Cognitive-behavioral high parental involvement treatments for pediatric obsessive-compulsive disorder: A meta-analysis

Family accommodation in obsessive-compulsive disorder: An updated systematic review and meta-analysis

Family accommodation might play a crucial role in obsessive-compulsive disorder (OCD). Previous systematic reviews on family accommodation in OCD have focused on specific populations or variables or are outdated. We conducted a preregistered systematic review and meta-analysis on family accommodation in adults, children, and adolescents with OCD (CRD42021264461). We searched PubMed, Scopus, and Web of Science using the keywords "family accommodation" and "obsessive-compulsive disorder. One hundred-eight studies involving 8928 individuals with OCD were included. Our results indicate that levels of family accommodation in OCD are moderate, that there is a significant positive correlation between family accommodation and OCD severity (r = 0.42), that baseline family accommodation does not predict pre- to post-treatment change in OCD severity (g = -0.03), and that family accommodation decreases as a result of both individual and family-focused cognitive behavioral therapy for OCD (g = 2.00 and g = 1.17, respectively). Our findings highlight the relevance of family accommodation in OCD and may help guide assessment and treatment.

Early Identification and Intervention in Pediatric Obsessive-Compulsive Disorder

Obsessive-compulsive disorder (OCD) is a psychiatric disorder characterized by persistent thoughts with subsequent repetitive behaviors. Interventions that are effective for adult OCD cannot simply be generalized to pediatric OCD, since OCD in children and adolescents usually has a different clinical presentation, etiology and course from adult OCD. Delayed and inadequate treatment is associated with a worse prognosis, making the need for early identification and intervention in pediatric OCD very urgent. In this paper, we reflected on the current constraints that make early interventions for pediatric OCD unpromoted and reviewed the approaches with potential application for early identification and early intervention in pediatric OCD, categorized by three-level prevention stages corresponding to a clinical staging model. Since the etiology of pediatric OCD is still unclear, primary prevention is most lacking, and early interventions for pediatric OCD are currently focused on the secondary prevention stage, which aims to prevent the conversion of obsessive-compulsive symptoms into full-blown OCD; tertiary prevention mostly focuses on the alleviation of mild to moderate OCD, while interventions for co-morbidities are still in their infancy. We closed by considering the important research questions on this topic.

Impact of Attention-Deficit/Hyperactivity Disorder Comorbidity on Phenomenology and Treatment Outcomes of Pediatric Obsessive-Compulsive Disorder

Objective: This study, with a case-control design, investigates the impact of attention-deficit/hyperactivity disorder (ADHD) comorbidity on the phenomenology and treatment outcomes in a clinical sample of pediatric obsessive-compulsive disorder (OCD). Methods: The data were derived from an evaluation of the sociodemographic and clinical characteristics of 364 children with OCD who were regularly followed up over a 4-year period. Between-group analyses of psychiatric scales were used to compare patients with ADHD comorbidity (n = 144, 39.5%) with their ADHD-free opponents. The clinical course and treatment outcomes of each patient were evaluated based on 4-year clinical follow-up data. Results: Substantial clinical variations in pediatric OCD caused by ADHD comorbidity were identified, including a male preponderance, higher rates of concurrent conduct problems, tic disorders, and learning disabilities, as well as prolonged symptom and treatment durations accompanied by poor response to first-line treatments and higher rates of treatment resistance. Contrary to previous findings, ADHD comorbidity had no impact on the age of OCD onset, and the severity of OCD symptoms was lower in ADHD. With ADHD comorbidity, the OCD symptom course tended to be chronically stable, which may have resulted in complaints persisting into adulthood. In ADHD-free patients, contamination, doubt, religious, somatic obsessions, and cleaning were all more common than in those with ADHD. There was a positive correlation between compulsion scores and the severity of ADHD symptoms, which may be related to increased compulsive coping in ADHD. Impulsivity or compulsivity dominance in the symptom presentation of OCD-ADHD comorbidity may determine phenomenological distinctions such as whether concurrent traits are more prone to tics, conduct problems, or internalizing problems. The primordial associations for clinical characteristics, which were independently associated with ADHD comorbidity, were adjusted using multivariate logistic regression analysis. Clinical variables such as being male, absence of cleaning compulsion, the existence of concurrent conduct problems, tic disorders, and dyslexia, as well as longer treatment duration and poorer treatment response, were all independent predictors of ADHD comorbidity. With an 80.8% accurate classification and relatively fine goodness-of-fit model, the regression model consisting of those predictors had good predictiveness for ADHD comorbidity (R² = 0.543). Conclusions: The close association between pediatric OCD, ADHD, and tic disorders can be defined as a specific subtype of pediatric OCD, characterized by more conduct problems, a chronically stable course of OCD symptoms, and poorer treatment outcomes. Correlational analyses in a longitudinal design and the inclusion of an impulsivity scale would be beneficial for further research to interpret the impulsivity-related correlates in the findings on tic and conduct problems.

Cognitive-Behavioral Therapy for Obsessive-Compulsive Disorder: 2021 Update

In this update of a previous review, the authors discuss cognitive-behavioral therapy (CBT) with exposure and response prevention for obsessive-compulsive disorder (OCD). This efficacious modality avoids side effects common to psychotropic medication and reduces risk of relapse once treatment has ended. Psychotherapy involves identification and ranking of stimuli that provoke obsessions, exposure to these stimuli while preventing compulsions, and cognitive restructuring. The family of the OCD patient plays a significant role in treatment. This article includes expanded research on family-focused CBT and treatment of pediatric OCD. The family's accommodation and emotional response to a patient's symptoms may interfere with therapy and perpetuate the disorder. The treatment of pediatric OCD involves the same considerations. However, the form of obsessions and compulsions may differ and therapeutic techniques are modified to make them age appropriate.

The relationship between peer victimization and social anxiety among adolescents: a moderated mediation model with cognitive flexibility and affect intensity

Building a friendship with peers is an important developmental task. However, peer victimization and social anxiety are among the most disturbing problems and have impaired adolescents' adaptive development. A total of 942 adolescents completed the survey. The results showed that peer victimization was related to social anxiety and that this effect was mediated by cognitive flexibility and moderated by affect intensity. Specifically, the damage of peer victimization and social anxiety was aggrevated for those with high levels of affect intensity. The current study provides evidence for the association between peer victimization and social anxiety. It contributes to the literature by clarifying the equivocal findings and uncovering the underlying mechanisms of the relationship between peer victimization and social anxiety. In the future, researchers and teachers should pay attention to adolescents' peer social status as early as possible, especially for adolescents with higher levels of affect intensity.

The Relationship of Family Accommodation with Pediatric Anxiety Severity: Meta-analytic Findings and Child, Family and Methodological Moderators

Given the importance of family accommodation for the course, treatment and prognosis of anxiety in pediatric populations, we conducted a meta-analysis to estimate the magnitude and potential moderators of the relationship between accommodation and anxiety severity. Study selection criteria were: (1) included quantitative measures of accommodation and anxiety severity, (2) sampled participants younger than 19 years, (3) a sample size greater than 10, (4) reported statistical data needed to compute effect sizes, and (4) be in English or Spanish. Search procedures included assessment of electronic databases, systematic reviews and empirical studies, and email inquiries. Effect size was Pearson correlation coefficient, assuming a random-effects model. Positive moderate association was observed for measures administered to parents. This was moderated by the percentage of children with separation anxiety and selective mutism. Global effect sizes were small for measures administered to children and when accommodation was reported by parents and anxiety by children. Implications for assessment and treatment are discussed.

Predictors of Parental Accommodation and Response Treatment in Young Children With Obsessive-Compulsive Disorder

Background: Cognitive-behavioral family-based treatment (CBFT) is the treatment standard in very young children with obsessive-compulsive disorder (OCD), which includes the same core components of cognitive-behavioral therapy (CBT) with significant family involvement. Although the latter reports high rates of remission, some children do not improve with treatments. Therefore, it is necessary to identify possible moderating variables such as comorbidity, severity of disorder, years of onset, parental anxiety, and parental accommodation. This study has two main aims: (1) to propose a predictive model on family accommodation (father and mother), taking into account variables related to the children (severity of obsessive-compulsive responses, internalizing and externalizing symptoms, and comorbidity) and with the parents before intervention (worry, accommodation of one parental member over the other) and (2) to examine the mediating role of externalizing symptoms and mother's accommodation in the relation between initial severity and improvement of severity of obsessive-compulsive responses in children aged 5-8 years. Methods: Participants comprised 56 children with OCD [mean = 6.61 (SD = 0.76)] and their parents; 79% of the sample was men. Treatment was implemented by two clinicians specialized in OCD (>15 years of experience). Clinicians were trained to administer CBT protocol in the same way. They were doctors of clinical psychology and researchers at the OCD. Results: Mother's accommodation was associated with child variables (Child Behavior Checklist-Externalizing and Initial Severity, Children's Yale-Brown Obsessive-Compulsive Scale). Father's accommodation could be explained by parent variables (mother's accommodation and worry). Simple mediation model tested using the SPSS macro PROCESS supported the relation of the initial severity of symptoms with that following intervention, through the simple indirect effect of externalizing symptoms of the child. Conclusions: Comorbidities with externalizing symptoms, father's worry, and mother's accommodation were variables that should be controlled in treatment of pediatric OCD.

Clinical significance of family accommodation and parental psychological distress in a sample of children and adolescents with obsessive-compulsive disorder aged 8-17 years old

BACKGROUND

Family Accommodation (FA) refers to the involvement of family members (especially parents) in the compulsive behaviors of children and adolescents with Obsessive-Compulsive Disorder (e.g. modifying family routines or facilitating avoidance of obsessive-compulsive triggers). Many studies have examined the high prevalence of FA in this clinical population; however, less is known about its clinical significance and relationship to the individual psychological distress of parents. In our study, we investigated the clinical significance of FA examining its relationship with obsessive-compulsive symptomatology, functioning, anxiety and depressive symptoms in a clinical sample (n = 51) of children and adolescents with Obsessive-Compulsive Disorder (OCD) aged 8-17 years old and their parents, included to examine their individual psychological distress.

METHODS

The sample was divided into two groups: the High Accommodation group (n = 36) and the Low Accommodation group (n = 15).

RESULTS

Results demonstrated that children and adolescents in the OCD High Accommodation group reported major functional impairment in global (p = .001313), social (p = .000334) and role (p = .000334) domains, and higher depressive symptoms than the Low Accommodation group. Both fathers and mothers from the High Accommodation group reported a higher level of individual psychological distress compared to mothers and fathers from the Low Accommodation group (p = .040365).

CONCLUSIONS

The findings of this study show that FA is common in children and adolescents with OCD and it could cause not only an impairment of the patient's global, social and role functioning but also a high level of individual psychological distress in the single parent. The presence of FA should therefore be carefully investigated and considered in planning assessment and treatment of OCD in children and adolescents.

Mindfulness-based skills training group for parents of obsessive-compulsive disorder-affected children: A caregiver-focused intervention

BACKGROUND AND PURPOSE

Parents of children with obsessive-compulsive disorder (OCD) report significant emotional and socio-occupational impacts. There is, however, currently insufficient support for these parents. This study examined a mindfulness-based intervention for parents of OCD-affected children, investigating its feasibility and impact on parental ability to tolerate their child's OCD-related distress, in addition to exploring potential indirect effects.

MATERIALS AND METHODS

Parents of OCD-affected children (n = 39) completed an eight-week baseline observation period followed by eight, weekly manualized mindfulness-based intervention group sessions. Measures of parental tolerance of child distress, dispositional mindfulness, family accommodation, family functioning, and OCD symptom severity were collected.

RESULTS

In comparison to the baseline observation period, parental tolerance of child distress and dispositional mindfulness significantly improved following mindfulness training. No other temporal differences were observed. Parents reported high satisfaction.

CONCLUSION

Mindfulness-based skills training for parents of OCD-affected youth appears to be feasible and to significantly increase tolerance related to the child's distress.

CLINICAL TRIAL REGISTRATION NUMBER

NCT03212703.

Family accommodation in psychopathology: A synthesized review

Family accommodation describes changes that family members make to their own behavior, to help their relative who is dealing with psychopathology, and to avoid or alleviate distress related to the disorder. Research on family accommodation has expanded greatly in the past few years. The aim of this study was to provide a synthesized review of recent findings on family accommodation in psychopathology. Electronic databases were searched for available, peer-reviewed, English language papers, published between September 2015 and March 2018, cross-referencing psychiatric disorders with accommodation and other family-related terms. Ninety-one papers were identified and reviewed, of which 69 were included. In obsessive-compulsive disorder and anxiety disorders family accommodation has been linked to symptom severity, functional impairment, caregiver burden, and poorer treatment outcomes. Several randomized controlled trials explored the efficacy of treatments aimed at reducing family accommodation. A growing number of studies have reported family accommodation in eating disorders where it is associated with greater symptom severity and caregiver burden. Family accommodation has also been studied in other disorders, including autism spectrum disorders, tic disorders, and posttraumatic stress disorder. Research on family accommodation in psychopathology is advancing steadily, expanding across disorders. The study highlights the importance of addressing family accommodation in the assessment and treatment of various disorders.

Family-based cognitive behavioural therapy for obsessive-compulsive disorder with family accommodation: case report from Saudi Arabia

Family accommodation in obsessive-compulsive disorder (OCD) refers to a condition in which a family member assists or facilitates the patient with OCD in performing the compulsion, or provides assurance to minimize or reduce the anxiety level. This condition can be significantly disabling to the individual as well as to the family dynamic. In this case report, a mother of a 14-year-old female patient carried out almost all the compulsive behaviours and rituals for her child. Family-based cognitive behavioural therapy was offered to this case over a 4-month period with a successful treatment outcome. This result provides initial evidence that this type of intervention is suitable for patients from Saudi Arabia, a non-Western culture.

Psychiatric Treatment and Management of Psychiatric Comorbidities of Movement Disorders

Pediatric movement disorders may present with psychiatric symptoms at many points during the course of the disease. For the relatively common pediatric movement disorder, Tourette syndrome, psychiatric comorbidities are well-described and treatment is well-studied. Managing these comorbidities may be more effective than improving the movements themselves. For more uncommon movement disorders, such as juvenile-onset Huntington disease, treatment of psychiatric comorbidities is not well-characterized, and best-practice recommendations are not available. For the least common movement disorders, such as childhood neurodegeneration with brain iron accumulation, psychiatric features may be nonspecific so that underlying diagnosis may be apparent only after recognition of other symptoms. However, psychiatric medication, psychotherapy, and psychosocial support for these disorders may prove helpful to many children and adolescents.

Family accommodation in adult obsessive-compulsive disorder: clinical perspectives

The term accommodation has been used to refer to family responses specifically related to obsessive-compulsive (OC) symptoms: it encompasses behaviors such as directly participating in compulsions, assisting a relative with obsessive-compulsive disorder (OCD) when he/she is performing a ritual, or helping him/her to avoid triggers that may precipitate obsessions and compulsions. At the opposite side, family responses to OCD may also include interfering with the rituals or actively opposing them; stopping accommodating OC symptoms or actively interfering with their performance is usually associated with greater distress and sometimes even with aggressive behaviors from the patients. This article summarizes progress of the recent research concerning family accommodation in relatives of patients with OCD. Family accommodation is a prevalent phenomenon both among parents of children/adolescents with OCD and relatives/caregivers of adult patients. It can be measured with a specific instrument, the Family Accommodation Scale, of which there are several versions available for use in clinical practice. The vast majority of both parents of children/adolescents with OCD and family members of adult patients show at least some accommodation; providing reassurances to obsessive doubts, participating in rituals and assisting the patient in avoidance are the most frequent accommodating behaviors displayed by family members. Modification of routine and modification of activities specifically due to OC symptoms have been found to be equally prevalent. Specific characteristics of patients (such as contamination/washing symptoms) and of relatives (the presence of anxiety or depressive symptoms or a family history positive for another anxiety disorder) are associated with a higher degree of family accommodation; these family members may particularly benefit from family-based cognitive-behavioral interventions. In recent years, targeting family accommodation has been suggested as a fundamental component of treatment programs and several interventions have been tested. Clinicians should be aware that family-based cognitive-behavior therapy incorporating modules to target family accommodation is more effective in reducing OC symptoms. Targeting family accommodation may be as well relevant for patients treated pharmacologically.