Pediatric Obsessive-Compulsive Disorder Workup

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

The diagnostic criteria for obsessive-compulsive disorder (OCD) specify that a child or adolescent may have either obsessions or compulsions, although nearly all children with this disorder have both. The symptoms must cause some distress, consume more than 1 hour per day, or must significantly interfere with school, social activities, or important relationships. [2]

Although most adolescents and some children with OCD recognize the senselessness of the disorder, the requirement of insight into the disorder is not required for the diagnosis of OCD in children.

As with many neuropsychiatric disorders, a chronic waxing and waning of symptoms occurs in the chronic disorder of OCD. Thus, many families choose not to seek treatment, because the symptoms have decreased independent of treatment in the past.

Of structured interviews and psychological tests used in diagnosing OCD, the Children's Yale–Brown Obsessive-Compulsive Scale (CY-BOCS) [3]  is the criterion standard to make the definitive diagnosis. OCD is diagnosed according to DSM-IV-TR [29] if on the Y-BOCS a person scores 2, 3, or 4 on any of the following items: (1) time spent on obsessions, (2) interference from obsessions, (3) distress of obsessions, (6) time spent on compulsions, (7) interference from compulsions, or (8) distress of compulsions. [21]


Imaging Studies

Structural magnetic resonance imaging does not differentiate people with obsessive-compulsive disorder (OCD) from healthy controls. [30]

Among unmedicated people with OCD, activation in the right dorsal-lateral prefrontal cortex during a mental task with fMRI was postively correlated with total scores on Y-BOCS. [21]  These findings suggest a possible location for neuromodulation intervention. [31]

Resting-state functional connectivity magnetic resonance imaging (rs-fcMRI) demonstrate increased connectivity in the right auditory system (Brodman area 43) and decreased connectivity in the right Brodman area 8 and in Brodman area 40 in the cingulate system. These findings support the hypothesis of dysfunction of the cortico-striatal-thalamo-cortical system in OCD. [32]

Diffusion tensor imaging (DTI) studies has shown increased white matter connectivity potentially due to premature myelination in pediatric and adolescent patients with early-onset OCD. [33]

On proton magnetic resonance spectroscopy (1H-MRS) there are greater concentrations of choline and N-acetyl-aspartate in the right prefrontal white matter in children and adolescents with OCD. [34]  Also there has been a possible increase in Glx (combination of glutamate and glutamine) in the striatum in OCD. [35]  Furthermore, the levels of choline, myoinositol, and N-acetyl-aspartate in the right prefrontal white matter in children and adolescents with OCD are correlated with the severity of symptoms. [34]  



Laboratory Studies

Evidence of an infection merits checking for group A beta-hemolytic streptococcal antigens to rule out pediatric autoimmune neuropsychiatric disorders associated with streptococcal infection (PANDAS). Streptococcal infections may be followed by the dramatic appearance of obsessive-compulsive disorder (OCD) and/or tics. [36]


Other Tests

Neuropsychological assessment by a pediatric neuropsychologist will help to establish the diagnoses of obsessive-compulsive disorder (OCD) and other disorders. Also a neuropsychologist who has performed a thorough neuropsychological evaluation can formulate an effective treatment plan. 

A comprehensive neuropsychological battery for people with possible OCD may include (1) executive function (Flanker Test), [37]  (2) cognitive set shifting [38] , (3) episodic memory, [39]  (4) working memory, [40]  (5) proxy for intelligence quotient (Picture Vocabulary), and (6) motor speed (Pegboard). [41]