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]