Pediatric Obsessive-Compulsive Disorder Differential Diagnoses

Updated: Sep 06, 2019
  • Author: James Robert Brasic, MD, MPH, MS, MA; Chief Editor: Caroly Pataki, MD  more...
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Diagnostic Considerations

As previously mentioned, 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. In one epidemiologic survey, 18 children were found to have OCD, but only 4 were receiving any professional mental health care, and not one of these 4 was diagnosed properly.

Diagnosis of obsessive-compulsive disorder (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, but they are certainly not rare.

Often, the nature of the excessive thoughts leads to misdiagnosis. Common misdiagnoses for OCD include posttraumatic stress disorder (PTSD) and ADHD.

For example, if a child has obsessive sexual thoughts, clinicians commonly assume that some type of sexual abuse is underlying these thoughts, leading to a diagnosis of PTSD. Unfortunately, treatment then takes the form of further exploration and discussion of these thoughts, which may make them more frequent and prominent.

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 and Asperger syndrome are commonly confused with OCD. As in OCD, children with mild autism or Asperger syndrome also may have repetitive thoughts and specific stereotypic compulsive behaviors. Although disorders in the autistic spectrum are considered to be pervasive developmental disorders (PDD) and quite different from OCD, at times the differential diagnosis between the 2 sets of disorders is somewhat difficult to make.

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 or Asperger 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 almost always those discussed earlier (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 Asperger syndrome on the PDD spectrum.

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