Assessment and co-occurring difficulties

Assessment brings together the experiences of the child and parents with information from school, the GP and relevant educational and mental health services.

See the route to assessment Back to the overview

The route to assessment begins in daily life

Parents can begin by describing what their child experiences, how the difficulties have developed and which situations trigger doubt, distress or an urge to act. Observations from school can show how the pattern affects attendance, schoolwork, breaks and relationships.

In Denmark, a school may involve the municipal Educational Psychology Service (PPR), which contributes information about the child’s functioning, development and support needs. Parents can also discuss their concerns with the child’s GP. The GP assesses the symptoms and physical health and may refer the child to a specialist in child and adolescent psychiatry or to the regional child and adolescent mental health service. The names and organisation of these services differ between countries, but the need to bring together information from daily life remains the same.

During a more comprehensive assessment, information is collected from the child, family, school and professionals who already know the child. The assessment considers when the difficulties began, how they have developed and how sleep, meals, school, leisure activities and relationships are affected. Previous support and treatment also matter: what was tried, what helped and what was difficult to carry through?

The same action can have different drivers. An assessment therefore explores what happens immediately beforehand, what the child feels they have to do and what changes once the action has been carried out.

In OCD, an action or mental process may bring short-term relief: a temporary sense of calm or certainty, or the feeling that something is finally right. When doubt or distress returns, the child may feel the need to check, ask, repeat or avoid again. This recurring sequence often tells us more than the content of the thoughts.

The child, family and school see different parts

The child’s own account is central, but OCD can be difficult to put into words. Some children hide unwanted thoughts because they feel ashamed or fear being misunderstood. Others primarily experience a rule, a bodily urge or a sense that something is wrong without being able to explain why.

Accounts often differ. Some children hold back their rituals at school and perform them when they return home. Others become particularly stuck around certain demands, places or social situations outside the home. These differences help identify where the difficulties arise and what the child is trying to manage.

The conversation needs to fit the child’s age and development

A younger child might say that they have to touch the door frame, that a cup must stand in a particular way or that a parent must say a sentence exactly right. Questions therefore need to be concrete: What happens if you do not do it? Does the action have to be repeated a certain number of times? How do you know when it is finished?

For young people, much of the checking may happen mentally. They may review conversations, memories or bodily reactions to decide whether something carries the meaning they fear. This calls for direct, calm questions about thoughts and rituals that may feel intimate or shameful. The young person needs to be able to talk about them without having to defend, prove or explain every detail.

Age alone does not show what a child understands or can describe. Language, attention, cognitive development, autism, ADHD and the level of distress all shape the conversation. Some children need a parent to help establish the timeline. Young people often also need an opportunity to discuss parts of their experience on their own.

Many children go through periods with fixed routines, lucky numbers or particular ways of doing things. The pattern becomes clinically relevant when it grows rigid, time-consuming or distressing and begins to limit daily life or development.

How necessary and convincing an OCD rule feels varies between children and may change with the situation or symptom severity. Repetition, the sense that the action is necessary, distress and the effects on daily life are therefore all part of the assessment.

Rating scales can provide an overview

Clinical interviews and questionnaires are used to ask systematically about symptoms and their impact. The Children’s Yale-Brown Obsessive Compulsive Scale (CY-BOCS) is one example of a clinician-rated scale that examines obsessions, compulsions, time spent, distress and interference.

The score helps describe the severity of OCD and track change over time. A diagnosis is based on the full clinical assessment, in which the score is considered alongside the child’s account, development, daily functioning and the other available information.

When several difficulties occur together

OCD may occur alongside other difficulties, and different problems can look similar from the outside. The possible overlap between OCD, ADHD and autism is one example. The assessment considers when symptoms arise, what function they serve and how they affect one another.

Anxiety and depression

Anxiety may appear as worry, vigilance and avoidance. In OCD, the worry is often linked to actions or mental rituals intended to create certainty: the child asks again, checks, neutralises or reviews the question until it feels resolved. Separation anxiety, social anxiety or more general worries may be present alongside OCD and do not necessarily follow the same ritualised sequence.

For some children, long-standing OCD affects mood, energy, hope and interest in other people. Depression may also produce low mood, reduced drive and withdrawal in its own right. The assessment distinguishes between the consequences of burdensome OCD and a depressive disorder with its own course.

Intrusive thoughts about harm and death

Intrusive thoughts or images about harm and death may form part of harm OCD or appear as suicidal obsessions in OCD. In OCD, the thoughts are experienced as unwanted and frightening, and the child often tries to check or avoid them.

The conversation explores both the OCD pattern around the thought—fear, checking, avoidance and mental rituals—and signs of hopelessness, self-harm, suicidal thoughts, intent or plans. Physical injury caused by rituals and serious self-neglect are also included in the assessment.

Tics, Tourette syndrome and compulsive movements

Tics and Tourette syndrome and compulsions can both involve blinking, touching, sounds or repeated movements. A tic may be preceded by a bodily urge or tension that is briefly relieved by the movement or sound. A compulsion is more often part of a rule, a feared consequence or an attempt to neutralise doubt and distress.

Tics and compulsions can overlap in the same movement. Some repetitions are driven by a strong not-just-right feeling, and in tic-related OCD the child or young person also has a current or previous tic disorder. The assessment therefore explores the movement, what precedes it and what the child feels the movement needs to achieve.

ADHD and attention difficulties

A child with OCD may seem unable to concentrate because their attention is tied up in mental rituals, checking or monitoring for possible danger. They lose the thread, take a long time or forget an instruction while much of their mental effort is focused elsewhere.

In ADHD, attention and organisational difficulties have typically been present from early in development and occur more broadly across tasks and situations. When both ADHD and OCD are possible explanations, the assessment considers when concentration breaks down, what occupies the child’s mind at that moment and what the difficulties looked like before OCD became prominent.

Slow reading, writing or organisation may be caused by OCD, a learning or language difficulty, or both. The child’s earlier development and their performance on tasks where OCD has less influence help distinguish between these explanations.

Autism, routines and repetition

For an autistic child, fixed routines and repetition may provide predictability, enjoyment, interest or regulation of sensory input. In OCD, the ritual is often an attempt to remove doubt, prevent something feared or achieve a sense that things feel just right. The action alone does not determine the difference.

An autistic child can also have OCD. Language, sensory profile and need for predictability affect how the child notices and explains their symptoms. The assessment considers development over time, the child’s experience of the action, what happens if it is interrupted and whether the repetition feels wanted, necessary or intrusive.

Eating and food-related difficulties

Eating and food-related OCD may restrict food and drink through fears of contamination, poisoning, an allergic reaction, vomiting, choking or harm. Meals may also be governed by checking ingredients or bodily sensations, following particular numbers or sequences, or rules that something must feel exactly right.

Other eating difficulties may be linked to weight and body image, sensory input, appetite or fear of the consequences of eating. These patterns may overlap. The assessment therefore covers thoughts and rules around food, actual intake, physical effects and the situations in which the child eats more or less freely.

If the child’s intake of food or fluids has become substantially restricted, their physical condition and nutrition are important parts of the overall assessment.

BDD, skin picking and hair pulling

A strong preoccupation with perceived flaws in appearance may indicate body dysmorphic disorder (BDD), particularly when mirror checking, comparison, attempts to conceal the perceived problem or avoidance become prominent. Skin-picking disorder and trichotillomania may involve sensory experiences, urges, tension or habit.

These patterns can also occur alongside OCD. The assessment explores what drives the preoccupation or action and how it affects the child.

When a child becomes angry or stuck

Medical investigations are tailored to the individual presentation

OCD cannot be detected by a blood test or scan. In a typical presentation, assessment is based primarily on conversations, clinical judgement and a detailed description of symptoms and functioning. A basic assessment of the child’s physical health may form part of the overall process.

A doctor determines whether blood tests, an EEG, scans or a more specialised neurological examination are needed. An EEG records the brain’s electrical activity. These investigations are chosen when there is a reason to do so based on the medical history, physical effects, specific symptoms or clinical findings. Examples include a sudden and marked change in the child’s condition, seizures or other neurological symptoms, clear physical effects of rituals, or substantial restriction of food or fluid intake.

What the assessment should make clear

The assessment results in an overall clinical judgement about whether OCD is present, how severely the difficulties affect the child and which other factors need to be considered. The child, family and relevant professionals should share a clear picture of:

• which patterns form part of OCD
• which other difficulties also require attention
• how the patterns affect one another
• where daily life is most restricted at present
• which strengths, interests and relationships the child can continue to build on
• whether a more targeted medical, developmental, educational or psychiatric assessment is needed
• what should take priority in the next stage of support

The explanation should use words that the child or young person understands and recognises. The overall plan should set out the next steps at home, at school and in any further support or treatment, as well as who will follow up.

Parents can begin the work in daily life

At OCD Klinikken, support for children under 15 is provided primarily through consultations with parents. Guidance can begin while the next steps with educational support services, the GP or mental health services are still being clarified, and can also supplement assessment or treatment elsewhere.

During the consultations, parents develop a shared understanding of the OCD pattern and practical tools for questions, rituals, avoidance and situations in which their child becomes stuck. Read about parent guidance and family consultations.