Diagnosing Pediatric OCD
Obsessive compulsive disorder (OCD) is characterized by both obsessions and compulsions.
Obsessions are intrusive and unwanted thoughts, images, or urges that occur over and over again and feel outside of the child’s control. These obsessions are unpleasant for the child and typically cause a lot of worry, anxiety, and distress.
Common obsessions may include:
- Worrying about germs, getting sick, or dying.
- Extreme fears about bad things happening or doing something wrong.
- Feeling that things have to be “just right.”
- Disturbing and unwanted thoughts or images about hurting others.
- Disturbing and unwanted thoughts or images of a sexual nature.
Compulsions (also referred to as rituals) are behaviors the child feels he or she “must do” with the intention of getting rid of the upsetting feelings caused by the obsessions. A child may also believe that engaging in these compulsions will somehow prevent bad things from happening.
Common compulsions may involve:
- Excessive checking (re-checking that the door is locked, that the oven is off).
- Excessive washing and/or cleaning.
- Repeating actions until they are “just right” or starting things over again.
- Ordering or arranging things.
- Mental compulsions (excessive praying, mental reviewing).
- Frequent confessing or apologizing.
- Saying lucky words or numbers.
- Excessive reassurance seeking (e.g., always asking, “Are you sure I’m going to be okay?”).
An OCD diagnosis is warranted when these obsessions and compulsions become so time-consuming that they impair day-to-day functioning (e.g., social, school, self care, etc.). Typically, these symptoms have a gradual onset, developing over the course of several weeks or months.
OCD can start at any time from preschool to adulthood. Although OCD can occur at any age, there are generally two age ranges when OCD tends to first appears:
- Between the ages 8 and 12.
- Between the late teen years and early adulthood.
In rare cases, symptoms may develop seemingly “overnight” with a rapid change in behavior and mood and sudden appearance of severe anxiety. If this is the presentation, then consider a sub-type of pediatric OCD caused by an infection (e.g., strep throat), which confuses the child’s immune system into attacking the brain instead of the infection. This then causes the child to begin having severe symptoms of OCD, often seemingly all at once, in contrast to the gradual onset seen in most cases of pediatric OCD. The sudden appearance of symptoms is very different from general pediatric OCD, where symptoms appear more gradually.
This type of OCD is called Pediatric Autoimmune Neuropsychiatric Disorder Associated with Streptococcus (PANDAS) if it is a strep infection, or Pediatric Acute-Onset Neuropsychiatric Syndrome (PANS) if it is any other infection. Click here to learn more about PANDAS/PANS.
Clinical assessment
To assess a child or adolescent with suspected OCD, it is strongly recommended that you meet with both the child or teen and the parents/family members. OCD symptoms often remain hidden from family members (especially those related to bad thoughts, aggressive, or sexual obsessions). Children and teens also sometimes understate the impacts of OCD on their lives due to related guilt and shame. Keep in mind that younger children often prefer to have their parents in the room to help with providing a history, whereas adolescents frequently wish to be seen alone. In these cases, it is important to also obtain a separate parent history to provide multiple perspectives.
As with any other psychosocial intake, a comprehensive clinical assessment should be conducted that includes the history of present illness, co-morbid symptoms, past psychiatric history, family psychiatric history, social and developmental history, medical and substance history, medications and drug allergies, and the mental status examination. Finally, a risk assessment of self-harm and harm to others should also be included in any mental health evaluation.
Symptom assessment
It is important to ask about the frequency, duration, and severity of OCD symptoms. Also make sure to ask about exacerbating factors, including family stressors (e.g. moving to a new home), school stressors (e.g. entering middle or high school), or a preceding physical illness. Inquire about the impact of OCD symptoms in the child’s home, school, and social environments. Finally, assess the level of insight, attempts at resisting the urge to engage in compulsions, and the degree to which he or she is successful in resisting compulsions. Family members’ insights and the degree to which they accommodate the child’s symptomatic behavior (which worsens OCD) are other important factors to be understood.
The Children’s Yale-Brown Obsessive Compulsive Scale (CY-BOCS) and checklist is helpful to record the severity and presence of specific symptoms. Scales that measure overall child functioning, family accommodation, and functioning include the Children’s Obsessive-Compulsive Impact Scale (COIS), the Family Accommodation Scale, and the OCD Family Functioning (OFF) Scale, respectively.
Differential diagnosis
In addition to collecting information about obsessive compulsive symptoms, other disorders and illnesses that may better account for these symptoms should be ruled-out, such as trichotillomania (recurrent hair pulling leading to visible hair loss) and body dysmorphic disorder (distorted recurrent thoughts regarding a body part). In addition, co-morbid illnesses that may require individual attention frequently exist among youth with OCD, including tic and other anxiety disorders, ADHD, depression, and eating disorders.
Treatment history
In the assessment of past psychiatric treatment, it is important to ask the duration, tolerability, and maximum dosage of every past medication trial. Medication trials are often prematurely stopped due to lack of realization that effects may take up to 3 months to appear. Also, full medication effects are often not achieved if doses are not raised (presuming the medication was well tolerated) towards the target dose.
The length and success of past psychotherapies also needs to be established. Careful attention should be paid to determine whether actual exposure and response prevention (ERP), a variant of cognitive behavioral therapy (CBT), was received.
Additional factors to consider
Genetics: Since OCD and related disorders may have a genetic component, a thorough family psychiatric history should be elicited for the presence of OCD. The value of this is that medication response may have an inherited component,. Therefore, information regarding family history of effective treatment trials and negative medication reactions should be gathered.
Co-occurring conditions: Other factors that may impact treatment include a history of substance abuse, which may impede compliance. Past mood instability may indicate the risk for a switch toward mania with administration of serotonergic agents. Panic attacks should stimulate use of caution with dosage increases, as these may trigger further attacks.
Medical history: The medical history is an important component of assessment, including a review of currently prescribed over-the-counter and birth control medications (for adolescents), as well as drug allergies. Physical and neurological illnesses should be listed in addition to possible symptoms that may overlap with medication side effects (i.e. insomnia or anergia). A history of head injuries or seizures should be noted, and pregnancy should be ruled out. If the patient is a child with abrupt onset OCD following illness, a history of streptococcal infections should be obtained, and throat cultures and immune markers may be collected.
Behavioral observation and mental status: The final component of any clinical assessment is the mental status examination. A general description of the patient and their behavior should include any external signs of OCD or OCRDs (e.g.- red, chapped hands, repeated behaviors, or bald spots). Abnormal movements (such as tics or choreiform movements) should be noted in addition to abnormalities of speech, the degree of eye contact, and cooperation. Mood and affect should note the levels of potential anxiety, depression, or anger. Thought form should be assessed with respect to circumstantiality and detail-focus and thought content with respect to overvalued ideation, delusions, and thoughts of suicide and homicide. The level of insight and degree of judgment exhibited by the child or adolescent are also important to note.
Unfortunately, there are no laboratory findings that are diagnostic of OCD and related disorders. However, for clinicians who are considering a diagnosis of PANDAS, a positive throat culture for Streptococcus A is required in addition to determination of other diagnostic criteria. Although characteristic neuroimaging findings have been reported for groups of individuals with OCD, there are no pathogenomic findings that may be used to diagnosis an individual with the disorder.