Struggle hours for endless demands: When a child with obsessive-compulsive disorder wears parents down?

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Masahide Usami, Yoshinori Sasaki, Mayuna Ichikawa CP, Miki Matsudo CP, and 24 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7604032/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 04 Feb, 2026 Read the published version in Scientific Reports → Version 1 posted 10 You are reading this latest preprint version Abstract Background: To evaluate time-of-day-specific functional impairments in children with obsessive–compulsive disorder (OCD) and identify related clinical and psychosocial factors. Methods: The registry data for a total of 136 children diagnosed with OCD was analyzed. Questionnaire - Children with Difficulties (QCD) was used to assess functional difficulties across daily lives and was reported by the parents. The QCD scores of the children with OCD were compared with community norms. Multiple regression analyses were used to examine the associations of the QCD domains with age, weekday sleep, anxiety, depression, behavioral problems, and siblings. Results: The mean age of patients in the OCD group was 11.46 years (SD = 2.27), with 69 boys (51.1%) and 66 girls (48.9%). The children with OCD scored significantly lower across all QCD domains (all p < .01), with large effects for night (d = − 2.04), total QCD (d = − 2.10), school (d = − 1.90), and after-school (d = − 2.03) compared to the community sample. In the regression analyses, higher behavioral problem scores predicted better functioning in the morning and evening, whereas a greater number of siblings predicted poorer morning functioning. Higher anxiety scores were significantly associated with better night-time functioning. However, depressive symptoms were not significantly associated with overall functioning. Conclusions: Children and adolescents with OCD demonstrated marked domain-specific functional impairments, particularly during school, after school, and nighttime routines. Distinct psychosocial factors, including behavioral problems, sibling presence, and anxiety symptoms, were associated with time-specific functioning, underscoring the need for targeted, time-sensitive interventions. Health sciences/Diseases Health sciences/Health care Health sciences/Medical research Biological sciences/Psychology Social science/Psychology Child Adolescent obsessive compulsive disorder Family burden Introduction Obsessive–compulsive disorder (OCD) is a serious neuropsychiatric condition that compromises children’s health and results in broad impairments across psychological and social functioning( 1 – 4 ). Pediatric OCD is not uncommon and can be considered as a routine concern in schools and clinics (lifetime prevalence is often estimated in the lower single digits). It affects both boys and girls across the elementary and junior high years, with an insidious onset and if left untreated can become chronic ( 1 – 6 ). Although diagnoses are anchored in obsessions and compulsions, they are often quantified using symptom scales (e.g., CY-BOCS). A practical understanding of time-of-day-specific functional difficulties is essential for care. Such information helps target exposure, reduces family accommodation, supports school functioning, and improves health-related quality of life (QoL) ( 1 – 3 , 7 – 10 ). Mental disorders in childhood are closely linked to poor daily functioning with a lower QoL( 7 – 12 ). In pediatric OCD, QoL is reduced relative to the peers and may result in other psychiatric conditions. The decrement relates to symptom severity, comorbidity, and family accommodation, that may persist beyond acute symptom relief ( 7 – 11 , 13 – 15 ). These findings highlight the need for multidimensional interventions that address not only obsessions/compulsions but also daily living skills, routines, and caregiver behaviors ( 1 – 3 , 7 – 11 , 13 – 15 ). School demands, homework, hygiene routines, bedtime transitions, and social/evaluative contexts can amplify rituals (e.g., checking, washing, and ordering) and reassurance seeking. Thereby increasing distress and family conflicts ( 1 – 3 , 7 , 9 , 10 , 13 , 16 ). Evidence-based care centers on cognitive-behavioral therapy with exposure and response prevention (CBT-ERP), and demonstrates large effects and high response/remission rates across individual, family-based, and group formats. Stepped-care approaches, as well as parent-led or telehealth variants, improve access without decrease in efficacy ( 16 – 23 ). Selective serotonin reuptake inhibitors (SSRIs) are also effective in pediatric OCD and are commonly combined with CBT-ERP in routine care ( 24 ). Family accommodation, is a well-documented practice in pediatric OCD, predicts worse functioning and is a primary therapeutic target ( 8 ). The Questionnaire–Children with Difficulties (QCD) has good reliability and validity. It also possesses delineated time-of-day profiles in depression, pervasive developmental disorders/autism, and ADHD, consistently showing lower total and subscale scores than community norms. Prior QCD studies have highlighted the roles of sex, psychiatric symptoms, and time of day in shaping functional difficulties. For example, ADHD frequently shows evening-skewed problems and depression shows morning/school/evening dips, whereas autism-spectrum presentations display domain-specific decrements with sex differences( 28 , 29 ). These patterns suggest that OCD may also exhibit distinct time-of-day vulnerabilities (e.g., after-school and evening routines); however, the systematic characterization of QCD in pediatric OCD among boys and girls and across elementary and junior high schools has been limited. Beyond the clinical presentation, family context is central to pediatric OCD. Siblings may be buffers or stressors—helping with routines or, conversely, being drawn into rituals or reassurance cycles—and their presence can shape the highest burden periods (typically the evening)( 8 , 15 ). Family based therapy frameworks emphasizes family as an active change agent to reduce accommodation and practice ERP in real time( 8 , 15 , 16 , 19 ). Comorbidities such as anxiety, depression, oppositional behaviors, ADHD, and tic disorders a re common and may result in functional impairment or a complicated CBT response. However, their independent contribution to day-to-day functioning after accounting for OCD itself remains debated. Pandemic-related disruptions appear to heighten service demand and family burden for various mental health conditions in children. Whether post-pandemic functioning in pediatric OCD has normalized equally across time-of-day contexts is an open question that warrants empirical investigation( 30 – 33 ). Notably, OCD in both children and adults is characterized by high levels of family accommodation in which relatives become involved in the patient’s rituals or avoidance behaviors. This phenomenon creates a unique intrafamilial dynamic and represents a substantial source of caregiver burden, highlighting OCD as one of the most demanding psychiatric conditions for families. In this study, we evaluated daily functional difficulties among boys and children with OCD in elementary and junior high school cohorts using QCD. We compared the total QCD and all time-of-day subscales with age-appropriate community norms, and examined associations with clinical (anxiety, depressive, oppositional, and ADHD symptoms) and family factors ( sibling presence ) . Given the salience of late day routines in pediatric OCD, we also inspected whether decrements clustered in the after-school and evening periods. Our study had four hypotheses. ( 1 ) Both boys and children with OCD (elementary and junior high) would score significantly lower than community controls on the QCD total and all subscales; ( 2 ) worse QCD would correlate with higher anxiety, depression, oppositional, and ADHD symptom burden; ( 3 ) sibling presence would be associated with time-of-day-specific functioning differences (e.g., evening routines), consistent with the literature on family accommodation; and ( 4 ) markers of higher clinical complexity (e.g., comorbidity or prior hospitalization when available) would align with more severe daily functional impairment. Methods Study design and setting This retrospective case-control study evaluated the daily functioning of children with OCD by administering the QCD. Participants were categorized into clinical (children with OCD) and community-based control groups, which comprised junior high school students from Ichikawa City, western Chiba Prefecture. Ichikawa is a residential and educational hub approximately 20 km from Tokyo, with a population of 501,209 as of April 2024, and ranks as the fourth largest city in the prefecture. The study was conducted as per the ethical principles outlined in the Declaration of Helsinki. The informed consent process followed the Ethical Guidelines for Clinical Epidemiology Research established by the Ministry of Health, Labour, and Welfare of Japan. Direct consent was not always required for observational studies that use anonymized clinical records without human tissue samples. However, researchers must publicly disclose the purpose and implementation of the study. This disclosure was posted in the outpatient clinic of the participating hospital. All personal identifiers (e.g., names and dates of birth) were excluded. This study was approved by the Ethics Committee of the National Center for Global Health and Medicine (NCGM-G-003042–10, NCGM-S-004487–03; Tokyo, Japan). Recruitment and participants Data were obtained from the clinical registry maintained by the Department of Child and Adolescent Psychiatry at the National Kohnodai Medical Center of the Japan Institute for Health Security. This registry has been collecting information on first-time outpatient visits since January 2016, which enables comparisons with community samples. We used registry data to examine the experiences of parents of children with OCD who visited outpatient clinics. The inclusion criteria were girls in the ninth grade or younger, first-time patients between January 2016 and March 2025, and with a OCD diagnosis given by a board-certified child plus an adolescent psychiatrist using the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) criteria. Of the 4,368 registrants, 136 elementary and junior high school students were diagnosed with OCD. Preschool cases of preschool were excluded. Finally, the data from 136 children were analyzed. Clinical data included responses from the QCD, Depression Self-Rating Scale (DSRS), and Oppositional Defiant Behavior Inventory (ODBI) as well as medical record information on suicidal ideation and school non-attendance. Patients with incomplete questionnaires or clinical data were excluded. Community control group The Ichikawa City Education Committee approved the survey for public elementary and junior high school students. Teachers distributed consent and assent forms along with four questionnaires (including the QCD) to the parents of 10,000 randomly selected children from September 20 to 30, 2008. We used the QCD scores of the children from this community sample, as reported in a previous study.( 21 ) Measures Questionnaire-Children with Difficulties The Questionnaire–Children with Difficulties (QCD) is a 20-item parent-report tool that evaluates children’s everyday routines at six points of the day: before school, during school, after school, evening, night, and overall behavior. Each item uses a four-point Likert scale (0 = strongly disagree to 3 = strongly agree), with higher scores reflecting fewer functional difficulties. Prior research has demonstrated acceptable internal consistency and construct validity in both community and clinical samples.( 25 – 28 ) Depression Self-Rating Scale The Depression Self-Rating Scale for Children (DSRS-C) contains 18 items capturing cognitive, emotional, and somatic aspects of depression. Responses are recorded on a three-point scale (‘never,’ ‘sometimes,’ ‘always’), and higher scores indicate greater severity. In Japan, a score of 16 or higher has been proposed as a screening threshold.( 34 ) Spence Children's Anxiety Scale The Spence Children’s Anxiety Scale (SCAS) is a 38-item measure of anxiety, covering domains such as separation fears, social anxiety, and obsessive–compulsive features. Items are rated from 0 (‘never’) to 3 (‘always’). The SCAS does not have a universally established cutoff score. Prior studies have proposed provisional thresholds (e.g., around 42), but these vary by population and context .( 35 ) Oppositional Defiant Behavior Inventory The Oppositional Defiant Behavior Inventory (ODBI) consists of 41 caregiver-rated items addressing oppositional, inattentive, and conduct-related behaviors. Each is scored from 0 to 3, and cumulative scores above 20 suggest heightened risk for oppositional defiant disorder.( 36 ) All the psychological questionnaires (DSRS, SCAS, and ODBI) were completed by the primary caregiver during the child’s first psychiatric consultation. Data were obtained during routine clinical assessments and a retrospectively analysis was performed. Sleep duration and history of inpatient treatment Caregivers provided information on children’s typical weekday and weekend sleep duration during the initial visit, and this was documented in the medical records. The registry was also reviewed to confirm whether each child had a history of psychiatric hospitalization. Statistical analysis Before parametric analyses, such as t-tests and Pearson’s correlations, we assessed the normality of the continuous variables using the Shapiro–Wilk test. Most variables followed a normal distribution. For variables that deviated from normality, we performed nonparametric analyses using the Mann–Whitney U test and Spearman’s rank correlation. These analyses yielded results comparable to those of the parametric tests. Therefore, this study only presents the parametric test results. All statistical analyses were conducted using R. Independent sample t-tests were used to compare between-group QCD subscale scores. Effect sizes were calculated using Cohen’s d. Pearson’s correlation coefficients were used to examine the associations between the QCD scores and clinical measures (DSRS, SCAS, and ODBI). Statistical significance was set at p < .05 for all the tests, and corrections for multiple comparisons were applied using the Bonferroni method, where appropriate. Multivariate regression analysis To examine the independent associations between clinical and psychosocial variables and daily functioning, multiple linear regression analyses were conducted with the QCD total and subscale scores as dependent variables. Covariates included age, weekday sleep duration, and history of inpatient treatment (coded 1 = yes, 0 = no). These variables were selected a priori based on their clinical relevance and previous studies. A separate regression model was performed for each QCD domain (morning, school, after-school, evening, night, and overall behavior). Standardized beta coefficients, 95% confidence intervals, and p-values are presented. All analyses were conducted using R software. Results Descriptive and clinical data for the OCD group The clinical sample comprised 136 children and adolescents (age range, 6–15 years) diagnosed with OCD according to the DSM-5 criteria by board-certified child and adolescent psychiatrists. The mean age was 11.46 years (SD = 2.27). The sample was almost evenly divided according to sex: 69 boys (51.1%) and 66 girls (48.9%). In terms of educational level, 79 participants (58.5%) were enrolled in elementary school and 56 (41.5%) in junior high school. The mean number of siblings was 0.96 (SD = 0.86), with a range from zero to three. Clinical background data revealed that 46.7% of the sample did not attend school, 11.1% had experienced domestic violence, and 11.1% reported suicidal ideation. The descriptive statistics (Table 1) characterized the study population as a clinically complex group with a notable psychosocial burden. QCD score distributions and comparison with community reference Table 2 presents the distributions of the QCD scores in the OCD and community reference groups. Across all six time-of-day domains and the total score, children with OCD showed significantly lower scores than the community sample (all p < 0.01). In the morning domain, the OCD group had a mean score of 5.95 (SD = 3.34), whereas the community group scored 8.27 (SD = 2.69), with a large effect size (d = − 0.78). For the school domain, the OCD group scored 3.84 (SD = 2.64) compared to 7.83 (SD = 1.58) in the community group (d = − 1.90). After-school functioning showed similar differences, with scores of 3.57 (SD = 2.53) in the OCD group versus 7.70 (SD = 1.58) in the community group (d = − 2.03). Evening functioning scores were also lower in the OCD group (M = 5.46, SD = 3.31) than in the community group (M = 9.87, SD = 1.70), with d = − 1.75. Nighttime functioning showed a marked difference, with OCD participants scoring 3.56 (SD = 2.76) compared to 8.08 (SD = 1.70) in the community sample (d = − 2.04). For overall behavior, mean scores were 3.16 (SD = 2.05) in the OCD group and 4.86 (SD = 1.26) in the community group (d = − 1.03). Finally, the total QCD score was substantially lower in the OCD group (M = 25.53, SD = 12.59) than in the community sample (M = 47.20, SD = 8.28), with a large effect size (d = − 2.10). Regression analyses of QCD domains Table 3 shows the results of the multiple regression analyses examining the associations between clinical and psychosocial variables and QCD subscale scores. In the morning domain, higher ODBI scores were significantly associated with better functioning (β = 0.281, 95% CI [0.10–0.46], p = .005). Conversely, a greater number of siblings was significantly associated with poorer morning functioning (β = − 0.189, 95% CI [–0.38 to − 0.00], p = .049). Other variables, including age, sleep duration, and anxiety and depression scores, were not significant. No predictors were statistically significant for school or after-school domains. In the evening domain, higher ODBI scores predicted better functioning (β = 0.281, 95% CI [0.09–0.46], p = .005). None of the other predictors were statistically significant. In the night domain, higher SCAS total scores were significantly associated with better functioning (β = 0.07, 95% CI [0.01–0.13], p = .02). None of the examined variables showed significant associations with overall behavior. Discussion Characteristics of daily functional impairments among children with OCD This study provides a comprehensive description of daily functional impairments in children and adolescents with OCD. Difficulties were observed across all time-of-day domains assessed by the QCD, with particularly marked impairments during school hours, after school, and at night. These patterns suggest that the disorder exerts its most profound impact during periods that require sustained attention, compliance with structured activities, and transitions between contexts, situations that are often disrupted by intrusive thoughts and compulsive behaviors. The functional profile identified here is consistent with previous research, indicating that pediatric OCD is associated with a broad reduction in quality of life, often exceeding that observed in other child psychiatric conditions. Our findings extend the literature by delineating time-specific vulnerabilities and emphasizing that impairment is not uniform throughout the day. School time difficulties may reflect the combined demands of academic performance, social interactions, and adherence to institutional rules, all of which can be compromised by OCD-related rituals and avoidance behaviors. After-school challenges may arise as accumulated fatigue interacts with symptom exacerbation in less-structured settings. Night-time impairments likely stem from bedtime rituals, prolonged checking, or heightened anxiety before sleep, which can disrupt rest and contribute to daytime fatigue and functional decline. These temporal patterns also align with clinical observations that symptom expression in OCD varies according to daily routines, environmental demands, and family interactions. By mapping these patterns, the present study highlighted the value of time-of-day-specific assessment tools such as QCD in guiding targeted interventions. Impact of physical and psychosocial factors on daily functioning Multivariate analyses revealed that factors associated with functional impairment varied by time domain, emphasizing the importance of a nuanced, context-sensitive approach to treatment planning. Behavioral problems, as measured using the ODBI, were linked to better functioning in the morning and evening. Counterintuitively, this may indicate that children with more overt externalizing behaviors receive greater parental supervision and prompts during these periods, which in turn supports their daily routines. However, increased involvement may also perpetuate dependency, highlighting the need for interventions that balance guidance with the promotion of autonomy. A higher number of siblings was associated with poorer morning functioning, possibly reflecting the competition for parental attention and household resources during busy preschool periods. This finding highlights the need to consider family structure when designing morning routine interventions, particularly in households with multiple children preparing for school simultaneously. Anxiety symptoms were associated with better nighttime functioning. This relationship may reflect greater parental involvement and vigilance at bedtime for children who are perceived as more anxious, which could help enforce bedtime routines. Nonetheless, excessive accommodation of anxiety can maintain or exacerbate OCD symptoms over time, suggesting the need for careful monitoring of family involvement during night-time routines. Depressive symptoms were not significantly associated with overall functioning in the present analyses. While depression is clinically known to impair motivation, energy, and concentration, our findings suggest that its independent contribution to daily functioning is not evident after accounting for other variables. Future studies with larger sample sizes may clarify whether depression exerts a broader impact on functioning in pediatric patients with OCD. Taken together, these findings suggest that functional impairments in pediatric OCD are result from a complex interplay of clinical symptoms and psychosocial context. Effective intervention requires tailoring strategies to specific times of the day in order to address not only OCD symptoms but also co-occurring emotional and behavioral problems, family structure, and parental involvement patterns. Limitations All participants were recruited from a single clinical center, which may have limited the external validity of our findings across different geographic regions and healthcare settings. Furthermore, we excluded cases with incomplete clinical records or missing questionnaire data, which could have introduced selection bias. These patients may have systematically differed in illness severity or sociodemographic characteristics. Additionally, the retrospective nature of data collection prevented a standardized assessment of potential confounders such as dietary habits, sleep patterns, and physical activity levels. Therefore, future studies should adopt prospective multicenter designs with predefined inclusion criteria and rigorous data-management protocols to minimize missing information. In addition, while our findings suggest a protective effect of sibling presence, we were unable to assess more nuanced aspects of sibling dynamics, such as birth order or sex composition, owing to inconsistent documentation in the clinical records. These variables may have significantly influenced family interactions and functional outcomes. Future studies should collect detailed family demographic information to enable stratified analyses and tailored, family based interventions. Furthermore, studies should integrate direct observational methods or digital activity monitoring with parent-reported QCD assessments to reduce reporting bias and provide a more comprehensive evaluation of daily functioning. From a statistical perspective, the sample size, although adequate for primary analyses, may have been underpowered to detect smaller effect sizes, particularly in the multivariate regression models for individual QCD domains. This limitation increases the risk of type II errors, and the reported nonsignificant associations should be interpreted with caution. Moreover, we did not perform cross-or external validation of the regression models limiting thegeneralizability of the identified associations. While we did not assess QOL and self-esteem directly, the observed impairments in daily functioning may reflect underlying deficits in these domains. Future research should incorporate validated measures of QOL to further elucidate their contribution to caregiver burden in patients with OCD. Clinical implications This study highlights the importance of recognizing time-of-dayspecific functional vulnerabilities in children with OCD. The QCD proved useful in identifying these periods, which can inform more targeted intervention strategies. Morning : Establish structured wake-up routines with consistent parental support to reduce inertia and conflict during school preparation. Families with multiple children may require additional strategies to manage their competing demands. After school , Introduce brief rest periods and low-demand activities to mitigate fatigue and prevent symptom escalation. Evening : Promotes predictable family-based routines. Provide psychoeducation to siblings to reduce unhelpful involvement in rituals and enhance supportive interactions. Night : While higher anxiety may prompt greater parental supervision, care should be taken to counteract maladaptive bedtime rituals. Integrating QCD assessments into routine care can help clinicians identify vulnerable time periods and develop individualized, time-sensitive intervention plans that address both core OCD symptoms and relevant family or psychosocial factors. Conclusion Children and adolescents with OCD demonstrate marked domain-specific functional impairments, with the greatest difficulties during school, after-school, and nighttime routines. Behavioral problems were associated with better functioning in the morning and evening, possibly reflecting increased parental engagement. Family structure, particularly the presence of siblings, influenced morning routine. Depressive symptoms were not significantly associated with overall functioning in the present analyses. These findings underscore the need for time-of-day-aligned intervention strategies to address both OCD symptoms and broader psychosocial contexts. Future longitudinal research should further refine these temporal profiles and evaluate targeted treatment protocols to improve daily functioning and the overall quality of life in this population. Declarations Acknowledgments None Data Availability The datasets generated and analyzed during the current study are not publicly available due to ethical restrictions, but they are available from the corresponding author upon reasonable request. Disclosure Statement None Author Contributions UM designed the study and drafted the manuscript. YS, MI, MM, MO, YH, YK, HM, YN, MM, YS, MO, KI, KY, MT, YY, SI, MI, KI, YH, and YM collected clinical data. MI, KM and NT managed the registry and discussed the results. Funding statement This study was supported by grants from the Japan Institute for Health Security (24A1014 and 24 ri 005) and a Health Labour Sciences Research Grant (23GC0013). The funder had no role in the conceptualization, design, data collection, analysis, decision to publish, or preparation of the manuscript. Patient consent statement None References Krebs G, Heyman I. Obsessive-compulsive disorder in children and adolescents. Vol. 100, Archives of Disease in Childhood. BMJ Publishing Group; 2015. p. 495–9. Stiede JT, Spencer SD, Onyeka O, Mangen KH, Church MJ, Goodman WK, et al. Obsessive–Compulsive Disorder in Children and Adolescents. Annu Rev Clin Psychol. 2023;20(1):355–80. Sukhodolsky DG, others. Functional impairment and family factors in pediatric obsessive–compulsive disorder. J Am Acad Child Adolesc Psychiatry. 2005; Weidle B, Jozefiak T, Ivarsson T, Thomsen PH. Quality of life in children with OCD with and without comorbidity. Health Qual Life Outcomes. 2014;12(1). 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Supplementary Files Table1.xlsx Table2.xlsx Table3.xlsx Cite Share Download PDF Status: Published Journal Publication published 04 Feb, 2026 Read the published version in Scientific Reports → Version 1 posted Editorial decision: Revision requested 13 Nov, 2025 Reviews received at journal 11 Nov, 2025 Reviewers agreed at journal 06 Nov, 2025 Reviews received at journal 22 Oct, 2025 Reviewers agreed at journal 03 Oct, 2025 Reviewers invited by journal 30 Sep, 2025 Editor assigned by journal 23 Sep, 2025 Editor invited by journal 23 Sep, 2025 Submission checks completed at journal 19 Sep, 2025 First submitted to journal 19 Sep, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-7604032","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Article","associatedPublications":[],"authors":[{"id":525442225,"identity":"a2faa483-0842-4149-9aee-1cda925f47bc","order_by":0,"name":"Masahide Usami","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAzUlEQVRIiWNgGAWjYLCCBAYGOcZmHgiHsYFILcYkagGCxAYGHiKVGpw//HTDA4Zt6c3tvIc/MPyyYWCeTcAagxtpZjcSGG7nNjbzpUkw9qUxMM45QEgLA0wLjxkDY89hBsYZCYQcdvwbSEs60PvGH4jTciAHbEsCUIuBBMMPIrRI3sgpu5FgcNsQ5DCJxIY0HoJ+4Tt/fNvNHxW35Q37zxh/+PDHRs6QUIhBncfAYAhSmNjGwGM4gxgdICAPJv8AGRLEahkFo2AUjIKRAgDvV0bL/717dAAAAABJRU5ErkJggg==","orcid":"","institution":"National Kohnodai Medical Center, Japan Institute for Health Security","correspondingAuthor":true,"prefix":"","firstName":"Masahide","middleName":"","lastName":"Usami","suffix":""},{"id":525442226,"identity":"777caf6f-0da4-4f68-86b9-b7c46c0a9025","order_by":1,"name":"Yoshinori Sasaki","email":"","orcid":"","institution":"Tokyo Medical and Dental University","correspondingAuthor":false,"prefix":"","firstName":"Yoshinori","middleName":"","lastName":"Sasaki","suffix":""},{"id":525442227,"identity":"f97efe95-52f4-4550-b558-9dbe5d6b04c9","order_by":2,"name":"Mayuna Ichikawa CP","email":"","orcid":"","institution":"National Kohnodai Medical Center, Japan Institute for Health Security","correspondingAuthor":false,"prefix":"","firstName":"Mayuna","middleName":"Ichikawa","lastName":"CP","suffix":""},{"id":525442228,"identity":"08f56f75-93ed-408e-b6e5-8359f188a28c","order_by":3,"name":"Miki Matsudo CP","email":"","orcid":"","institution":"Tokyo Medical and Dental University","correspondingAuthor":false,"prefix":"","firstName":"Miki","middleName":"Matsudo","lastName":"CP","suffix":""},{"id":525442229,"identity":"d201745c-ebf0-4185-8bc3-8aaa5ec1c906","order_by":4,"name":"Ayaka Hashimoto CP","email":"","orcid":"","institution":"Tokyo Medical and Dental 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Medicine","correspondingAuthor":false,"prefix":"","firstName":"Saori","middleName":"","lastName":"Inoue","suffix":""},{"id":525442245,"identity":"17ebb743-bc97-4cf4-8557-072202b0f3cc","order_by":20,"name":"Masahiro Ishida","email":"","orcid":"","institution":"Fukuoka University Fukuoka","correspondingAuthor":false,"prefix":"","firstName":"Masahiro","middleName":"","lastName":"Ishida","suffix":""},{"id":525442246,"identity":"5490d684-ce10-44dc-a023-97a5aa40cf69","order_by":21,"name":"Masaya Ito","email":"","orcid":"","institution":"National Center of Neurology and Psychiatry","correspondingAuthor":false,"prefix":"","firstName":"Masaya","middleName":"","lastName":"Ito","suffix":""},{"id":525442247,"identity":"b064f11d-69d2-4962-842b-f703351c66e2","order_by":22,"name":"Katsunaka Mikami","email":"","orcid":"","institution":"Tokai University School of Medicine","correspondingAuthor":false,"prefix":"","firstName":"Katsunaka","middleName":"","lastName":"Mikami","suffix":""},{"id":525442248,"identity":"bed5f2c8-f61a-4489-8792-f6db1f7991d7","order_by":23,"name":"Noa Tsujii","email":"","orcid":"","institution":"Toyama University Hospital","correspondingAuthor":false,"prefix":"","firstName":"Noa","middleName":"","lastName":"Tsujii","suffix":""},{"id":525442249,"identity":"a1f27123-03a2-4d6f-9a4c-874669fedeee","order_by":24,"name":"Hiroaki Kihara","email":"","orcid":"","institution":"Kanazawa Medical University","correspondingAuthor":false,"prefix":"","firstName":"Hiroaki","middleName":"","lastName":"Kihara","suffix":""},{"id":525442250,"identity":"b71d8af6-446b-4ca0-89c5-2f840d2a6647","order_by":25,"name":"Kumi Inazaki","email":"","orcid":"","institution":"National Kohnodai Medical Center, Japan Institute for Health 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22:29:18","extension":"xlsx","order_by":2,"title":"","display":"","copyAsset":false,"role":"supplement","size":14787,"visible":true,"origin":"","legend":"","description":"","filename":"Table3.xlsx","url":"https://assets-eu.researchsquare.com/files/rs-7604032/v1/c64c0ce99d0c9e99f695bbf5.xlsx"}],"financialInterests":"No competing interests reported.","formattedTitle":"\u003cp\u003eStruggle hours for endless demands: When a child with obsessive-compulsive disorder wears parents down?\u003c/p\u003e","fulltext":[{"header":"Introduction","content":"\u003cp\u003eObsessive\u0026ndash;compulsive disorder (OCD) is a serious neuropsychiatric condition that compromises children\u0026rsquo;s health and results in broad impairments across psychological and social functioning(\u003cspan additionalcitationids=\"CR2 CR3\" citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e). Pediatric OCD is not uncommon and can be considered as a routine concern in schools and clinics (lifetime prevalence is often estimated in the lower single digits). It affects both boys and girls across the elementary and junior high years, with an insidious onset and if left untreated can become chronic (\u003cspan additionalcitationids=\"CR2 CR3 CR4 CR5\" citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e). Although diagnoses are anchored in obsessions and compulsions, they are often quantified using symptom scales (e.g., CY-BOCS). A practical understanding of time-of-day-specific functional difficulties is essential for care. Such information helps target exposure, reduces family accommodation, supports school functioning, and improves health-related quality of life (QoL) (\u003cspan additionalcitationids=\"CR2\" citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan additionalcitationids=\"CR8 CR9\" citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eMental disorders in childhood are closely linked to poor daily functioning with a lower QoL(\u003cspan additionalcitationids=\"CR8 CR9 CR10 CR11\" citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e). In pediatric OCD, QoL is reduced relative to the peers and may result in other psychiatric conditions. The decrement relates to symptom severity, comorbidity, and family accommodation, that may persist beyond acute symptom relief (\u003cspan additionalcitationids=\"CR8 CR9 CR10\" citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan additionalcitationids=\"CR14\" citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e). These findings highlight the need for multidimensional interventions that address not only obsessions/compulsions but also daily living skills, routines, and caregiver behaviors (\u003cspan additionalcitationids=\"CR2\" citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan additionalcitationids=\"CR8 CR9 CR10\" citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan additionalcitationids=\"CR14\" citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eSchool demands, homework, hygiene routines, bedtime transitions, and social/evaluative contexts can amplify rituals (e.g., checking, washing, and ordering) and reassurance seeking. Thereby increasing distress and family conflicts (\u003cspan additionalcitationids=\"CR2\" citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e). Evidence-based care centers on cognitive-behavioral therapy with exposure and response prevention (CBT-ERP), and demonstrates large effects and high response/remission rates across individual, family-based, and group formats. Stepped-care approaches, as well as parent-led or telehealth variants, improve access without decrease in efficacy (\u003cspan additionalcitationids=\"CR17 CR18 CR19 CR20 CR21 CR22\" citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e). Selective serotonin reuptake inhibitors (SSRIs) are also effective in pediatric OCD and are commonly combined with CBT-ERP in routine care (\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e). Family accommodation, is a well-documented practice in pediatric OCD, predicts worse functioning and is a primary therapeutic target (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eThe Questionnaire\u0026ndash;Children with Difficulties (QCD) has good reliability and validity. It also possesses delineated time-of-day profiles in depression, pervasive developmental disorders/autism, and ADHD, consistently showing lower total and subscale scores than community norms. Prior QCD studies have highlighted the roles of sex, psychiatric symptoms, and time of day in shaping functional difficulties. For example, ADHD frequently shows evening-skewed problems and depression shows morning/school/evening dips, whereas autism-spectrum presentations display domain-specific decrements with sex differences(\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e, \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e). These patterns suggest that OCD may also exhibit distinct time-of-day vulnerabilities (e.g., after-school and evening routines); however, the systematic characterization of QCD in pediatric OCD among boys and girls and across elementary and junior high schools has been limited.\u003c/p\u003e\u003cp\u003eBeyond the clinical presentation, family context is central to pediatric OCD. Siblings may be buffers or stressors\u0026mdash;helping with routines or, conversely, being drawn into rituals or reassurance cycles\u0026mdash;and their presence can shape the highest burden periods (typically the evening)(\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e). Family based therapy frameworks emphasizes family as an active change agent to reduce accommodation and practice ERP in real time(\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e). Comorbidities such as anxiety, depression, oppositional behaviors, ADHD, and tic disorders \u003cb\u003ea\u003c/b\u003ere common and may result in functional impairment or a complicated CBT response. However, their independent contribution to day-to-day functioning after accounting for OCD itself remains debated. Pandemic-related disruptions appear to heighten service demand and family burden for various mental health conditions in children. Whether post-pandemic functioning in pediatric OCD has normalized equally across time-of-day contexts is an open question that warrants empirical investigation(\u003cspan additionalcitationids=\"CR31 CR32\" citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e). Notably, OCD in both children and adults is characterized by high levels of family accommodation in which relatives become involved in the patient\u0026rsquo;s rituals or avoidance behaviors. This phenomenon creates a unique intrafamilial dynamic and represents a substantial source of caregiver burden, highlighting OCD as one of the most demanding psychiatric conditions for families.\u003c/p\u003e\u003cp\u003eIn this study, we evaluated daily functional difficulties among boys and children with OCD in elementary and junior high school cohorts using QCD. We compared the total QCD and all time-of-day subscales with age-appropriate community norms, and examined associations with clinical (anxiety, depressive, oppositional, and ADHD symptoms) and family factors \u003cb\u003e(\u003c/b\u003esibling presence\u003cb\u003e)\u003c/b\u003e. Given the salience of late day routines in pediatric OCD, we also inspected whether decrements clustered in the after-school and evening periods.\u003c/p\u003e\u003cp\u003eOur study had four hypotheses. (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e) Both boys and children with OCD (elementary and junior high) would score significantly lower than community controls on the QCD total and all subscales; (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e) worse QCD would correlate with higher anxiety, depression, oppositional, and ADHD symptom burden; (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e) sibling presence would be associated with time-of-day-specific functioning differences (e.g., evening routines), consistent with the literature on family accommodation; and (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e) markers of higher clinical complexity (e.g., comorbidity or prior hospitalization when available) would align with more severe daily functional impairment.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003eStudy design and setting\u003c/p\u003e\u003cp\u003eThis retrospective case-control study evaluated the daily functioning of children with OCD by administering the QCD. Participants were categorized into clinical (children with OCD) and community-based control groups, which comprised junior high school students from Ichikawa City, western Chiba Prefecture. Ichikawa is a residential and educational hub approximately 20 km from Tokyo, with a population of 501,209 as of April 2024, and ranks as the fourth largest city in the prefecture.\u003c/p\u003e\u003cp\u003e The study was conducted as per the ethical principles outlined in the Declaration of Helsinki. The informed consent process followed the Ethical Guidelines for Clinical Epidemiology Research established by the Ministry of Health, Labour, and Welfare of Japan. Direct consent was not always required for observational studies that use anonymized clinical records without human tissue samples. However, researchers must publicly disclose the purpose and implementation of the study. This disclosure was posted in the outpatient clinic of the participating hospital. All personal identifiers (e.g., names and dates of birth) were excluded.\u003c/p\u003e\u003cp\u003e This study was approved by the Ethics Committee of the National Center for Global Health and Medicine (NCGM-G-003042\u0026ndash;10, NCGM-S-004487\u0026ndash;03; Tokyo, Japan).\u003c/p\u003e\u003cp\u003eRecruitment and participants\u003c/p\u003e\u003cp\u003eData were obtained from the clinical registry maintained by the Department of Child and Adolescent Psychiatry at the National Kohnodai Medical Center of the Japan Institute for Health Security. This registry has been collecting information on first-time outpatient visits since January 2016, which enables comparisons with community samples.\u003c/p\u003e\u003cp\u003eWe used registry data to examine the experiences of parents of children with OCD who visited outpatient clinics. The inclusion criteria were girls in the ninth grade or younger, first-time patients between January 2016 and March 2025, and with a OCD diagnosis given by a board-certified child plus an adolescent psychiatrist using the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) criteria.\u003c/p\u003e\u003cp\u003eOf the 4,368 registrants, 136 elementary and junior high school students were diagnosed with OCD. Preschool cases of preschool were excluded. Finally, the data from 136 children were analyzed. Clinical data included responses from the QCD, Depression Self-Rating Scale (DSRS), and Oppositional Defiant Behavior Inventory (ODBI) as well as medical record information on suicidal ideation and school non-attendance. Patients with incomplete questionnaires or clinical data were excluded.\u003c/p\u003e\u003cp\u003eCommunity control group\u003c/p\u003e\u003cp\u003eThe Ichikawa City Education Committee approved the survey for public elementary and junior high school students. Teachers distributed consent and assent forms along with four questionnaires (including the QCD) to the parents of 10,000 randomly selected children from September 20 to 30, 2008. We used the QCD scores of the children from this community sample, as reported in a previous study.(\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e)\u003c/p\u003e\u003cp\u003eMeasures\u003c/p\u003e\u003cp\u003eQuestionnaire-Children with Difficulties\u003c/p\u003e\u003cp\u003eThe Questionnaire\u0026ndash;Children with Difficulties (QCD) is a 20-item parent-report tool that evaluates children\u0026rsquo;s everyday routines at six points of the day: before school, during school, after school, evening, night, and overall behavior. Each item uses a four-point Likert scale (0\u0026thinsp;=\u0026thinsp;strongly disagree to 3\u0026thinsp;=\u0026thinsp;strongly agree), with higher scores reflecting fewer functional difficulties. Prior research has demonstrated acceptable internal consistency and construct validity in both community and clinical samples.(\u003cspan additionalcitationids=\"CR26 CR27\" citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e)\u003c/p\u003e\u003cp\u003eDepression Self-Rating Scale\u003c/p\u003e\u003cp\u003eThe Depression Self-Rating Scale for Children (DSRS-C) contains 18 items capturing cognitive, emotional, and somatic aspects of depression. Responses are recorded on a three-point scale (\u0026lsquo;never,\u0026rsquo; \u0026lsquo;sometimes,\u0026rsquo; \u0026lsquo;always\u0026rsquo;), and higher scores indicate greater severity. In Japan, a score of 16 or higher has been proposed as a screening threshold.(\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e)\u003c/p\u003e\u003cp\u003eSpence Children's Anxiety Scale\u003c/p\u003e\u003cp\u003eThe Spence Children\u0026rsquo;s Anxiety Scale (SCAS) is a 38-item measure of anxiety, covering domains such as separation fears, social anxiety, and obsessive\u0026ndash;compulsive features. Items are rated from 0 (\u0026lsquo;never\u0026rsquo;) to 3 (\u0026lsquo;always\u0026rsquo;). \u003cem\u003eThe SCAS does not have a universally established cutoff score. Prior studies have proposed provisional thresholds (e.g., around 42), but these vary by population and context\u003c/em\u003e.(\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e)\u003c/p\u003e\u003cp\u003eOppositional Defiant Behavior Inventory\u003c/p\u003e\u003cp\u003eThe Oppositional Defiant Behavior Inventory (ODBI) consists of 41 caregiver-rated items addressing oppositional, inattentive, and conduct-related behaviors. Each is scored from 0 to 3, and cumulative scores above 20 suggest heightened risk for oppositional defiant disorder.(\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e)\u003c/p\u003e\u003cp\u003e All the psychological questionnaires (DSRS, SCAS, and ODBI) were completed by the primary caregiver during the child\u0026rsquo;s first psychiatric consultation. Data were obtained during routine clinical assessments and a retrospectively analysis was performed.\u003c/p\u003e\u003cp\u003eSleep duration and history of inpatient treatment\u003c/p\u003e\u003cp\u003eCaregivers provided information on children\u0026rsquo;s typical weekday and weekend sleep duration during the initial visit, and this was documented in the medical records. The registry was also reviewed to confirm whether each child had a history of psychiatric hospitalization.\u003c/p\u003e\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003ch2\u003eStatistical analysis\u003c/h2\u003e\u003cp\u003eBefore parametric analyses, such as t-tests and Pearson\u0026rsquo;s correlations, we assessed the normality of the continuous variables using the Shapiro\u0026ndash;Wilk test. Most variables followed a normal distribution. For variables that deviated from normality, we performed nonparametric analyses using the Mann\u0026ndash;Whitney U test and Spearman\u0026rsquo;s rank correlation. These analyses yielded results comparable to those of the parametric tests. Therefore, this study only presents the parametric test results.\u003c/p\u003e\u003cp\u003eAll statistical analyses were conducted using R. Independent sample t-tests were used to compare between-group QCD subscale scores. Effect sizes were calculated using Cohen\u0026rsquo;s d. Pearson\u0026rsquo;s correlation coefficients were used to examine the associations between the QCD scores and clinical measures (DSRS, SCAS, and ODBI). Statistical significance was set at p\u0026thinsp;\u0026lt;\u0026thinsp;.05 for all the tests, and corrections for multiple comparisons were applied using the Bonferroni method, where appropriate.\u003c/p\u003e\u003cp\u003eMultivariate regression analysis\u003c/p\u003e\u003cp\u003eTo examine the independent associations between clinical and psychosocial variables and daily functioning, multiple linear regression analyses were conducted with the QCD total and subscale scores as dependent variables. Covariates included age, weekday sleep duration, and history of inpatient treatment (coded 1\u0026thinsp;=\u0026thinsp;yes, 0\u0026thinsp;=\u0026thinsp;no).\u003c/p\u003e\u003cp\u003eThese variables were selected a priori based on their clinical relevance and previous studies. A separate regression model was performed for each QCD domain (morning, school, after-school, evening, night, and overall behavior). Standardized beta coefficients, 95% confidence intervals, and p-values are presented. All analyses were conducted using R software.\u003c/p\u003e\u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eDescriptive and clinical data for the OCD group\u003c/p\u003e\u003cp\u003eThe clinical sample comprised 136 children and adolescents (age range, 6\u0026ndash;15 years) diagnosed with OCD according to the DSM-5 criteria by board-certified child and adolescent psychiatrists. The mean age was 11.46 years (SD\u0026thinsp;=\u0026thinsp;2.27). The sample was almost evenly divided according to sex: 69 boys (51.1%) and 66 girls (48.9%). In terms of educational level, 79 participants (58.5%) were enrolled in elementary school and 56 (41.5%) in junior high school. The mean number of siblings was 0.96 (SD\u0026thinsp;=\u0026thinsp;0.86), with a range from zero to three.\u003c/p\u003e\u003cp\u003eClinical background data revealed that 46.7% of the sample did not attend school, 11.1% had experienced domestic violence, and 11.1% reported suicidal ideation. The descriptive statistics (Table\u0026nbsp;1) characterized the study population as a clinically complex group with a notable psychosocial burden.\u003c/p\u003e\u003cp\u003eQCD score distributions and comparison with community reference\u003c/p\u003e\u003cp\u003eTable\u0026nbsp;2 presents the distributions of the QCD scores in the OCD and community reference groups. Across all six time-of-day domains and the total score, children with OCD showed significantly lower scores than the community sample (all p\u0026thinsp;\u0026lt;\u0026thinsp;0.01).\u003c/p\u003e\u003cp\u003eIn the morning domain, the OCD group had a mean score of 5.95 (SD\u0026thinsp;=\u0026thinsp;3.34), whereas the community group scored 8.27 (SD\u0026thinsp;=\u0026thinsp;2.69), with a large effect size (d = \u0026minus;\u0026thinsp;0.78). For the school domain, the OCD group scored 3.84 (SD\u0026thinsp;=\u0026thinsp;2.64) compared to 7.83 (SD\u0026thinsp;=\u0026thinsp;1.58) in the community group (d = \u0026minus;\u0026thinsp;1.90). After-school functioning showed similar differences, with scores of 3.57 (SD\u0026thinsp;=\u0026thinsp;2.53) in the OCD group versus 7.70 (SD\u0026thinsp;=\u0026thinsp;1.58) in the community group (d = \u0026minus;\u0026thinsp;2.03). Evening functioning scores were also lower in the OCD group (M\u0026thinsp;=\u0026thinsp;5.46, SD\u0026thinsp;=\u0026thinsp;3.31) than in the community group (M\u0026thinsp;=\u0026thinsp;9.87, SD\u0026thinsp;=\u0026thinsp;1.70), with d = \u0026minus;\u0026thinsp;1.75. Nighttime functioning showed a marked difference, with OCD participants scoring 3.56 (SD\u0026thinsp;=\u0026thinsp;2.76) compared to 8.08 (SD\u0026thinsp;=\u0026thinsp;1.70) in the community sample (d = \u0026minus;\u0026thinsp;2.04). For overall behavior, mean scores were 3.16 (SD\u0026thinsp;=\u0026thinsp;2.05) in the OCD group and 4.86 (SD\u0026thinsp;=\u0026thinsp;1.26) in the community group (d = \u0026minus;\u0026thinsp;1.03). Finally, the total QCD score was substantially lower in the OCD group (M\u0026thinsp;=\u0026thinsp;25.53, SD\u0026thinsp;=\u0026thinsp;12.59) than in the community sample (M\u0026thinsp;=\u0026thinsp;47.20, SD\u0026thinsp;=\u0026thinsp;8.28), with a large effect size (d = \u0026minus;\u0026thinsp;2.10).\u003c/p\u003e\u003cp\u003eRegression analyses of QCD domains\u003c/p\u003e\u003cp\u003eTable\u0026nbsp;3 shows the results of the multiple regression analyses examining the associations between clinical and psychosocial variables and QCD subscale scores.\u003c/p\u003e\u003cp\u003eIn the morning domain, higher ODBI scores were significantly associated with better functioning (β\u0026thinsp;=\u0026thinsp;0.281, 95% CI [0.10\u0026ndash;0.46], p\u0026thinsp;=\u0026thinsp;.005). Conversely, a greater number of siblings was significantly associated with poorer morning functioning (β = \u0026minus;\u0026thinsp;0.189, 95% CI [\u0026ndash;0.38 to \u0026minus;\u0026thinsp;0.00], p\u0026thinsp;=\u0026thinsp;.049). Other variables, including age, sleep duration, and anxiety and depression scores, were not significant. No predictors were statistically significant for school or after-school domains. In the evening domain, higher ODBI scores predicted better functioning (β\u0026thinsp;=\u0026thinsp;0.281, 95% CI [0.09\u0026ndash;0.46], p\u0026thinsp;=\u0026thinsp;.005). None of the other predictors were statistically significant. In the night domain, higher SCAS total scores were significantly associated with better functioning (β\u0026thinsp;=\u0026thinsp;0.07, 95% CI [0.01\u0026ndash;0.13], p\u0026thinsp;=\u0026thinsp;.02). None of the examined variables showed significant associations with overall behavior.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eCharacteristics of daily functional impairments among children with OCD\u003c/p\u003e\u003cp\u003eThis study provides a comprehensive description of daily functional impairments in children and adolescents with OCD. Difficulties were observed across all time-of-day domains assessed by the QCD, with particularly marked impairments during school hours, after school, and at night. These patterns suggest that the disorder exerts its most profound impact during periods that require sustained attention, compliance with structured activities, and transitions between contexts, situations that are often disrupted by intrusive thoughts and compulsive behaviors.\u003c/p\u003e\u003cp\u003eThe functional profile identified here is consistent with previous research, indicating that pediatric OCD is associated with a broad reduction in quality of life, often exceeding that observed in other child psychiatric conditions. Our findings extend the literature by delineating time-specific vulnerabilities and emphasizing that impairment is not uniform throughout the day. School time difficulties may reflect the combined demands of academic performance, social interactions, and adherence to institutional rules, all of which can be compromised by OCD-related rituals and avoidance behaviors. After-school challenges may arise as accumulated fatigue interacts with symptom exacerbation in less-structured settings. Night-time impairments likely stem from bedtime rituals, prolonged checking, or heightened anxiety before sleep, which can disrupt rest and contribute to daytime fatigue and functional decline.\u003c/p\u003e\u003cp\u003eThese temporal patterns also align with clinical observations that symptom expression in OCD varies according to daily routines, environmental demands, and family interactions. By mapping these patterns, the present study highlighted the value of time-of-day-specific assessment tools such as QCD in guiding targeted interventions.\u003c/p\u003e\u003cp\u003eImpact of physical and psychosocial factors on daily functioning\u003c/p\u003e\u003cp\u003eMultivariate analyses revealed that factors associated with functional impairment varied by time domain, emphasizing the importance of a nuanced, context-sensitive approach to treatment planning.\u003c/p\u003e\u003cp\u003eBehavioral problems, as measured using the ODBI, were linked to better functioning in the morning and evening. Counterintuitively, this may indicate that children with more overt externalizing behaviors receive greater parental supervision and prompts during these periods, which in turn supports their daily routines. However, increased involvement may also perpetuate dependency, highlighting the need for interventions that balance guidance with the promotion of autonomy.\u003c/p\u003e\u003cp\u003eA higher number of siblings was associated with poorer morning functioning, possibly reflecting the competition for parental attention and household resources during busy preschool periods. This finding highlights the need to consider family structure when designing morning routine interventions, particularly in households with multiple children preparing for school simultaneously.\u003c/p\u003e\u003cp\u003eAnxiety symptoms were associated with better nighttime functioning. This relationship may reflect greater parental involvement and vigilance at bedtime for children who are perceived as more anxious, which could help enforce bedtime routines. Nonetheless, excessive accommodation of anxiety can maintain or exacerbate OCD symptoms over time, suggesting the need for careful monitoring of family involvement during night-time routines.\u003c/p\u003e\u003cp\u003eDepressive symptoms were not significantly associated with overall functioning in the present analyses. While depression is clinically known to impair motivation, energy, and concentration, our findings suggest that its independent contribution to daily functioning is not evident after accounting for other variables. Future studies with larger sample sizes may clarify whether depression exerts a broader impact on functioning in pediatric patients with OCD.\u003c/p\u003e\u003cp\u003eTaken together, these findings suggest that functional impairments in pediatric OCD are result from a complex interplay of clinical symptoms and psychosocial context. Effective intervention requires tailoring strategies to specific times of the day in order to address not only OCD symptoms but also co-occurring emotional and behavioral problems, family structure, and parental involvement patterns.\u003c/p\u003e\u003cp\u003eLimitations\u003c/p\u003e\u003cp\u003eAll participants were recruited from a single clinical center, which may have limited the external validity of our findings across different geographic regions and healthcare settings. Furthermore, we excluded cases with incomplete clinical records or missing questionnaire data, which could have introduced selection bias. These patients may have systematically differed in illness severity or sociodemographic characteristics. Additionally, the retrospective nature of data collection prevented a standardized assessment of potential confounders such as dietary habits, sleep patterns, and physical activity levels. Therefore, future studies should adopt prospective multicenter designs with predefined inclusion criteria and rigorous data-management protocols to minimize missing information.\u003c/p\u003e\u003cp\u003eIn addition, while our findings suggest a protective effect of sibling presence, we were unable to assess more nuanced aspects of sibling dynamics, such as birth order or sex composition, owing to inconsistent documentation in the clinical records. These variables may have significantly influenced family interactions and functional outcomes. Future studies should collect detailed family demographic information to enable stratified analyses and tailored, family based interventions.\u003c/p\u003e\u003cp\u003eFurthermore, studies should integrate direct observational methods or digital activity monitoring with parent-reported QCD assessments to reduce reporting bias and provide a more comprehensive evaluation of daily functioning.\u003c/p\u003e\u003cp\u003eFrom a statistical perspective, the sample size, although adequate for primary analyses, may have been underpowered to detect smaller effect sizes, particularly in the multivariate regression models for individual QCD domains. This limitation increases the risk of type II errors, and the reported nonsignificant associations should be interpreted with caution. Moreover, we did not perform cross-or external validation of the regression models limiting thegeneralizability of the identified associations.\u003c/p\u003e\u003cp\u003eWhile we did not assess QOL and self-esteem directly, the observed impairments in daily functioning may reflect underlying deficits in these domains. Future research should incorporate validated measures of QOL to further elucidate their contribution to caregiver burden in patients with OCD.\u003c/p\u003e"},{"header":"Clinical implications","content":"\u003cp\u003eThis study highlights the importance of recognizing time-of-dayspecific functional vulnerabilities in children with OCD. The QCD proved useful in identifying these periods, which can inform more targeted intervention strategies.\u003c/p\u003e\u003cp\u003e\u003cul\u003e\u003cli\u003e\u003cp\u003e\u003cb\u003eMorning\u003c/b\u003e: Establish structured wake-up routines with consistent parental support to reduce inertia and conflict during school preparation. Families with multiple children may require additional strategies to manage their competing demands.\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003e\u003cb\u003eAfter school\u003c/b\u003e, Introduce brief rest periods and low-demand activities to mitigate fatigue and prevent symptom escalation.\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003e\u003cb\u003eEvening\u003c/b\u003e: Promotes predictable family-based routines. Provide psychoeducation to siblings to reduce unhelpful involvement in rituals and enhance supportive interactions.\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003e\u003cb\u003eNight\u003c/b\u003e: While higher anxiety may prompt greater parental supervision, care should be taken to counteract maladaptive bedtime rituals.\u003c/p\u003e\u003c/li\u003e\u003c/ul\u003e\u003c/p\u003e\u003cp\u003eIntegrating QCD assessments into routine care can help clinicians identify vulnerable time periods and develop individualized, time-sensitive intervention plans that address both core OCD symptoms and relevant family or psychosocial factors.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eChildren and adolescents with OCD demonstrate marked domain-specific functional impairments, with the greatest difficulties during school, after-school, and nighttime routines. Behavioral problems were associated with better functioning in the morning and evening, possibly reflecting increased parental engagement. Family structure, particularly the presence of siblings, influenced morning routine. Depressive symptoms were not significantly associated with overall functioning in the present analyses.\u003c/p\u003e\u003cp\u003eThese findings underscore the need for time-of-day-aligned intervention strategies to address both OCD symptoms and broader psychosocial contexts. Future longitudinal research should further refine these temporal profiles and evaluate targeted treatment protocols to improve daily functioning and the overall quality of life in this population.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003eAcknowledgments\u003c/p\u003e\n\u003cp\u003eNone\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;Data Availability\u003c/p\u003e\n\u003cp\u003eThe datasets generated and analyzed during the current study are not publicly available due to ethical restrictions, but they are available from the corresponding author upon reasonable request.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;Disclosure Statement\u003c/p\u003e\n\u003cp\u003eNone\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;Author Contributions\u003c/p\u003e\n\u003cp\u003eUM designed the study and drafted the manuscript. YS, MI, MM, MO, YH, YK, HM, YN, MM, YS, MO, KI, KY, MT, YY, SI, MI, KI, YH, and YM collected clinical data. MI, KM and NT managed the registry and discussed the results.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;Funding statement\u003c/p\u003e\n\u003cp\u003eThis study was supported by grants from the Japan Institute for Health Security (24A1014 and 24 ri 005) and a\u0026nbsp;Health Labour Sciences Research Grant\u0026nbsp;(23GC0013). The funder had no role in the conceptualization, design, data collection, analysis, decision to publish, or preparation of the manuscript.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;Patient consent statement\u003c/p\u003e\n\u003cp\u003eNone\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eKrebs G, Heyman I. Obsessive-compulsive disorder in children and adolescents. Vol. 100, Archives of Disease in Childhood. BMJ Publishing Group; 2015. p. 495\u0026ndash;9.\u003c/li\u003e\n\u003cli\u003eStiede JT, Spencer SD, Onyeka O, Mangen KH, Church MJ, Goodman WK, et al. Obsessive\u0026ndash;Compulsive Disorder in Children and Adolescents. 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Available from: https://pubmed.ncbi.nlm.nih.gov/15254847/\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003eTables are available in the Supplementary Files section.\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"scientific-reports","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"scirep","sideBox":"Learn more about [Scientific Reports](http://www.nature.com/srep/)","snPcode":"","submissionUrl":"","title":"Scientific Reports","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Scientific Reports","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Child, Adolescent, obsessive compulsive disorder, Family burden","lastPublishedDoi":"10.21203/rs.3.rs-7604032/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7604032/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground:\u003c/h2\u003e\u003cp\u003eTo evaluate time-of-day-specific functional impairments in children with obsessive\u0026ndash;compulsive disorder (OCD) and identify related clinical and psychosocial factors.\u003c/p\u003e\u003ch2\u003eMethods:\u003c/h2\u003e\u003cp\u003eThe registry data for a total of 136 children diagnosed with OCD was analyzed. Questionnaire - Children with Difficulties (QCD) was used to assess functional difficulties across daily lives and was reported by the parents. The QCD scores of the children with OCD were compared with community norms. Multiple regression analyses were used to examine the associations of the QCD domains with age, weekday sleep, anxiety, depression, behavioral problems, and siblings.\u003c/p\u003e\u003ch2\u003eResults:\u003c/h2\u003e\u003cp\u003eThe mean age of patients in the OCD group was 11.46 years (SD\u0026thinsp;=\u0026thinsp;2.27), with 69 boys (51.1%) and 66 girls (48.9%). The children with OCD scored significantly lower across all QCD domains (all p\u0026thinsp;\u0026lt;\u0026thinsp;.01), with large effects for night (d = \u0026minus;\u0026thinsp;2.04), total QCD (d = \u0026minus;\u0026thinsp;2.10), school (d = \u0026minus;\u0026thinsp;1.90), and after-school (d = \u0026minus;\u0026thinsp;2.03) compared to the community sample. In the regression analyses, higher behavioral problem scores predicted better functioning in the morning and evening, whereas a greater number of siblings predicted poorer morning functioning. Higher anxiety scores were significantly associated with better night-time functioning. However, depressive symptoms were not significantly associated with overall functioning.\u003c/p\u003e\u003ch2\u003eConclusions:\u003c/h2\u003e\u003cp\u003eChildren and adolescents with OCD demonstrated marked domain-specific functional impairments, particularly during school, after school, and nighttime routines. Distinct psychosocial factors, including behavioral problems, sibling presence, and anxiety symptoms, were associated with time-specific functioning, underscoring the need for targeted, time-sensitive interventions.\u003c/p\u003e","manuscriptTitle":"Struggle hours for endless demands: When a child with obsessive-compulsive disorder wears parents down?","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-10-13 22:29:13","doi":"10.21203/rs.3.rs-7604032/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-11-13T13:10:52+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-11-11T13:34:04+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"220806718364525598098610233220905234371","date":"2025-11-06T07:27:45+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-10-22T10:19:02+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"152954112031451645040478924919979441626","date":"2025-10-03T11:26:02+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-09-30T16:14:54+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-09-23T12:38:49+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-09-23T12:19:00+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-09-19T08:27:10+00:00","index":"","fulltext":""},{"type":"submitted","content":"Scientific Reports","date":"2025-09-19T08:20:53+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"scientific-reports","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"scirep","sideBox":"Learn more about [Scientific Reports](http://www.nature.com/srep/)","snPcode":"","submissionUrl":"","title":"Scientific Reports","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Scientific Reports","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"bc3fc6f8-b5f3-4bd2-a5d6-fe21f7adf93d","owner":[],"postedDate":"October 13th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[{"id":56234744,"name":"Health sciences/Diseases"},{"id":56234745,"name":"Health sciences/Health care"},{"id":56234746,"name":"Health sciences/Medical research"},{"id":56234747,"name":"Biological sciences/Psychology"},{"id":56234748,"name":"Social science/Psychology"}],"tags":[],"updatedAt":"2026-02-09T16:01:29+00:00","versionOfRecord":{"articleIdentity":"rs-7604032","link":"https://doi.org/10.1038/s41598-026-37027-7","journal":{"identity":"scientific-reports","isVorOnly":false,"title":"Scientific Reports"},"publishedOn":"2026-02-04 15:57:38","publishedOnDateReadable":"February 4th, 2026"},"versionCreatedAt":"2025-10-13 22:29:13","video":"","vorDoi":"10.1038/s41598-026-37027-7","vorDoiUrl":"https://doi.org/10.1038/s41598-026-37027-7","workflowStages":[]},"version":"v1","identity":"rs-7604032","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7604032","identity":"rs-7604032","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}