Assessing possible pediatric OCD involves understanding what the child is experiencing, how symptoms affect their day-to-day life, and whether other conditions may also need attention.
Because children may hide symptoms, have difficulty describing them, or experience them differently across settings, an effective assessment should include information from both the child and their caregivers.
Talking with children and caregivers
OCD symptoms often remain hidden from family members, especially when they involve disturbing, aggressive, or sexual thoughts. Children and teens may also understate the impact of OCD because they feel guilt or shame about their symptoms.
Younger children may prefer to have a parent or caregiver in the room to help provide their history. Adolescents may wish to speak with the provider alone. In these cases, obtaining a separate parent or caregiver history can provide another important perspective.
What to assess
OCD is diagnosed when obsessions or compulsions become so time-consuming that they interfere with day-to-day functioning. Consider how symptoms affect the child’s home life, school, social activities and relationships, self-care, and daily functioning. Ask about:
- The frequency, duration, and severity of OCD symptoms
- Factors that make symptoms worse
- The impact of symptoms at home, at school, and in social settings
- The child’s level of insight
- Attempts to resist compulsions
- The child’s ability to resist compulsions
- The degree to which family members accommodate the child’s symptoms
- Co-occurring symptoms or conditions
- Previous mental health treatment
Factors that may worsen symptoms include family stressors, such as moving to a new home; school stressors, such as entering middle or high school; or a preceding physical illness.
Family accommodation is also important to assess. Family members may participate in rituals or change their behavior in response to the child’s symptoms. Although family members may do this to relieve the child’s distress, accommodation can worsen OCD.
Screening and assessment tools
The ultra-brief, 5-question version of the OCI-CV-5 for youth has been shown to be psychometrically valid in research studies and is a useful tool for initial screening.
Differential diagnosis and co-occurring conditions
Other disorders and illnesses may better account for a child’s symptoms and should be considered as part of a comprehensive clinical assessment.
Conditions that may co-occur with pediatric OCD include:
- Tic disorders
- Other anxiety disorders
- ADHD
- Depression
- Eating disorders
Other conditions, including trichotillomania and body dysmorphic disorder, may also need to be ruled out.
Because symptoms can overlap, some conditions may be confused with OCD or vice versa. Understanding all of the child’s symptoms and challenges is important when developing an appropriate treatment plan.
Reviewing previous treatment
When a child has received previous mental health treatment, ask about:
- The duration, tolerability, and maximum dosage of previous medication trials
- The length and outcome of previous psychotherapy
- Whether previous therapy included exposure and response prevention
Careful attention should be paid to whether the child received actual ERP, a form of cognitive behavioral therapy used to treat OCD.
Additional clinical considerations
A comprehensive clinical assessment should include:
- History of the current illness
- Co-occurring symptoms
- Past psychiatric history
- Family psychiatric history
- Social and developmental history
- Medical and substance history
- Current medications and drug allergies
- A mental status examination
- An assessment of the risk of self-harm or harm to others
Behavioral observations may include external signs of OCD or related disorders, such as red or chapped hands, repeated behaviors, or bald spots. Abnormal movements, including tics, may also be noted.
There are no laboratory findings that are diagnostic of OCD and related disorders.
When symptoms begin suddenly
Most pediatric OCD symptoms develop gradually over several weeks or months. If a child experiences an abrupt onset of OCD symptoms following an illness, obtain a history of streptococcal infections. Throat cultures and immune markers may also be collected.
Connecting families with care
If a child’s symptoms may indicate OCD, connect the child and family with a licensed mental health professional experienced in assessing and treating pediatric OCD.