When a child asks the same question over and over, it may not be curiosity — it may be intrusive thoughts
The defining feature of an intrusive thought is that it is ego dystonic — the child feels the thought is not them, and feels shame about it. Reassurance brings only brief relief; what actually works is helping the child separate the thought from themselves, then boss it back.
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The argument · timestamps estimated from transcript position
Intrusive thoughts don't belong only to disordered kids
Rebecca Hershberg stresses that intrusive thoughts can come from many sources, including entirely normal development. This matters: when a parent sees a thought recurring in their child, they don't have to jump straight to "is it OCD or PANS?" Sarah Bren adds that whether the thought comes from a diagnosis, OCD, anxiety, or just normal development, the way you handle it is "more or less the same." So the tools in this episode don't depend on a diagnosis — parents can start intervening at the behavioral level.
— Dr. Rebecca HershbergThe difference between PANS and PANDAS is the type of virus
Rebecca Hershberg explains: PANS and PANDAS are essentially the same thing, except PANDAS specifically refers to cases triggered by strep infection, while PANS refers to cases triggered by other viruses. The mechanism is that the child's body produces inflammation in response to the virus, and that inflammation simultaneously causes more extreme emotional, behavioral or psychiatric symptoms, often showing up as OCD-related symptoms. Treatment usually involves a course of antibiotics to reduce the infection-related inflammation, and the OCD symptoms lessen along with it. But it isn't black and white — a child may retain some symptoms because of their own inflammatory tendencies.
— Dr. Rebecca HershbergThere are far more PANS cases than there used to be, and no one knows why
Rebecca Hershberg raises two notable points. First, doctors and scientists don't fully understand why, but there are now far more PANS/PANDAS cases than there used to be. Her pediatrician gave the example that during training he was told he might see this kind of case once or twice in a lifetime, and now he sees it far more often. Second, many children don't fully meet the diagnostic criteria for PANS/PANDAS, but as long as a virus is present, you see certain symptoms rise markedly. She uses her own son as an example, saying that whenever he has a virus, a whole set of symptoms goes up significantly.
— Dr. Rebecca HershbergMedications can also trigger PANS-like behavior
Emily Upshur adds an easily overlooked trigger: her own child once had a PANS-type behavioral reaction to an asthma medication. So besides viruses, certain medications can also "kick open" a latent tendency toward OCD or intrusive thoughts. She suggests that if a child is on an unusual medication and the child has this kind of sensitive tendency, parents should watch for that possibility. This widens the range of triggers parents should check — not just infection, but also changes in medication.
— Dr. Emily UpshurAbout half the symptoms fade after the infection is treated, but some get "stuck"
Emily Upshur gives parents a rule of thumb: once the strep is treated, the medication is stopped, and the underlying virus eases, she sees about 50% of symptoms fade quickly. But some behaviors remain, and she calls this kind of thing "sticky thinking." That's exactly why she's glad this parent is already arranging CBT — treatment is multifaceted. Some symptoms disappear immediately; others are "stickier" and need targeted effort to reduce. Rebecca Hershberg adds: even when the diagnosis is still unclear, you can still do psychosocial intervention aimed at the behavioral presentation — you just can't do medical treatment.
— Dr. Emily UpshurThe core of an intrusive thought is "this isn't like me"
Sarah Bren gives the key feature that defines an intrusive thought: it is distressing, it is not "ego syntonic." That is, the child doesn't just have the thought — they're confused about "why am I having this thought," "why can't I turn it off," "this isn't like my thoughts." Rebecca Hershberg adds that what follows is intense shame — the child says "is there something wrong with me," "am I dirty," "am I disgusting." Sarah Bren says the words children commonly use also include "I'm bad," "I'm disgusting," "I'm the only one who thinks this." This ego dystonic quality is exactly what separates intrusive thoughts from ordinary curiosity.
— Dr. Sarah BrenTell reassurance-seeking from information-seeking: if they ask again after the answer, it's the former
Sarah Bren offers an operational test: if it's an "information-gathering" question, it stops once the information is received; if it's a "reassurance-seeking" question, they'll keep asking the same thing after getting the information. She treats this as the signal that you've entered the territory of intrusive thoughts and compulsive reassurance-seeking. Emily Upshur adds that parents often miss it at first, because some questions look perfectly normal, and parents keep trying to reason it out until their "mouth is dry" and it still doesn't work. She also warns that many children are clever and will ask the same question a different way.
— Dr. Sarah BrenTurn the thought into "sticky thinking" and peel the sticker off
Rebecca Hershberg's approach is to have the child call the thought a "sticky thought" and put a sticky note on their head to represent the thought sticking around. Emily Upshur says she uses exactly the same language, and calls this the first step of intervention: tell the child "oh, that's a sticky thought, you know that isn't you." Sarah Bren stresses that this is helping the child consciously separate from the thought, observe it and name it. Rebecca goes further: separate the child from the thought — "the child is good, it's the thought that's the problem, and you and the child fight the thought together."
— Dr. Rebecca HershbergHave the child "boss back" — the point isn't the content of the thought
Rebecca Hershberg introduces "boss back" from CBT: tell the child they can be as fierce as they want toward the thought, saying "no, you can't do this, my thoughts are mine to decide." She says that later in CBT, OCD is compared to a bully, and the child bosses the bully back. The key is for the child to feel empowered and in control, rather than getting stuck on the content of the thought. She gives an example: the child says "I can't stop thinking about exposing my genitals on the school bus," and the parent doesn't need to lecture that "we don't expose our genitals on the school bus" — the child knows that, and the actual risk of it happening is extremely low. What you respond to is "there's a sticky thought you don't like — how do we boss it back and not let it run your day."
— Dr. Rebecca HershbergName the thought, give it a time limit, make it wait
Emily Upshur's approach is to give the thought a name or draw it, to "depersonalize" it, then build a "toolbox" with the child to make this annoying character go away. Her tools include "boss back," and also giving the thought a time limit — "I'm not thinking about this for the next five minutes," which she calls "kick the can," as in "I can wait and think about it at recess, not before recess." The core in every case is to give the child a renewed sense of being in charge. Sarah Bren adds that you can name the "sticky brain" together with the child, and if the child picks a scary name (like Venom), deliberately make it comical — give it a squeaky voice, make it very small, actively reduce its intimidation factor.
— Dr. Emily UpshurIn their own words · checked verbatim
This is a common one though. It is. Sorry, I didn't mean to interrupt you. It's a common one. And even if kids don't have pans, I think that's important to say the intrusive thoughts can be part of so many different things, including typical development.
Dr. Rebecca Hershberg2:11
I say I often see, like what I say to parents is I see about 50% of the symptoms sloughing off quickly. But you still have some behaviors that stick around that do.
Dr. Emily Upshur10:11
one of the hallmark qualities that defines an intrusive thought is that it is distressing. It isn't what we would call ego syntonic, meaning I have this though and this though feels comfortable and I don't notice that it's like misaligned. It's actually ego dystonic, which means this doesn't fit.
Dr. Sarah Bren14:10
if it's information gathering, when you get the information, it stops. If it's reassurance seeking, once you get the information, you will find that you continue to see them asking for the same information over and over and over again.
Dr. Sarah Bren17:14
So the first thing you're doing is separating your kid from the thought. Your kid is good and all the things. And it's the though that it's like me and you kid against the thought.
Dr. Rebecca Hershberg24:49
And so you would respond to, I can't stop thinking that I'm going to show my penis on the bus, the same way you would respond to like, I can't stop thinking that I'm going to eat 10 candy bars.
Dr. Rebecca Hershberg26:23
It's sort of like you're not going to sort of, if your child runs over to you in distress, necessarily you don't give them sort of like 10 hugs.
Dr. Rebecca Hershberg28:14
Figures
| Share of symptoms that fade quickly after the infection is treated | about 50% | 10:11 |
Glossary
- PANS/PANDAS
- Inflammation triggered by viral infection causes sudden-onset OCD, anxiety or tic symptoms; PANDAS specifically refers to cases triggered by strep.
- intrusive thoughts
- Recurring, distressing thoughts that feel inconsistent with the self; children often feel "this isn't me."
- ego dystonic
- The thought doesn't match the sense of self — the child feels "this isn't like me" — and this is the core feature of an intrusive thought.
- sticky thinking
- Emily Upshur's term for thought patterns that remain after an infection clears and need targeted intervention.
- boss back
- A CBT technique that teaches the child to respond forcefully to intrusive thoughts and take back a sense of control.
- SPACE
- An evidence-based intervention for parents of anxious children that reduces symptoms by changing how parents respond.
How to listen
Parents of children aged 3-10 who ask the same question repeatedly or have disturbing thoughts; and pediatric and mental health practitioners who want to understand PANS/PANDAS and OCD behavioral intervention.
The show intro and resource list at 0:00-2:03 can be skipped.