Clinical Assessment of OCD in Children and Adolescents
by S. Evelyn Stewart, M.D.
To assess a child or adolescent with suspected OCD, a systematic and thorough approach should be used that allows both the child or teen and the parents/family members to tell ‘their side of the story’. This is because OCD symptoms often remain hidden from family members (e.g. especially related to ‘bad thoughts’, aggressive or sexual obsessions), and also because children or teens may understate the impacts of OCD on their lives, due to related guilt and shame. Younger children often prefer to have their parents in the room to help with providing a history, whereas adolescents frequently wish to be seen alone. In these cases, it is important to also obtain a separate parent history to provide multiple perspectives. Components of clinical assessment include the history of present illness, co-morbid symptoms, past psychiatric history, family psychiatric history, social and developmental history, medical and substance history, medications and drug allergies, and the mental status examination.Regarding the history of present illness, the duration and severity of OCD symptoms and their precipitating, exacerbating, and ameliorating factors should be determined. Examples of exacerbating factors may include family (e.g. move into a new home) or school (e.g. entering middle school) stressors, or a preceding physical illness. The Children’s Yale-Brown Obsessive Compulsive Scale (CY-BOCS) and checklist is helpful to record the severity and presence of specific symptoms. Functional consequences of OCD symptoms in home, school, and social environments and the level of insight, resistance, and control over symptoms should also be assessed. Family insight and accommodation of symptoms (which worsens OCD) are other important factors to be determined. Scales that measure overall child functioning, family accommodation and functioning include the Children’s Obsessive-Compulsive Impact Scale (COIS), the Family Accommodation Scale and the OCD Family Functioning (OFF) Scale, respectively.In addition to collecting information about obsessive-compulsive symptoms, other illnesses that may better account for these should be ruled-out, such as trichotillomania (recurrent hair pulling leading to visible hair loss) and body dysmorphic disorder (distorted recurrent thoughts regarding a body part). In addition, comorbid illnesses that may require individual attention frequently exist among youth with OCD, and include tic and other anxiety disorders, ADHD, depression and eating disorders. Risk assessment of self harm and harm to others should also be included in any mental health evaluation.
In the assessment of past psychiatric treatment, it is important to ask the duration, tolerability and maximum dosage of every past medication trials. Medication trials are often prematurely stopped due to lack of realization that effects may take up to 3 months to appear. Also, full medication effects are often not achieved if doses are not raised (presuming the medication was well tolerated) towards the target dose. The length and success of past behavior or cognitive therapies and other psychotherapies also needs to be established. Careful attention should be paid to determine whether actual exposure and response prevention or cognitive therapy forms of cognitive-behavioral therapy (CBT) were received or if, alternatively, this was a form of supportive therapy that has not been reported as efficacious for OCD. Other factors that may impact on the treatment include a history of substance abuse, which may impede compliance. Past mood instability may indicate the risk for a switch towards mania with administration of serotonergic agents. Panic attacks should stimulate use of caution with dosage increases, as these may trigger further attacks.
Since OCD and related disorders may have a genetic component, a thorough family psychiatric history should be elicited for the presence of OCD. Furthermore, since medication-response may also have an inherited component, information regarding family history of effective treatment trials and negative medication reactions should be gathered.
A review of systems should be conducted to establish a baseline of symptoms. The medical history is an important component of assessment; it includes currently prescribed, over-the-counter, and birth control medications (for adolescents), as well as drug allergies. Physical and neurological illnesses should be listed, in addition to possible symptoms that may overlap with medication side effects (i.e.- insomnia or anergia). A history of head injuries, or seizures should be noted and pregnancy should be ruled-out. If the patient is a child with an abrupt onset OCD following illness, a history of streptococcal infections should be obtained and throat cultures and immune markers may be collected.
The final component of any psychiatric assessment is the mental status examination. A general description of the patient and their behavior should include any external signs of OCD or OCRDs (e.g.- red, chapped hands, repeated behaviors, or bald spots). Abnormal movements (such as tics or choreiform movements) should be noted, in addition to abnormalities of speech, the degree of eye contact, and cooperation. Mood and affect should denote the levels of potential anxiety, depression, or anger. Thought form should be assessed with respect to circumstantiality and detail-focus and thought content with respect to over-valued ideation, delusions, and thoughts of suicide and homicide. The level of insight and degree of judgment exhibited by the child or adolescent are also important to note.
Unfortunately, there are no laboratory findings that are diagnostic of OCD or OCRDs. However, for clinicians who are considering a diagnosis of PANDAS, a positive throat culture for Streptococcus A is required, in addition to determination of other diagnostic criteria. Although characteristic neuroimaging findings have been reported for groups of individuals with OCD, there are no pathognemonic findings which may be used to diagnosis an individual with the disorder.