If you missed today’s final workshop of the FCP 2017 Spring Series, you missed another great presentation. This workshop was presented by Anthony Puliafico,  Ph.D., and entitled Assessment and Treatment of Pediatric Obsessive-Compulsive Disorder.

As described,  Dr. Puliafico’s  presentation provided an overview of pediatric obsessive-compulsive disorder (OCD), including its presentation and current assessment and treatment guidelines.  His presentation Agenda included:

1. Assessing OCB in children and adolescents
2. Review of Exposure and Ritual Prevention
3. Case Studies, and,
4. Overcoming Obstacles to Treatment

Dr. Puliafico balanced discussion of content, research, and response to questions during his presentation. He started his workshop by passing around envelopes with small pieces of paper for each participant. Each paper had an assigned worry statement typical of an “obsession thought” for someone with OCD.  My assigned “obsessive worry” said that “I may burn the house down today”. Dr. Puliafico warned that the statements may be uncomfortable to think about, but most would not give the worry a second thought. On the other hand, the person with OCD can’t stop thinking about these worries and is compelled to perform an unnecessary behavior to reduce anxiety. Of course, I didn’t let my assigned “obsessive worry” bother me all day, but I did choose not to cook dinner on the grill. I told my wife it was too cold outside!

Anyway, Dr. Puliafico accomplished his objectives for this workshop with ease. These objectives included:

At the end of this activity, the learner will be able to

• Identify common symptoms of pediatric OCD
• Describe assessment methods for pediatric OCD
• Discuss current treatment guidelines for pediatric OCD, with a focus on exposure and ritual prevention

Dr. Puliafico described Obsessive-Compulsive disorder as: “An anxiety disorder involving obsessions and compulsions that are time consuming, cause marked distress and interfere with social or occupational functioning. “ He pointed out that we all have intrusive thoughts and rituals that we perform every day, but these do not usually interfere with day-to-day relationships or jobs. The person with OCD has marked distress and impairment in these areas. He also said that left untreated,  OCD symptoms can lead to even more serious physical and behavioral health problems. Dr. Puliafico stated that OCD is one of the most impactful of the psychiatric disorders. OCD generally has onset in early childhood or adolescence with 1.6 million people affected.

Obsessions always trigger anxiety, distress and compulsions always reduce anxiety in the short run, as explained Dr, Puliafico. He said that obsessions are repetitive thoughts, impulses or images that are intrusive, inappropriate and a product of one’s own mind. Compulsions are repetitive behaviors performed in response to an obsession. These are excessive behaviors aimed at reducing distress or preventing feared consequences.  Common obsessions in youth include excessive:

Contamination fears

• Fear of aggressive harm toward self or others
• Perfectionism
• Sexual thoughts or images
• Religious concerns
• Hoarding

Common Compulsions in youth include excessive:

• Checking
• Cleaning/washing
• Repeating
• Ordering/Arranging
• Collecting
• Counting

Dr. Puliafico  said that children with OCD have trouble tolerating anxiety. He also said that they may not see obsessions as excessive or unreasonable, are afraid or embarrassed to talk about them and may involve other family members in their compulsive rituals,

In discussing assessment of OCD, Dr. Puliafico mentioned that  care must be taken to differentiate this from tic disorders, and General Anxiety Disorder. A close look at the history and symptoms can usually separate these diagnoses. He also said that OCD is different than the stereotypical rituals of a child with Autism. The Autistic rituals are generally pleasurable, and sensory related as compared to the anxiety reducing compulsions in OCD. Children with Autism though, may also suffer from OCD. OCD may also be confused with psychosis. Dr. Puliafico suggests looking for other signs of psychotic behavior to rule this out.

Dr. Puliafico said that the “Gold-Standard” of assessing pediatric OCD symptoms is the Children’s Yale-Brown Compulsive scale. This symptom checklist is a 10 item severity scale that covers a range of common obsessions and compulsions. It measures impairment and distress caused by OCD symptoms and can be helpful as a measure of change during treatment.

He also pointed out that parents are typically better reporters of compulsions compared to obsessions. Children are often not forthcoming in discussing symptoms. The assessment must also consider that sometimes parents or children have learned to accommodate for symptoms over time, and no longer see them as problematic.  Dr. Puliafico also warned that specific symptoms can vary widely, so the assessor must “drill-down” to the specific concern of the child. For example, concern about touching a door knob may be either a fear of contracting germs, or a fear of spreading germs. This detail is important for treatment.

.In general, Dr. Puliafico said that the goal of treatment is to improve tolerance for anxiety, not to promise to remove all risk. Psycho-education is very important. As he said during the workshop, “Normalize, Normalize, Normalize” are three words that help treatment. To the extent that the child and parents realizes that their symptoms are not unique to them, they are more likely to become active participants in treatment.

Medication has been effective in treatment as explained by Dr. Puliafico. He said that SRI medication such as Luvox or Zoloft have shown 21 percent improvement compared to a placebo. He also said that CBT, including Exposure and Ritual prevention has shown 39 percent improvement, but the combination of medication and CBT treatment has shown almost 54 percent improvement compared to a placebo.

Exposure and Ritual prevention treatment includes exposure to a feared situation, and resisting compulsive behavior using a hierarchy of distress over time to develop increased tolerance to the anxiety and eventual elimination of symptoms. Dr. Puliafico said that there are 4 treatment steps.

1. Psychoeducation helps the child develop a vocabulary to describe the obsessions, compulsions, “Normalize” how common these symptoms are, and remove blame from the parent and child.
2. Teaching children to “Talk Back” to the OCD symptoms helps them take control over their response to the obsessions. Giving the symptoms a silly name works with younger children. This works best without a promise that all fear will go away. Tolerance of anxiety is the goal.
3. Rating the amount of anxiety experienced in a specific situation is important. The child should be helped to develop a hierarchy of anxiety-provoking symptoms. Ratings of “Subjective Units of Distress” can be developed to rate each exposure on the list.
4. Exposures can be either real life, or imaginary. Typically, the child is guided through the list from the least anxious producing to the most anxious producing exposure.

Dr. Puliafico said that parents are an important factor in the success of treatment, especially for the younger child. Parents can act as “coaches” and “cheerleaders” to help the child resist compulsions. Finally, Dr. Puliafico pointed out that success in treatment is dependent on several factors including the quality of overall psychosocial functioning  of the child, other mental health problems and family support for treatment.

Dr. Puliafico had a very easy-going presentation style. His expertise in his subject matter was evident throughout, in his relaxed response to many questions, and his discussion of workshop content. He allowed time at the end of each agenda section for questions, but also responded to a limited number of questions throughout his presentation. He was able to complete the bulk of his 72 slides without the mad rush at the end that frequently occurs in short workshops. In general, I thought, as did those around me, that this was a very satisfying 3 hours.

What did you think?