their kids manage anxiety effectively.

November 30, 2021 | 27 min

Transcript | Does My Child Have OCD?

Ask Lisa Podcast, Ep. 58: Does My Child Have OCD?

 

The Ask Lisa Podcast does not constitute medical advice and is not a substitute for professional

mental health advice, diagnosis or treatment. If you have concerns about your child’s well-being,

consult a physician or mental health professional.

 

REENA: You’ve got to explain something to me. I just recently cleaned out my garage. There are so many places in my home that need to be cleaned out. Why did it bring me such joy and relief to have the freaking garage clean? Of all the places, Lisa, why the garage?

 

LISA: Probably because you could do it. You know what I mean?

 

REENA: Yeah.

 

LISA: It’s so nice to have a task that you can do from start to finish. It sounds like you got it done. Whereas, the whole house is overwhelming.

 

REENA: Yeah, it could be, but I’m like, I’m not living in the garage, but I think about it all the time. My garage is clean. Things are up and put on racks.

 

LISA: It gives you a good feeling. Absolutely.

 

REENA: It does. It does give me a good feeling. We’re going to dive in, actually, to the topic of OCD, which I have always said to myself, I wish I was OCD and because I think of people as organized. You’re going to tell me if we dispel that myth or not. Here’s the letter we got from a parent. It says: ‘My 10-year-old daughter has brought up some concerns around some OCD-style behavior she sees in herself. Things like needing to have a desk chair in the exact right spot when she isn’t using it. Her closet door can’t be ajar. Her stuffies have to be lined up in exactly the same role she’s afraid they’ll quote, ‘’be upset,’’and needing to wash her hands if she touches the garbage can, not because of germs, but just a compulsion feeling that she has to do it. This has been going on with her pre-COVID. It doesn’t seem like COVID has exacerbated it, but I’m not sure. I’ve asked her if she’s worried about it she says, yes but she’s used to it. She’s very high achieving in school, extracurricular activities as well, without being pressured by us, but she really puts pressure on herself to be quote ‘‘perfect,’’ but definitely struggles with some anxiety, but overall I would say she has a very happy life, good friends and a loving family. How do you recommend I proceed? I don’t want her to feel self conscious about it or turn it into something bigger unnecessarily, but I also don’t want her hurt in the long run by downplaying it either. Please help.’ So, I’m going back to my question here. I’m, as somebody who doesn’t know or understand OCD, thinking she’s organized. She’s got her desk chair in the right place. She washes her hands when she thinks it feels icky. Is this so bad?

 

LISA: It’s a tough one, Reena. It can be. It can be. And I’ve cared for people whose lives became absolutely dominated by obsessive and compulsive behaviors, and just really imprisoned by it.

 

REENA: Wow. Okay.

 

LISA: So, we want to think about the continuum on which this exists because it does, and you don’t really want anyone, especially your own child, finding themselves moving further and further up that continuum of having obsessive and compulsive concerns in their lives.

 

REENA: Could you just define for us, Lisa, what his OCD to begin with?

 

LISA: Yeah. It’s one of the things that people talk about, like, oh I’ve got OCD whatever, and it’s actually one of the better named disorders. Sometimes we have names for disorders that when I’ve taught abnormal psychology classes to college students, I’m like, okay this name doesn’t make sense. Here’s what we really mean. But for obsessive compulsive disorder the explanation is actually in the name. So, an obsession is a worry, a thought, that is upsetting, and then the compulsion is the behavior of the person does to reduce the anxiety caused by the thought. So, that’s the construction. So obsession and then compulsion. So, thought and then a behavior that get linked, and the thought is anxiety-provoking and the behavior somehow causes the anxiety to go down, and so if we think about the hand washing, and I heard in this letter that the writer said it’s not that, you know, the kid’s worried her hands are dirty, but there’s something to it.

 

REENA: A compulsive feeling, is what the parent describes here.

 

LISA: Yeah. So, if you think about people who get into obsessive hand washing, the thought is, oh my gosh my hands are dirty, or I’m contaminated or I have germs, so that’s the anxiety-provoking obsession, and then the compulsion is, well, I’ll go wash my hands. So, that’s the behavior, and you can see that one a very logical pairing between the obsessive thought about germs and then the compulsive behavior around cleanliness and how that compulsive behavior would temporarily reduce anxiety, and that’s where this gets tricky, which is it becomes reinforced. So, I have this thought, I do this thing, and my anxiety goes down. So, when the anxiety comes back there’s this powerful urge to do the compulsive behavior and it can really then reinforce itself very powerfully, and where we worry is if there’s the sense of can’t stop, right? I can’t not do it.

 

REENA: Meaning you can’t control it?

 

LISA: You can’t control it. So, like, I took care of a little boy who had this obsessive compulsive thing happening where he was worried he might say a swear word out loud in church. This was his worry. It was his obsessive concern. He was thinking about it and worrying about it all the time, and so he came up with the system where he felt that if he walked from the car to the door of the church and he could arrive on an even numbered step, then he wouldn’t swear in church, like he had this idea, and we’ll come back to how it doesn’t really make a ton of sense, you know, but he had this idea, and so then if he would get to the door of the church and be on odd numbered step, he would feel he had to go all the way back to the car to start again. Like he couldn’t go in the church. It was a can’t stop feeling, and so sometimes for parents they’re like, what are you doing? You know the kid’s like, I’ve got to go back to the car, I’ve got to go back to the car, and it looks difficult or naughty, but it’s like they can’t not do the thing. So, that’s what OCD is, and it can get pretty disruptive.

 

REENA: When do you think a parent needs to intervene and get help?

 

LISA: I wouldn’t actually wait too long.

 

REENA: Really?

 

LISA: Yeah.

 

REENA: Can I just say I’m shocked to hear you say this because I’ve always associated OCD as like a good thing. It’s a psychological term that’s thrown around and as somebody who’s not Type A, I’m always like, oh I wish I was a little more organized, but what I’m hearing from you is it’s not organization. It’s so much more than that.

 

LISA: It is, okay but to rest on this idea, Reena, because you’re not wrong. So, say a person has an obsessive concern that there’s a typo in an important essay they’re sending somewhere or an article, and their compulsion is to very, very carefully proofread it, and so the obsessive thought is, I’m worried there’s a typo. The compulsive is a behavior that actually can check for typos, and it keeps them from sending in articles or pieces or whatever that have mistakes in them. Fundamentally that’s a good thing, right? That’s going to make their work better.

That’s not a bad thing. Though, what we want to watch out for, and this is where the line gets crossed, which is it stops being functional. It starts to get in the way. So, there are some people who can’t send their work in because they are so anxious that there might be an error in it that they are compulsively going over and over and over it again, and it turns from being adaptive, right? Improving the quality of one’s work to actually hamstringing the person and they can’t get their work in on time or they feel, you know, really, really uncomfortable when it finally gets pulled out of their hands, you know, so that’s the, you know, it’s interesting that most psychopathology occurs on a continuum. Like most things that we ultimately diagnose have garden variety versions in daily life, and OCD is a good example.

 

REENA: You know I’m thinking about our desks, right? Your and I’s. It’s just so typical. Yours is always nice and tidy, and mine is like mountains of paper all over, manila folders scattered everywhere, and as I’m doing this I’m thinking, okay I’ve got to clean this up. This is just gross, but it’s not stopping me from doing the podcast or doing other things. When is it really a problem? I’m thinking about it and it is preventing me from doing my work sometimes, but when does it become a red flag?

 

LISA: Well, this child, it’s not really, it seems, like getting in her way that much. You know and think that’s this parent’s letter is really thoughtful of like, do I a big deal of this or am I going to look back on this and wish I had made a bigger deal of it, and I would say, you know, if a person of any age has, you know, kind of obsessive compulsive tendencies in a basically functional domain, you know, something where like they double check their writing or they just one more time go back in and check to make sure the stove is off, you know, things like that, and it’s, you know, it fits with making sense in the world and they can check it once or twice and be done with it. I would leave it be. If, however, and this could be up for debate. This is sort of what I’m thinking as I go. Let me think it through a little bit more, but what makes me a little concerned about this child is there’s several things she’s doing and it’s clearly caught up with worry that’s kind of vague, like worried that the stuffed animals will be upset, you know, needing the door closed. It doesn’t really have a functional purpose, right? Like straightening the stuffed animals isn’t checking to make sure that you actually did turn off the stove, right? I mean it doesn’t sort of have that kind of real world implications, what we know is, and I think this may already be underway, obsessive compulsive behaviors can start to spread, and sometimes they’re about very specific concerns like, my hands are dirty and so I wash my hands a lot, but often, especially with younger kids, they’re are about much amorphous, like I feel uneasy, so I’m going to go touch all of the furniture in this very particular order. Now I feel better. Right?

 

REENA: Oh. Really?

 

LISA: Yeah, and it can be these interesting, you know, kind of pairings, and then what happens is when they feel uneasy they may go do that, and then they may find, like but yet I still feel uneasy. Okay, so I’m going to add a ritual. I’m also going to close all the doors. Okay, hm. Yep I still feel uneasy, so I’m going to do the touching. I’m going to do the door closing, and I’m still going to straighten out the pillows. And that’s where it can start to spin into this life-disrupting, dominating world, and no one wants that for themselves or their child.

 

REENA: You know, it’s interesting. You mention rituals about things that might help because in Hinduism there are bhajans, like prayers, chants, mantras that you say. I think in the church for Catholics or, you know, I grew up in the Assyrian Orthodox Church. There’s hail Marys or similar prayers.

 

LISA: Crossing yourself or things?

 

REENA: Yes. Yes. How does that help?

 

LISA: Well, it’s funny. It’s so good that you bring this up because we do have all of these like rituals that we use in religion or in life that if you really look at them hard, you’re like, that’s kind of random, you know, that we decided that that thing protects you from that other thing. So, it’s not actually a big stretch to have this idea of, I feel anxious. I’ll go touch the furniture, right? There’s other versions of that in our worlds where we have something we wish were different or we have a feeling that’s uneasy, and so then we do something that isn’t obviously logically linked to it, and it gives a sense of relief. What’s different here, first of all is there’s a whole bunch of stuff that’s culturally sanctioned, right? Like we all agree, or a lot of people agree,  prayer is a thing, and so we don’t, you know, it’s sort of in the bounds of what we normally expect people to be doing if that’s what they do, but it’s also it’s the disruptive question, right? So there are also people who could find themselves feeling that they have to repeat silent prayers over and over and over and over again to the point where they can’t really focus on their work or they can’t do the things they need to do. So, it’s that line of, yeah, we all have rituals, or lots of people do. Entire religions sanction, you know, agreed upon rituals, but the question we would always come back to is, is this getting in the person’s way or is it making their life click along as they need it to click along? Right that whatever the category is, and then if you start to see the spreading that I think is actually quite beautifully described in this letter, you know, that it’s now several rituals, then I would say, okay, it’s time to interfere with this. It’s time to treat this.

 

REENA: Is there any age where OCD really begins?

 

LISA: You know it’s funny. There are points in development where kids can look a little OCD. It’s interesting. Around toileting kids can look pretty OCD because they’re, you know, they’re thinking about their bodies.

 

REENA: Really? That early?

 

LISA: Yeah. They’re also suddenly thinking a lot about poop and where it goes, and I took care of a little kid who was toileting and who was very obsessive, this will crack you up. It was actually very sweet, but also very, in some ways, very concrete, about the brown crayons and the urine-colored crayons. Needing to be very, very carefully organized so that they were at the furthest distance from the non-toileting looking crayons, and was and was very rigid about this, and had the parents concerned that there was obsessive phenomenology at work, and there kind of was, but it was also very much bound to the developmental moment of this kid thinking a lot about poop and pee and trying to get it where it belongs and away from everything else and so typically stuff like that will resolve of its own accord, you know, as soon as toileting becomes mastered and feels more comfortable, the crayons can all be mixed up again. It doesn’t matter anymore. But I would say it could start pretty much at any point.

 

REENA: Really? Okay.

 

LISA: Yeah, and I will say we saw a lot more of it in the pandemic. We’re seeing quite a bit more, and I would just chalk it up to vague and, you know, uncomfortable and hard to describe anxiety, right? Just like the sense of free floating anxiety, and if you can, you know, if you can give yourself a break from it for a minute by, you know, doing some ritual, I get it. I get why we’re seeing more of this.

 

REENA: So, Lisa, can greater anxiety lead to OCD? And also is OCD inherited?

 

LISA: That’s a good question. So, we consider OCD to be an anxiety disorder, and anxiety disorders can without question be inherited, and so yes, this can run in families, and the other way to think about this, Reena, if you’re asking kind of the developmental question, one thing that my colleagues and I started to observe in the pandemic is that we were seeing OCD in younger kids and eating disorders in older kids.

 

REENA: Oh. Wow.

 

LISA: And eating disorders are close neighbors to OCD. That often for eating disorders, especially the restricting ones, the obsession is, I’m fat, and the compulsion is, I’m going to go run 10 miles, and so if you had like bullion overlap, there’s bullion overlap between obsessive compulsive behaviors and eating disordered behaviors. That one of the phrases we use in psychology is that our diagnostic system does not cleave nature at its joints. You know that there’s overlap. So, if you’re a parent and you think your kid might need treatment, what are your options?

 

LISA: I’d start with some home remedies. I would give it a try, and the technical term we use is exposure and response prevention. So ERP. Exposure and response prevention. Which is basically to not let them do the compulsion, to make them ride out the anxiety until it dies down on its own accord, to not have the reinforcement of doing the compulsive behavior.

 

REENA: That sounds so hard.

 

LISA: It is hard, and it’s uncomfortable, and you want to probably teach your child some anxiety management strategies before you do this. So, you know, we’ve talked about breathing as a way to bring anxiety down. We’ve talked about reframing things, you know, is it really dangerous to have your hands maybe be dirty or are you going to be okay? Do you have a good working immune system, and so I would, if I were a parent, I would look up some techniques for helping manage anxiety. Breathing, reframing. Have those ready, and then say to your child, you know what? I’m going to ask you to not straighten your chair. I’m going to ask you to wash your hands only after you use the restroom or before you eat, and I know you’re going to get uncomfortable, and I’m here to help you with that discomfort, but we need to find ways for you to manage your discomfort that don’t involve these rituals because they’re kind of taking over. So, that’s where  a parent would want to start, which is basically to uncouple the anxiety from the ritualized behavior that is very, very temporarily getting that anxiety to go down.

 

REENA: Lisa, I also want to get to the part of this letter where the parent talks about perfectionism. How do you help your kids with that?

 

LISA: Yeah. It’s so common, and so punishing, you know, so often for kids.

 

REENA: What can you say? I think we all strive to be perfect and great and, you know, you’ve got social media putting out these images of what you should be and look like. What works when you’re trying to get your kids understand it’s not about being perfect?

 

LISA: Yeah. I think there’s two things. You know for me, especially with school-age kids, I quickly make a division of my mind around perfectionism around school work and perfectionism around everything else because the perfectionism around the school work is hugely taxing on time and stress, and for me what I’m really interested in watching in a kid’s academic development is I want to see kids get their work ethics in place. I actually do want to see every kid come to a point where they know actually how to do something to its highest level that they can do. You know that we don’t want kids phoning it in all the time. So, Reena, if you think about your kids, do you feel that they’re both in a place where if they had to polish something to an incredibly high shine, they know how to do that?

 

REENA: I don’t know that they necessarily would. I think when they’re passionate about something they naturally do that, but when they’re not I don’t even strive to try to reach that goal.

 

LISA: Yeah. I think we want them to develop that skill set, and developmentally they’re not really probably where they have that yet, but you’re working on it, right now. That we want kids, even on the work they don’t like, and that is the key point in this, even on the work they don’t like we want them to show us that if they have to do something at a hundred percent, they have the work ethic to do it. Like we really need kids to develop that kind of work ethic. So, I wouldn’t worry about perfectionism until that’s in place, and usually if a kid’s perfectionistic that’s going to get in place pretty early. Only then do we start to chip away a bit at a perfectionistic work ethic, and the way to do that at school is to talk about it in terms of tactics, right? So when does it make good sense for you to polish something to a high shine? When is it tactical in terms of your energy and your time and your need for sleep for you to phone this in? You know or to do less or to, you know, bluntly, I would say cut corners. You know we don’t usually talk about school that way, but I think especially for hyper conscientious kids it’s helpful to say, you know, there’s times when you give it your all and there’s times where you find the quickest, fastest path and take it. So, I think that’s one approach. But then, on the overhaul perfectionism, the best thinking I ever saw on this comes from a psychologist I really admire named Nancy McWilliams, and she was talking about how when we are trying to work against perfectionism in our clients, part of how we do it is we model for them that we can acknowledge our own shortcomings while still holding ourselves at a reasonable level of self-regard. That we can say, you know what? I apologize I started the session late. I owe you some time at the end if you can do that today. You know so, to own our mistakes and shortcomings, but without this bowing, scraping, I’m so awful, I hate myself. You know, so we can do this all the time in parenting. We can both acknowledge our shortcomings while making clear, like I still feel like I’m an okay person, you know, and I think that’s how we model behavior that can work against perfectionism in our kids.

 

REENA: Wow. You have just opened the door wide open on a topic I think that people throw around but know nothing about. I am shocked at how little I knew about this topic.

 

LISA: Yeah. Let me add one more thing because I think parents should know this. Medication can also help. I’m never a fan of medication without a good evaluation. I would really rather have a kid also in psychotherapy, but for some folks whose OCD gets very out of control where they just have these really persistent and extremely uncomfortable worries and thoughts, maybe about contamination or that they’re going to do something dangerous or something like that, and they can’t get it to stop, antidepressants have turned out to be very effective at making those obsessive thoughts quieter, and so I would not offer it as a first line of defense, and I would want it to be done really thoughtfully, but I just I just want people to know that psychotherapy can be very effective, especially exposure and response prevention psychotherapy, and then, you know, working with someone really, really careful and thoughtful if needed to consider the possibility of medication if that might give some desperately needed relief.

 

REENA: So, for parents who want more, Lisa, are there resources out there or a website or something that we can direct parents to?

 

LISA: You know there are some good books on this. Edna Foa is somebody who’s written really thoughtfully. She’s a real expert in this field. So, I’ll put in the show notes some books that I think will be useful to families.

 

REENA: That is so great, and what do you have for us for parenting to go?

 

LISA: We’ve talked a lot about anxiety on this podcast over time, and it feels like a good time to revisit the difference between healthy and unhealthy anxiety. So, healthy anxiety is what we feel when something’s really wrong, and it helps us to pay attention, to make a change, and unhealthy anxiety is when we feel anxious, but nothing’s really wrong, or we feel way too anxious for the situation. And so OCD, you can see, fits pretty clearly in the second category, and that can make it distinct from just the general anxiety that we sometimes feel as human beings.

 

REENA: That’s one of the things I’ve learned from you throughout our seasons here is that anxiety is perfectly normal and can be healthy, but then there are moments where it needs to be checked.

 

LISA: Yep. Sometimes it can get too much.

 

REENA: Thank you, Lisa. I still am grateful I went to Costco and got those metal wires to hang all my stuff up in the garage.

 

LISA: Absolutely. Absolutely, and you feel better. It’s functional.

 

REENA: I feel so much better, and I love my metal shelving. I’ve got to tell you. So, next week we’re going to talk about what do you do if your daughter is the mean girl in school.

 

LISA: All right, well, look forward to seeing you next week.

 

REENA: Sounds great. See you next week.