At what point can a child be diagnosed with Obsessive-Compulsive Disorder (OCD)?

Diagnosing OCD in Children

A child can be diagnosed with Obsessive-Compulsive Disorder (OCD) at any age when their obsessions and compulsions are time-consuming (taking up more than 1 hour per day) and cause substantial distress or functional impairment. 1

Key Diagnostic Considerations

• OCD typically starts early in life, with nearly a quarter of males showing onset before 10 years of age 1
• In females, onset often occurs during adolescence, though it can also appear in the peripartum or postpartum period in women 1
• Recent epidemiological studies indicate a lifetime prevalence of pediatric OCD of approximately 1-4% in the USA 2
• Up to 80% of all OCD cases begin before the age of 18 years 2

Differentiating Normal Development from OCD

• Intrusive thoughts and repetitive behaviors are common in the general population, including children 1
• Rituals are a normal part of child development 1
• The key distinction is that in OCD, these thoughts and behaviors:
  • Are time-consuming (taking more than 1 hour daily) 1
  • Cause substantial distress to the child 1
  • Result in functional impairment (academic, social, or family functioning) 1, 2

Diagnostic Criteria and Assessment

• A comprehensive assessment is critical for accurate diagnosis 1
• Structured diagnostic interviews appropriate for children include:
  • Anxiety Disorders Interview Schedule for DSM-5 (ADIS-5) child/parent version 1
  • Mini International Neuropsychiatric Interview (MINI version 7.0) for children/adolescents 1
• The Obsessive Compulsive Inventory-Revised (OCI-R) can be used to assess symptom severity, with scores of 29 or higher suggesting clinically significant symptoms 3

Common Symptom Dimensions in Children with OCD

• Concerns about contamination with subsequent cleaning behaviors 1
• Concerns about harm with subsequent checking behaviors 1
• Concerns about symmetry with subsequent ordering behaviors 1
• These symptom dimensions are remarkably consistent across different countries and cultures 1

Important Clinical Subtypes

• Early-onset OCD (before puberty) is more common in males and often associated with comorbid tics 1
• The DSM-5 includes specifiers for insight level that are important to assess in children:
  • Good or fair insight
  • Poor insight
  • Absent insight or delusional beliefs 1
• A tic specifier is also included in DSM-5, which is particularly relevant for children 1

Comorbidity Considerations

• OCD in children frequently co-occurs with other conditions:
  • Anxiety disorders 1
  • Mood disorders 1
  • Tic disorders 1
  • Other obsessive-compulsive related disorders 1
• Comorbidity may negatively influence treatment response and long-term outcomes 4

Clinical Pitfalls to Avoid

• Misdiagnosing OCD with absent insight as a psychotic disorder 1
• Failing to distinguish OCD from normal developmental rituals 1
• Overlooking OCD symptoms due to comorbid conditions that may be more obvious 1
• Underdiagnosing and undertreating OCD despite its significant impact on functioning 1