Pediatric Obsessive-Compulsive Disorder Workup

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

The diagnostic criteria for 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. [13]

The Diagnostic and Statistical Manual of Mental Disorders, FifthEdition (DSM-5), is quite clear that at some point, patients affected with OCD need to recognize that their obsessions come from within their own minds and are not worries about genuine problems. In a similar way, compulsions must be observed as excessive or unreasonable. Thus, the clinician does not include nightly bedtime rituals or other typical normative daily patterns as suggestive of this disorder.

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.

Another requirement to make the diagnosis is that specific content of obsessions cannot be related to another psychiatric diagnosis (eg, obsessive thoughts about food may be the result of an eating disorder, paranoid thoughts may be related to a psychotic thought disorder).

Of structured interviews and psychological tests used in diagnosing OCD, the Children's Yale–Brown Obsessive-Compulsive Scale (CY-BOCS) [4]  is the criterion standard to make the definitive diagnosis. OCD is diagnosed according to DSM-IV-TR [21] 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. [22]


Imaging Studies

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. [23]

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. [24]  Also there has been a possible increase in Glx (combination of glutamate and glutamine) in the striatum in OCD. [25]  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. [24]  

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. [26]


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). 


Other Tests

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