Childhood-onset OCD — structured clinical viva

This is severe paediatric OCD with inadequate prior psychological treatment (no true ERP), likely under-dosed/under-duration SSRI, high family accommodation, school crisis, and parental pressure for antipsychotic plus PANDAS medicalisation — not a first-line antipsychotic case.[3][5]

Formulation. Multi-dimensional OCD with negative reinforcement of rituals and accommodation; school impairment and peer stress; risk of shame and secondary mood symptoms. Measure with CY-BOCS serially.[4]

Psychological care. Name ERP: hierarchy, response prevention for washing/checking/mental rituals, reduce reassurance. Coach parents to withdraw accommodation gradually with support. Supportive counselling is not an adequate ERP trial.[3][5]

Medication. Three weeks at 50 mg is not an adequate OCD SSRI trial. Optimise sertraline toward therapeutic paediatric OCD ranges with black-box monitoring (activation/suicidality), or switch within SSRI class if intolerability after true adequacy — March sertraline evidence; POTS supports sertraline and combination with CBT for severity.[1][7][3]

POTS II lesson. If partial response after optimised SRI, add CBT rather than medication-only management.[2]

Antipsychotic request. Not first-line for primary OCD thoughts. Adult refractory antipsychotic augmentation evidence exists but is specialist, low-dose, monitored, after SRI and ERP adequacy — not for three-week under-treatment.[8][3]

PANDAS. Acknowledge concept (Swedo). Gradual multi-year OCD with remote sore throat is not classic abrupt PANDAS; do not delay ERP/SSRI for speculative antibiotics. Specialist input only if acute-onset criteria truly met.[6][3]

School. Liaison letter: staged bathroom plan, anti-bullying, exam accommodations, collaborative attendance plan without endless ritual enabling.[3]