Obsessive-compulsive disorder in children — formative SAQs

SAQ 1 (10)

A 9-year-old boy is referred for "severe anxiety and lateness". On direct questioning he describes intrusive thoughts that his mother will die unless he reties his shoelaces until they feel "just right", which takes 40 minutes each morning. He is distressed, hides the thoughts from friends, and his parents have begun tying his laces for him to get him to school. [22]

1. Define paediatric OCD using the obsession–compulsion cycle and impairment criteria. (3) [22] [17]
2. List four differential diagnoses and one distinguishing feature for each. (4) [17] [22]
3. Outline your initial clinical assessment plan. (3) [22]

Model answer

Definition. Obsessive-compulsive disorder is an impairing cycle in which intrusive, unwanted thoughts, images or urges (obsessions) generate intense distress, and the child performs repetitive behaviours or mental acts (compulsions) to neutralise that distress. The relief is brief, so the cycle repeats for more than about one hour per day and causes clinically significant impairment across settings; it is not better explained by another disorder or a substance/medical cause. [22] [17]

Differentials. Normal childhood rituals (enjoyed, time-limited, not impairing); autism restricted/repetitive behaviours (preferred, self-regulating, dysregulation when interrupted rather than fear); tic disorders (involuntary, premonitory urge, brief); generalised anxiety disorder (real-life worries without a neutralising ritual). Comorbid depression, ADHD and trauma reactions may also coexist. [17] [22]

Assessment plan. Direct private interview with the child; map each obsession, its compulsion, time per day and triggers; multi-setting impairment (home, school, sleep, friendships); CY-BOCS baseline severity; comorbidity and red-flag screen (suicidality, bipolar, safeguarding, acute-onset neurological features); skin and growth/weight examination; synthesis with child and family. [22]

SAQ 2 (10)

A 12-year-old with confirmed moderate-to-severe OCD has partially responded to a full course of CBT with ERP. She has comorbid depression but no suicidality or bipolar history. The family is engaged. [1]

1. Outline the stepped pharmacotherapy decision and justify adding an SSRI. (3) [1] [2] [22]
2. Give an exam framework for sertraline initiation and the key safety monitoring. (3) [4] [5]
3. State the refractory-care pathway if adequate ERP plus two SSRIs fail. (2) [8] [22]
4. Explain the role of family accommodation in treatment. (2) [14]

Model answer

SSRI decision. For moderate-to-severe OCD with partial ERP response and comorbidity, combine continued CBT/ERP with an SSRI. POTS 2004 showed combination treatment was highly effective and POTS II showed CBT augmentation of an SSRI improves outcomes over SSRI alone — medication is added to ERP, not substituted for it. [1] [2] [22]

Sertraline framework and monitoring. Start low, titrate weekly toward response over 6–10 weeks to an adequate dose (confirm local product information). Monitor activation, sleep, appetite, weight, mood change and suicidal ideation early and after dose changes (youth suicidality warning); document baseline suicidality and screen for bipolar history. [4] [5]

Refractory pathway. Maximise SSRI dose and duration; trial clomipramine with ECG and cardiac monitoring; escalate to intensive or family-based ERP; refer to a specialist OCD service. [8] [22]

Family accommodation. Well-meant reassurance, ritual participation and trigger avoidance maintain the cycle and predict poorer response; reducing accommodation (without blame) is an explicit CBT/ERP target. [14]