History

A complete family history is essential, especially any history of relatives who may have obsessive-compulsive disorder (OCD) or Tourette syndrome (TS).

Adequate assessment of a child with potential OCD includes inquiry for a history of any infection that may have preceded the onset of symptoms. Accurate assessment is essential. Of structured interviews and psychological tests used, the Children's Yale–Brown Obsessive Compulsive Scale (CY-BOCS), which is a clinician-rated scale based on the Yale–Brown Obsessive-Compulsive Scale (Y-BOCS),^{[21, 22, 23]}is considered the instrument of choice in making the definitive diagnosis.^[24]The CY-BOCS is used for children younger than 18 years old and the Y-BOCS is for adults aged 18 years and older.^[3]

Usual behavioral features

Sets of common obsessions and compulsions are observed in pediatric individuals with obsessive-compulsive disorder (OCD). Typically, these sets are described best as "just so" behaviors, in which certain things have to be arranged or performed in a particular way to relieve the anxiety. The most clinically useful and detailed symptoms checklist is included in the Y-BOCS.^[3]

Common themes of obsessions include contamination, aggression, sex, the need for symmetry and order, harm to oneself or others, and the need to confess. These excessive thoughts result in the common compulsive behaviors of washing, repeating, checking, touching, counting, arranging, hoarding, or praying. The presence of hoarding symptoms is associated with an earlier age of onset and with the presence of attention-deficit/hyperactivity disorder and anxiety disorder.^[25]

When overt, observable compulsive behaviors are relatively easy to observe to make the diagnosis (eg, washing, repeating, checking, touching); covert behaviors (eg, counting, praying, reading something again and again) are harder to assess and evaluate. If OCD is suspected and if a child is taking an extremely long time to complete some tasks, a high likelihood exists that the child may be engaged in one of these covert rituals.

Rage is a common behavior of youth with OCD. Severe rage attacks may seriously impair functioning in the family. Rage attacks may aggravate the functional impairment of obsessions and compulsions.^[26]

Social functioning

Youth with OCD often demonstrate impaired peer relationships. They are fearful of negative evaluations. They exhibit victimization. They have fewer behaviors to facilitate social interactions with peers. They have fewer friends than peers. Also they want more friends than their peers. They have trouble making friends. Parents and teacher can facilitate optimal social functioning of young people with OCD.^[27]

Parental accommodation

Parents themselves may experience anxiety associated with excessive hand washing and other severe compulsions and oppositional behaviors of the child. Parents may then alter their activities to accommodate the obsessions, compulsions, and the rage attacks of the child.^{[28, 26]}

Physical Examination

Physical examination of children with pediatric obsessive-compulsive disorder (OCD) may reveal the effects of compulsions. Repeated handwashing and showering may result in redness and irritation of the skin of the hands and other parts of the body.^[2]

Complications

Children with obsessive-compulsive disorder (OCD) may develop other anxiety disorders, including panic disorder, social anxiety disorder, generalized anxiety disorder, and specific phobia; depressive or bipolar disorder. They may develop suicidal thoughts and self-destructive behaviors.^[2]They may also develop attention-deficit/hyperactivity disorder or tics and Tourette syndrome (TS).^[2]

Differential Diagnoses

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Author

James Robert Brasic, MD, MPH, MS, MA Assistant Professor, Russell H Morgan Department of Radiology and Radiological Science and Neurology, Division of Nuclear Medicine and Molecular Imaging, Assistant Professor, Department of Neurology, Johns Hopkins University School of Medicine

James Robert Brasic, MD, MPH, MS, MA is a member of the following medical societies: American Academy of Child and Adolescent Psychiatry, American Academy of Neurology, International Parkinson and Movement Disorder Society, Society for Neuroscience, Society of Nuclear Medicine and Molecular Imaging

Disclosure: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for: Johns Hopkins University School of Medicine<br/>Serve(d) as a speaker or a member of a speakers bureau for: Society of Nuclear Medicine and Molecular Imaging, Maryland Regional Council of Child and Adolescent Psychiatry<br/>Received research grant from: National Institutes of Health, Johns Hopkins University School of Medicine, Intellectual & Developmental Disabilities Research Center (U54 HD079123) at the Kennedy Krieger Institute<br/>Received income in an amount equal to or greater than $250 from: Gerson Lehrman Group; Guidepost<br/>Received royalty from Medscape for other.

Coauthor(s)

Ashley B Durbin, BS, BA

Disclosure: Nothing to disclose.

Specialty Editor Board

Mary L Windle, PharmD Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose.

Chief Editor

Caroly Pataki, MD Health Sciences Clinical Professor of Psychiatry and Biobehavioral Sciences, University of California, Los Angeles, David Geffen School of Medicine

Caroly Pataki, MD is a member of the following medical societies: American Academy of Child and Adolescent Psychiatry, New York Academy of Sciences, Physicians for Social Responsibility

Disclosure: Nothing to disclose.

Additional Contributors

Farzaneh Farhadi, MD

Disclosure: Nothing to disclose.

Acknowledgements

This research is supported by the Essel Foundation, the Brain and Behavior Research Foundation (NARSAD), the Tourette Syndrome Association Inc, and the National Institutes of Health.

The authors and editors of Medscape Reference gratefully acknowledge the contributions of previous author W Douglas Tynan, PhD, to the development and writing of the source article.