**3.4. Generalized anxiety disorder**

A child who has difficulty controlling worries about everyday issues would likely be exhibiting symptoms of generalized anxiety disorder (GAD). GAD involves excessive worry about real-life concerns, while OCD centers on irrational fears that are unrealistic and beyond the scope of daily life problems [22, 28]. At times, these disorders can be clearly distinguished, for example, when one child worries excessively about an upcoming math test while another is overwhelmingly concerned about receiving a deadly illness from germs or turning into an animal by the power of their thoughts. Sometimes, however, the differential diagnosis may be less clear-cut; for example, a child's concern about his mother flying on an airplane could be categorized as a worry about his mother's well-being (GAD) or irrational fear of harm toward loved ones (OCD). Furthermore, pathological worry may function similarly to mental compulsions as both are self-initiated and aimed at reducing distress [28]. It has been suggested that compulsions can be distinguished from pathological worry by its frequency (compulsions will likely have a higher number of repetitions), rigidity (a child with OCD is more likely to seek the same answer over and over, whereas a child with GAD may ask numerous questions about different risks), quality (compulsions are likely to be more illogical such as tapping an object repeatedly to prevent harm to a loved one), and function (compulsions for OCD often seek to reduce distress related to thought of future negative events, whereas pathological worry seeks to reduce occurrence of future negative event but as no compulsions or acts involved in preventing the outcome) [28].

#### **3.5. Tic disorders**

Tics refer to sudden, repetitive, stereotyped movements or sounds. While tics are often perceived as involuntary, they usually are accompanied by premonitory sensory urges [29]. Simple tics include eye blinking, neck jerking, shoulder shrugging, or throat clearing. Complex tics can involve facial gestures, touching, smelling objects, or repeating words or phrases; often complex tics involve repeating certain actions until it feels right. Simple tics are more easily distinguished from compulsions due to their brevity, lack of purpose, and seemingly involuntary nature, while complex tics can present quite similarly to compulsions [29]. A behavior that functions to reduce distress or anxiety (e.g., repeatedly tapping the sidewalk to prevent a feared consequence) is likely to be related to OCD, while a behavior that functions to relieve somatic discomfort or tension (e.g., repeatedly moving arm in certain way in response to discomfort) [22]. Additionally, clinicians can ask if withholding the behavior would result in anxiety or physical discomfort. Looking at the symptom in context of the child's history can be helpful as well depending on if the child has presented with anxiety and/or distinct obsessions or compulsions vs. simple tics with minimal anxiety [22].
