Pediatric Obsessive-Compulsive Disorder Differential Diagnoses

Updated: Feb 10, 2022
  • Author: James Robert Brasic, MD, MPH, MS, MA; Chief Editor: Caroly Pataki, MD  more...
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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