Diagnostic Considerations

Obsessive-compulsive disorder (OCD) often goes unrecognized in children and adolescents. Reasons advanced for the under diagnosis of and lack of treatment for pediatric OCD include some factors specific to the disorder, including the secretiveness of OCD and lack of insight by the patients. Also, many of the symptoms of OCD are found in other disorders, leading to misdiagnosis.

Diagnosis of OCD is not exclusionary. Other anxiety disorders, tic disorders, and disruptive behavior disorders, as well as learning disabilities, are common comorbidities with OCD. Other obsessive-compulsive type disorders, such as body dysmorphic disorder, trichotillomania, and habit problems (eg, nail biting), are less common.

In general, a psychodynamic approach (ie, discussing these problems at length to get at underlying causes) may reinforce and worsen the symptoms. Thus, for a child presenting with anxiety symptoms and compulsive behaviors that are worsening or not responding to talk therapy, the clinician should consider the possibility of OCD.

OCD also can be confused with ADHD. At first, seeing how these 2 disorders overlap may be difficult; however, in the classroom situation, these disorders may present in a similar fashion. When children with OCD are preoccupied with their obsessive thoughts and covert counting or rereading rituals in school, the teacher perceives the children as being inattentive. Children engaged in the compulsively driven behaviors often have a very high level of energy and activity.

Because the behaviors observed in persons with OCD often are stereotypical and repetitive, autism spectrum disorder is commonly confused with OCD. As in OCD, children with autism spectrum disoder also may have repetitive thoughts and specific stereotypic compulsive behaviors.

However, in individuals with OCD, compulsive behaviors may change form. Thus, a child with OCD may have a handwashing compulsive behavior, but this may change later to a need for order. In persons with autism spectrum disorder, the compulsive behaviors do not tend to change over time. Often, a child with autism may have the same preoccupation for years. In addition, autistic stereotypic behaviors tend to be unique to the child; in persons with OCD, stereotypic behaviors are usually those commonly seen in children with OCD (see History).

Moreover, a child with OCD, when not preoccupied with obsessive thoughts, does not have social difficulties of relatedness or communication problems. Social difficulties and communication problems are key intrinsic features of autism spectrum disorder.

Major depressive disorder is another condition to consider in the differential diagnosis of OCD.

Go to Pediatric Generalized Anxiety Disorder and Pediatric Panic Disorder for complete information on these topics.

Differential Diagnoses

Asperger Syndrome
Autism Spectrum Disorder
Childhood Habit Behaviors and Stereotypic Movement Disorder
Depression
Eating Disorders
Obsessive-Compulsive Personality Disorder
Pediatric Attention Deficit Hyperactivity Disorder (ADHD)
Pediatric Posttraumatic Stress Disorder
Pediatric Tourette Syndrome
Pediatric Trichotillomania
Pervasive Developmental Disorder
Psychotic Disorders
Tourette Syndrome and Other Tic Disorders

Workup

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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; New York City Health and Hospitals/Bellevue, New York University Langone Health<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 Postdoctoral Research Fellow, Johns Hopkins Hospital

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.

Sections Pediatric Obsessive-Compulsive Disorder
Overview
Presentation
DDx
Workup
Treatment
Medication
References

Pediatric Obsessive-Compulsive Disorder Differential Diagnoses

Diagnostic Considerations

Differential Diagnoses

References

Tables

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