Obsessive-compulsive disorder in children — viva

Stem

Examiner-led viva on paediatric OCD. [22]

Examiner: How do you open this "lateness and anxiety" presentation? [22]

Strong answer: I greet the child first, then ask directly and privately about intrusive thoughts that keep coming back and rituals he performs to settle them — children hide obsessions, so I do not wait for him to volunteer them. I frame this as a full assessment, not a same-day label. [17] [22]

Examiner: He admits that unless his laces feel "just right" his mother will die. What defines this as OCD rather than a quirk? [22]

Strong answer: The impairing obsession–compulsion cycle: an intrusive, ego-dystonic thought (mother dies) drives a repetitive ritual (retying) that gives brief relief and restarts, consuming more than an hour a day and causing distress and impairment — unlike a normal ritual, which is enjoyed, time-limited and not impairing. [17] [22]

Examiner: Parents are now tying his laces for him. What is that, and does it help? [14]

Strong answer: That is family accommodation. It is well-intentioned but prevents extinction learning, maintains the cycle and predicts poorer response — so reducing accommodation (without blaming the parents) is an explicit treatment target within CBT/ERP, not a sustainable solution. [14]

Examiner: What is first-line treatment for moderate OCD? [1]

Strong answer: Cognitive–behavioural therapy with exposure and response prevention, roughly 12–16 sessions, is first-line and often effective without medication. The family is involved to reduce accommodation and support exposures. [1] [22]

Examiner: When and what do you add pharmacologically? [2]

Strong answer: For moderate-to-severe illness, partial ERP response, or significant comorbidity, I add an SSRI such as sertraline — start low, titrate over 6–10 weeks. POTS II showed CBT augmentation of an SSRI improves outcomes over SSRI alone, so ERP continues alongside. [2] [4]

Examiner: What suicidality counselling do you give? [5]

Strong answer: SSRIs carry a youth suicidality warning; I document baseline ideation, screen for bipolar history, and review mood and activation early and after dose changes. The absolute risk is small and outweighed by substantial OCD treatment benefit, so I do not let the warning deny effective care. [5]

Examiner: Refractory after ERP and two SSRIs? [8]

Strong answer: Maximise dose and duration, trial clomipramine with ECG and cardiac monitoring, escalate to intensive or family-based ERP, and refer to a specialist OCD service. [8]

Examiner: What if onset had been acute with choreiform movements and urinary frequency? [10]

Strong answer: That pattern suggests PANDAS/PANS. I would recognise the explosive onset, exclude streptococcal infection and neurological causes, and refer for specialist evaluation — routine antibiotics or immunomodulatory treatment are not standard general-paediatric practice. [10]