59. Navigating OCD with Dr. Elisa Song

OCD behaviors, Pans and pandas are among the most debilitating conditions that children can face. And when a child cannot articulate the repetitive thoughts in their head, for example, if they are non speaking, the stress can be too much. Thank you for joining me today. I'm your host, Vaish, and in this podcast, Functional Nutrition and Learning for Kids, we try to look at different symptoms from the lens of functional medicine and nutrition and neurodiversity, learning and education. And today, I'm really excited to interview Dr. Elisa Song, MD, a holistic pediatrician, a pediatric functional medicine expert, and mama to two crazy fun kids in her integrative pediatric practice, which is called Whole Family Wellness. You can find this@wholefamilywellness.org here. She's helped thousands of kids get to the root causes of their health concerns and help their parents understand how to help their children thrive body, mind and spirit by integrating conventional pediatrics with functional medicine, homeopathy, acupuncture, herbal medicine, and essential oils. These health concerns have ranged from frequent colds, ear infections, asthma, and eczema to autism, ADHD, PANS, PANDAS, anxiety, depression, and autoimmune illnesses.

Dr. Elisa Song, I've been so eager to have you on this podcast because not only are you the expert that I think of and I think of.

Pans and pandas or infectious diseases or.

Autism, but you explain things so well.

Thank you so much. I'm honored to be here.

And I want to start off by.

Asking if you can explain what OCD.

Is and specifically, when does it warrant a diagnosis for a child?

When you're moving?

When does repetitive behavior cross over and.

Warrant a diagnosis of ocd?

Sure. Because ocd, Obsessive Compulsive disorder, it is a diagnosable mental health disorder. Right. And not all of our kids who have obsessions or compulsions at times have ocd, technically. So, you know, with ocd, in order for it to really be.

A diagnosed condition, it really has to be impacting life significantly. When kids get so stuck in either their repetitive thoughts or their need to do repetitive actions that they really can't move on, they literally are stuck in that moment. And it can feel so, so frightening to kids when they don't know what's going on. It can be shameful. Right. As kids try to hide what's going on, it can be really frustrating because they, on the one hand, many kids will know logically, okay, I need to get out of this loop. But unable to. And then, of course, we have so many of our kids on the autism spectrum who have OCD that may not be able to tell us how they're feeling inside their brains, may not be able to express how safe stuck they are. But OCD really is very distressing to both children and parents. Right. And can be so challenging to move beyond. So we need to look at OCD from a more integrative, holistic approach, from that functional medicine, functional nutrition approach, as you do with all of your guests and what you've done with your children and in the clinic. So I'm really glad that you're talking about this issue right now.

Thank you.

What is the first thing that you address in your practice, Doctor, when you.

Are treating OCD in a child.

If.

There is such a thing?

Yeah. What's the first thing? Wow. We know the importance and function of medicine, of the gut brain connection and the gut brain access, even without any apparent GI symptoms. Of course, I'm always going to be looking at what's going on in the gut, what the microbial composition is, if there's gut dysbiosis. We know that the vast majority, 85% plus of our neurotransmitters are made in our gut, including serotonin, which is implicated in ocd, and of course all of our other neurotransmitters like dopamine and acetylcholine, which are so important. So I look at the gut, I'll look at of course, what things are irritating to the gut, whether or not there are foods that are impacting the brain. Gluten and dairy. For parents who are listening, if they have not tried going off of gluten and dairy, that can be a huge factor in not just oc, but in the anxieties that our kids can feel in any of the neurotransmitter imbalances, because I'm sure you've spoken about this before, but gluten and dairy in particular for susceptible children, even adults, can get converted into these morphine like compounds, these opioid like compounds called gliotomorphins and casomorphins that literally drug the brain and can get the brain into the state where it can't get out of whatever loop it's in looking into neurotransmitter balancing. We don't have great ways to measure neurotransmitters. We have indirect ways to look in our urine. So a urine organic acid test may be helpful, but it also might be helpful just to see how can we support serotonin with amino acids like 5 HTP or GABA and theanine. So things that can really calm the brain really have more of a supportive role. So that can be one way. Some of our kids, parents are looking into medications that impact serotonin levels, which there is, of course, a time and a place for everything. It's not an either or. But as we look at serotonin reuptake inhibitors that might be used for OCD, the dosages used are fairly high. For OCD, we need to use higher dosages of SSRIs than we might for anxiety or depression. And what I discuss with parents is these SSRIs, these serotonin, selective serotonin reuptake inhibitors, what they do in the brain synapse and that connection in that space between your brain cells or your neurons is they slow down the reuptake of serotonin by the cells, meaning your neurons see serotonin for longer periods in between those neurons. Now, if at baseline, though, your child has low serotonin levels and there's not a lot of serotonin, the brain cells to begin with, the SSRIs are not going to have as much of an impact. So you may need to consider that at some point. But I would say let's get back to the fundamentals, the foundations. Let's support the gut, let's support serotonin, and let's see how else we can support OCD from a foundational perspective. Now, there's also the question of could this be pans or pandas? Right, because we know that pans, pediatric acute neuropsychiatric syndrome, and also pandas, which is a subset of pans specific, specifically triggered by strep bacteria. We know that pans is sort of an umbrella term. You can have these sudden onset of ocd, tics, anxieties, behavioral regressions, cognitive slowing that can be triggered by multiple factors, including infections like strep or Lyme or Epstein Barr or influenza, also different toxins like mycotoxins, mold toxins and heavy metals. So what is triggered specifically by strep is called pandas. So how do we know the difference? Right, right. It's so challenging, especially for our kids on the spectrum or perhaps our kids with other developmental concerns where they haven't been completely 100% quote neurotypical before the OCD started. And this is where it takes a little bit of detective work. We also know with PANs and PANDAs, the diagnostic criteria are this sudden onset. It's like a light turned on, and all of a sudden they're a different child. We know that's not the case for many of our kids with pans and pandas, you can have a more gradual onset where parents are noticing something's different, something changed ever since they went on those antibiotics for that pneumonia, or ever since we went on a vacation and they had a really frightful experience, or ever since the water spilled in the laundry machine, something's changed a little more gradual and it hasn't gotten better. And the anxiety is still there, the OCD is still there. So for parents who can think back and think, okay, this wasn't always the case. There was a time where things were different and then the OCD started and then they got worse and worse, or they're just staying and not going away, that's when I would look for pans or pandas.

So, doctor, if you were to separate ocd, that's not pans and pandas and OCD from pans or pandas is the main difference the presence of an infection?

The presence of an infection or a toxic trigger. Right. You know, not necessarily.

Not have to be infectious. It can be a non infectious trigger as well.

Exactly. That's right. Now you know, how do we know? So unfortunately, there's not a single test alone that can tell you your child has pans or pandas. That's one of the most frustrating things about pans and pandas, because I can't write a blood test and say, yes, 100%, your child has pans or pandas. We can do some detective work, though. We can look at a urine test for mold exposure. We can do blood tests for a variety of different infections to see if that could be a factor. One thing that I will do if I'm not quite certain if it could be pans or pandas, this is more of a clinical test. So it doesn't involve blood work, doesn't involve a urine test. What I will do is do a trial of anti inflammatories for a child. So do a trial of whatever anti inflammatories you might typically use. I actually use ibuprofen, so Motrin or Advil, and give ibuprofen for.

Three times a day, the typical dose. Now, of course, we always want to run this by your practitioner, but the typical dose that I do is 10 milligrams per kilogram for a child three times a day for a week. And then I have parents report back to me. What did you notice? Are they sleeping better? Is their mood better? Do they have less ocds? Are they less anxious? If they're noticing some Change for the better. That's when I think, I wonder if there could be an infectious or toxic perpetuating factor for the ocd, a trigger for the ocd. And then I'll do more detective work because of course, as you know, for children, blood work isn't always the easiest to get. And of course now we're in a pandemic where we may not want to go to the lab. So this is just a bit of a diagnostic test that I'll do.

Right, so the thinking is that the infection is causing inflammation and you are trying out an anti inflammatory to see if that's the root cause of the OCD.

100%. And there are other anti inflammatories that you might consider. You might consider curcumin, which is a wonderful anti inflammatory. I also use a specialized fish oil. They're called specialized pro resolving mediators. So they're actually molecules that are derived from the omega 3 essential fatty acids that are purified out because they're really incredible.

Inflammatory modulators. And for many of my kids with pans and pannas, these SPMs, as they're called, have been one of the game changers for their treatments. It is something that I'll use for any kid who has inflammatory overdrive or autoimmune reactivity. Because we do know for pans and pannas there is this piece that's this autoimmune reaction. There's inflammation in the brain, but. But there's also the piece of your immune system attacking parts of the brain, attacking different components, different pieces of the brain cell that may be triggering these neuropsychiatric symptoms.

If I may ask you one more question about the infection, One question that came up when you were saying is that maybe identifying pans or pandas based on the reaction to anti inflammatories, could there be a chronic infection that is not acting, that is causing ocd, but not through inflammation, or is it always through inflammation?

That's a great question.

If infection is driving the ocd, there will always be a component of immune dysregulation. Now how that manifests, whether or not there's a ton of inflammation or if it's just more this dysregulation.

It'S hard to say. It is true that for the vast majority of kids with OCD driven by infection, when it's pans or pandas, when I look for inflammatory markers in the blood, they're totally normal.

You will typically have a normal sedimentation rate, a normal C reactive protein. When you dive deeper into some of the more specialized T and B cell functioning, natural killer cell functioning, which is not conventional testing by any means. That's typically going to be what's ordered by an immunologist. We might see some imbalances there. So, yes, I think that there, for the most part, there is. Inflammation may not be measurable by our conventional methods from easily accessible standpoint, but there is always immune dysregulation.

I think you make a great case that this is individual detective work, which is why there isn't a standard protocol for anybody.

Yeah, absolutely.

To back up from all this complexity, would you say that the first thing to do, regardless of where you are, is to work on the diet, or is that not the case for everybody?

Yes and no. Because I think that no matter what child I'm seeing in front of me, I always work on the diet. Because, as you know, food is medicine, so that has to be a foundational piece. It may not be the biggest hitter in terms of ocd, but if we're trying to really help your child's brain calm down, reduce this OCD tendency, it's going to be a big uphill battle. If we're just fueling the flame of inflammation in your body and brain with foods that aren't serving your child's brain.

Right.

So if your child is eating a ton of processed foods, a ton of foods with sugar and artificial flavors and colors and preservatives, that's not helping. So we need to really look at how do we clean up the diet to the extent that we can, because we will see a lot of brain healing going on just with that. So diet and lifestyle are foundational, but there are times where, you know, you have a child coming in and their OCD is so crippling, you're so.

Consuming, that they're not able to learn in school, even remote school. Right. Whatever schooling looks like for you, they're not able to participate in therapies, they're not able to participate in life because their brain is so stuck. And in that case, then I might try some targeted supplements that can be helpful, that have been found to be helpful for ocd. The two supplements that just really come up off the top of my head are inositol and N acetylcysteine. So those are two that have really been found to be helpful for repetitive thoughts, for anxieties, for tics even, and for ocd. And so that is what I would think about, especially if you're in a place where.

Where it is really interfering with your child's day to day functioning. And they're very overall very safe supplements to try again. The dosages can vary quite a bit. And this is where working with a functional medicine practitioner to find the right dose for your child can be really, really helpful.

Thank you. Thank you for those recommendations, Doctor. My next question is on the line. When I am teaching a student, one of the questions that teachers hate is, is it going to be on the exam? Right. So I'm going to ask you my version of that question.

Sure.

How long does it take?

How long does it take? Wow.

OCD is very challenging to treat. Very challenging. From a conventional kind of psychiatric standpoint, it is one of the more challenging conditions to really manage. As I mentioned, even in terms of medications, we don't have a lot of great medications. And typically the medications have to be titrated up to a fairly high dosage. And even then we may not see the benefits before we start seeing side effects, because all medicines have side effects.

But if we have a multi pronged approach with working on the gut and diet factors, trying some supplements like Inositol and N acetylcysteine, and also incorporating a third leg, which is cognitive behavioral therapy, which is very, very important for ocd, then we can start to see improvements. I mean, I would say even within a month we'll start to see improvements, but it's going to be an ongoing process.

As parents know, you can have times where OCD waxes and wanes, where sometimes, you know, things are great and smooth and you can get out the door because your child doesn't have to do this thing, you know, 50 times or isn't stuck in their head about, you know, doing things in a particular order and other times where, you know, it's the exact opposite. Right. And so.

Those tools may ebb and flow as well. But for your children who can do cognitive behavioral therapy, that is one of the cornerstones of treatment for ocd. If you have kids with ocd, one of the best books that you can work with your child as a parent on is a book called what to do when youn Brain Gets Stuck. It's by one of my favorite child psychologists ever. She's a friend now. She's a dear friend. She's in Vermont. Her name is Dawn D A W N Huebner. H U E B N E R. She pronounces it Dawn Hebner, actually. And she teaches cognitive behavioral techniques to children through these, quote, self help workbooks designed for kids. Of course, as parents, it's really helpful to Work through the books with your child so that you know the tools too. And so when you see them getting stuck, you can help work through some of the exercises with them. And that would. And if you also, if you have a great therapist who specializes in CBT for kids and CBT for kids, especially around ocd and if they have pans and pandas, understands pans and pandas, that's also really important too.

And thank you for mentioning Dawn Huebner's book, because I think this is the second time she's been mentioned on this podcast and I've been meaning to reach out to her too. So thank you for that.

She's amazing and she would be wonderful for your podcast. I will connect you. Her books, what to do when youn Worry Too Much are really important for, for kids, especially now. This past year has been quite a year for a lot of our kids with anxieties, but she has so many books that are helpful for our kids. What to do when you dread your bed.

Another one of my favorites is what to do when you grumble too much. I mean, there's so much in life right now to grumble about. So how do we get out of that state of negativity so that we can move forward?

Right.

You mentioned OCD vaccine and waning, and one of the questions that's been on my mind is that is that often a symptom of infection? Because sometimes infections can flare and not. So is that ever a diagnostic criteria when things wax in, wane?

So absolutely. For pans and pandas. Pans and pandas is a waxing and waning condition. Right. It is a disease for, with flares and remissions. And hopefully if you find the root cause or causes of the pans and treat those, then your child will stay in remission forever. Right? That is the goal of treating pans and pannas. But that is another tip off for me. When things ebb and flow, you know, wax and wane, there are flares and then all of a sudden they're, they're totally fine and the OCD is gone. That's another tip off that that could be pans. And what could be that trigger? It's interesting. I have a lot of kids with pans where they do actually flare in the late winter, early spring as we get more pollen and blooms and this histamine release. And that does seem to be a big trigger for kids. That may be one of the signs that there's this underlying pans issue. And then you throw on another inflammatory trigger like infection like pollens, your. Your pan symptoms will flare, or sometimes it's. It's stress too. Right. We can't forget that psychological stress creates as much inflammation in our bodies as physiologic stress. And so there may be times where psychological stress and a big stressor will all of a sudden trigger these new or the return of those neuropsychiatric symptoms that you had thought had been resolved.

Now, if there is a flare out of the blue, quote out of the blue, then I do more digging. Do you need to look to see, Is there mold that's growing.

On the floorboard of your child's room behind their bed?

Was there a water spill in the garage that you're unaware of?

So really that's why you mentioned the water spill earlier in relation to mold.

Yes. Yes. Mold is definitely a big.

Trigger and also a perpetuating factor. So sometimes you will have a child with, let's say it is strep and they have pandas, and they are getting better with your treatments, but perhaps not as quickly or not as fully as you would like. And then we think, well, what else could be gone? Is there another infection? Because you can have more than one infection, unfortunately, that you might have to deal with, or is there a toxin issue that you're not addressing? And mold is a very common toxic issue that affects our kids and oftentimes unknowingly, until we start looking.

You've seen so many kids in your practice. Among the kids that get better, are there any common, either lifestyle factors or habit factors that you notice that enable some children to get better faster?

You mean specifically from ocd or from pans or pandas?

I guess I meant anything. But we can say OCD now.

Yeah. I will say one of the pieces in healing, especially when we think about gut healing. And this would be not just for ocd. This would be for. For across the board, really looking at all of our kids who have chronic health conditions, which, as you know, is too many of our children. But when we start with the gut, there is in functional medicine something called the 5R Protocol. Now, when I first trained in functional medicine, and this is now 17 years ago, it was called the 4R program, where you remove anything that's irritating to the gut, like abnormal bugs or foods. You re inoculate with the good bugs with probiotics. You replace whatever is missing, like digestive enzymes. So repair.

I'm sorry, replace, like, digestive enzymes, and you repair with gut healing nutrients like glutamine and sink. Okay, so that was the 4R program for a very, very long time. And you could get your kids and your adult patients very well, you know, much further along the spectrum towards healing. But oftentimes, and what I found was you could get your kids well, I could even get my kids into remission, but I couldn't necessarily keep them there. They would keep sliding back. And so what was that missing piece? I really do think that 5th R, now called the 5R program, is one of the most important pieces for all of our kids. The fifth R is restore. It's really restoring that mind, body, spirit connection. It's really looking at how do we incorporate mindfulness and movement and how do we really engage our vagus nerve to keep our immune system and our nervous system in that state that wants to be well, we will always, every day in this modern world have factors that are trying to push our body and our brain towards inflammation. It's a fact of life. I mean, we can't live in a bubble.

So as those hits happen, if our nervous system is engaged, our vagus nerve is engaged to stay in that healing state, we can tackle whatever toxic hit comes our way without relapsing. I mean, this is for anything. This is for kids with ocd. This is for kids with pans and panas. This is for kids with Crohn's disease or rheumatoid arthritis or asthma or eczema. It's this final piece. And when we think about mind body medicine, for a lot of people listening and even for me, I mean, years ago, I will say it was really, I thought it was okay. That's kind of an optional thing when we have time. We have to work on the diet first, we have to give supplements first, we have to kill the bugs first.

Right.

But that 100% is not the case. It has to be layered in. And if you're going to have sustained healing and I want to remove. When I think about mind body medicine, it really is.

With the goal of engaging our vagus nerve, reducing the sympathetic, engaging the parasympathetic. There is a physiologic basis and there's an immunologic basis for this that will keep your body well.

What would you say for parents that are starting out on this journey, that are getting into. That have a child that's really struggling with ocd? Are there two or three things that they could start off with right away.

Just like the big hitters right now? Because CBT and vagus nerve work is a journey not going to necessarily right away be quick. However, there are some videos that you can look at. In fact, there is.

A woman.

Who.

See, now I'm going to forget, but she has videos online that I've had several families have very good results with around ocd. It is Natasha Daniels. Natasha Daniels. And she has videos for kids that they can watch on helping them with their ocd. So that would be one thing. I would say the inositol and the N acetylcysteine I mentioned, those can definitely.

Help take the edge off so that you can start then working on the cbt. Because when we're in this state where our brain is just so stuck. Stuck, it can be hard to do the cognitive behavioral therapy. But inositol and N acetylcysteine are two of the supplements that immediately can have some benefits. The other thing that if your audience has ever tried homeopathy, I'm a huge fan of homeopathy. There is a lot of good evidence around the benefits of homeopathy. And even if you're a skeptic, it does no harm.

Right.

No matter what other supplements or medications. Your children and I have seen some really good changes using homeopathic medicines. Now, the most effective homeopathic medicines are going to be the ones that are individualized for your child. But barring that, of course, you can work with a classical homeopath. But apart from that, there are some homeopathic medicines that can really help symptomatically with some of the ocds. And one of the top ones that I found is Homeopathic Arsenicum album. So just to throw that out there, homeopathy can work fairly quickly and definitely can work on some of the emotional components, the neuropsychiatric components. So I would consider that as well, because I love homeopathy as a toolkit.

I love homeopathy. And thank you for mentioning that. We've only had a homeopath once on this podcast and I need to get on track inviting more homeopaths in here. But thank you. You've been so generous with your recommendations and they've been very specific, very actionable, and thank you so much. And I think those three were definitely. I'm going to repeat the three hard hitters that you said. You said homeopathy, you said inositol and N acetylcysteine. And then what was the third one?

The videos.

The videos by Natasha Daniels. Yes. Yes. Okay. Thanks so much, Dr. Song. Thanks for being on this podcast. And where can listeners find you and your work if they're interested?

Yeah. So I want to thank you for having your podcast. You provide such valuable information to parents in very accessible chunks. So that's so great as a mom, right?

That we need that.

So the best way to find me is on my online educational site, my blog site. It's called Healthy Kids, happy kids. So HealthyKids happy kids.com and you can also find me. I post fairly regularly on new updates in the news and also my clinical insights into integrated pediatrics on my Instagram and Facebook account. So you can just search Healthy Kids, Happy Kids and you should find me there.

Thank you for listening. As you may have heard, Dr. Song created healthy Kids, Happy Kids and you can find this at www.healthykidshappykids.com to share her advice and adventures as a holistic pediatrician and mama. You can also follow her on Facebook and that is facebook.com Dr. ElisaSongMD and Instagram. And you can just search for Healthy Kids Happy Kids on Instagram. Now speaking of Instagram, if you haven't heard, I host weekly Instagram Lives on Monday at 11am PST. Now these are often different and a little bit more informal than the general podcast format. So if you want to join in and ask questions, they're also interactive. My handle is DrVaish Sarathi. So that's Dr. Vaish Sarathi. Or you can just search for Functional Nutrition for Kids. Hopefully I pop up. I also host Facebook Lives on second Tuesdays of every month. And there's one coming up. Well, there's one coming up depending on when you're listening to this. But there that's the 9th of February 2021 at 11:30am we're going to be talking about rhythm and learning and presuming competence now saying goodbye until next week. This is Vaish, your host from Functional Nutrition for Kids and Music was by Maitri Ghosh. But before I say goodbye, I realize that I forgot to tell you you my Facebook handle. And you can look for Functional Nutrition and Learning for Kids podcast as well there. Bye.