psychology paper

DEPRESSION AND ANXIETY 31:1018–1025 (2014)

Research Article

COMPARING FAMILY ACCOMMODATION IN PEDIATRIC

OBSESSIVE-COMPULSIVE DISORDER, ANXIETY

DISORDERS, AND NONANXIOUS CHILDREN

Eli R. Lebowitz, Ph.D., 1∗Lindsay A. Scharfstein, Ph.D., 1and Johnna Jones, Ph.D. 2

Background: Family accommodation describes ways in which parents modify

their behavior to help a child avoid or alleviate distress caused by emotional

disorders. Accommodation is associated with increased symptom severity, lower

functioning, and poorer treatment outcomes. Accommodation is prevalent in

childhood obsessive-compulsive disorder (OCD) and anxiety disorders (ADs) but

no studies have compared accommodation in these groups or compared them to

healthy controls to ascertain if accommodation is prevalent in the general popu-

lation. This study addresses these gaps by comparing patterns of accommodation,

factors that maintain accommodation, and its relation to symptom severity in

OCD and AD, relative to healthy controls. Method: We directly compared reports

of accommodation to childhood OCD (N = 26) and AD (N = 31), and a compar-

ison group of nonanxious (NA) children (N = 30). Mothers completed measures

of accommodation (Family Accommodation Scale (FAS)/Family Accommodation

Scale–Anxiety (FASA)), anxiety (Screen for Childhood Anxiety Related Emo-

tional Disorders–Parent Report (SCARED-PR)), and OCD (Children’s Yale-

Brown Obsessive Compulsive Scale (CYBOCS)). Results: Family accommoda-

tion is prevalent among mothers of children with OCD and AD. Few differences

were found between the two clinical groups who reported more accommodation

(F[2,84] = 23.411, P < .001, partial η2= .358), greater distress (F[2,84] =

24.050, P < .001, partial η2= .364), and more consequences of not accommo-

dating (F[2,84] = 18.967, P < .001, partial η2= .311), than the NA group.

Accommodation was associated with severity of anxiety in AD (r = .426, P =

.017) and OCD (r = .465, P = .017), but not in the NA group. Conclusions:

Findings highlight family accommodation as a phenomenon that applies broadly

and in a similar manner to children with AD and OCD. Evaluating accommo-

dation provides useful information for clinical care and is an important part of

the assessment of children with AD and OCD. Depression and Anxiety 31:1018–

1025, 2014. C 2014 Wiley Periodicals, Inc.

Key words: family accommodation; child/adolescent; anxiety disorders; fam-

ily/marital; obsessive compulsive disorder; assessment/diagnosis

1Yale Child Study Center, New Haven, Connecticut2University of Texas, Austin, Texas

∗Correspondence to: Dr. Eli Lebowitz, Yale Child Study Cen- ter, PO Box 207900, New Haven, CT 06520-7900. E-mail:[email protected]

INTRODUCTION

P arent and family factors have been tied to the etiology

and trajectory of childhood anxiety disorders (ADs) and

Received for publication 25 November 2013; Revised 6 January 2014; Accepted 18 January 2014

DOI 10.1002/da.22251 Published online 22 February 2014 in Wiley Online Library(wileyonlinelibrary.com).

C 2014 Wiley Periodicals, Inc. Research Article: Accommodation in Childhood OCD and Anxiety 1019

obsessive-compulsive disorder (OCD). Parental anxi-

ety, hostile or critical style, modeling of anxious be-

havior, and overcontrol are among the factors linked to

childhood AD. [1–5] Parental expressed emotion, over-

protection, and low warmth are associated with OCD

in childhood. [6–12] One pattern of parental behavior

observed in both childhood 1OCD and AD is family

accommodation. [ 13–16 ]

Family accommodation describes the ways in which

parents modify their behavior to help a child avoid or

alleviate states of distress and negative affect caused by

emotional disorders. Though well intentioned, family

accommodation is linked to greater symptom severity,

lower functioning, and poorer treatment outcomes.

Childhood OCD and AD are both characterized by

high degrees of family accommodation. [13, 15–17] No

studies have compared family accommodation in OCD

and AD to investigate whether the accommodation,

its relation to symptom severity, or the factors that

maintain it are similar or different in these clinical

groups. Additionally, studies of accommodation in

OCD and AD have generally not included comparisons

to healthy control subjects, making it difﬁcult to

discern how speciﬁc these behaviors are to the clinical

populations. This study aims to address these gaps.

We ﬁrst brieﬂy review the literature regarding family

accommodation in pediatric OCD and AD, and then

present the ﬁrst direct comparison between parental

reports of accommodation in children with OCD or

AD, relative to a nonanxious (NA) control group.

ACCOMMODATION IN OCD

Studies of pediatric OCD have reported high frequen-

cies of accommodating behaviors. These include active

participation in the child’s symptoms (e.g., parents wash-

ing their hands excessively) and modiﬁcations to routines

and schedules (e.g., returning home early from work).

More than 90% of parents report at least some accom-

modation, and most report accommodating daily. [13, 16]

The most common forms of accommodation in OCD

include providing reassurance and awaiting completion

of rituals. [17, 18]

Greater family accommodation is associated with

more severe symptoms in the child and poorer function-

ing for child and family. [ 17, 19–21 ] Accommodation also

predicts poorer outcomes for behavioral and pharma-

cological therapy. [ 16, 22 ] Greater accommodation before

treatment predicts less therapeutic gains and more re-

fractoriness, whereas successful treatment is associated

with reduced accommodation. [13, 21, 23]

Various factors maintain ongoing family accommo-

dation. Parents commonly report temporary exacerba-

tion of the child’s symptoms and/or displays of dis-

tress when they do not accommodate, suggesting that

accommodation is powerfully reinforced. [13, 24, 25] Many

1The term “child” is used throughout this article to describe individuals aged 18 and younger, and includes adolescents.

parents report their child becoming angry or abusive

when symptoms are not accommodated. [13, 17] Accom-

modation may be imposed through rage, [26] physical ag-

gression, or emotional blackmail from the child (e.g.,

“you hate me”). [27–29] Some children feel unable to com-

plete daily tasks when not accommodated, placing more

pressure on the parents to accommodate. Parental psy-

chopathology, particularly symptoms of OCD and other

internalizing disorders, has been associated with greater

accommodation, a link that may be explained by greater

difﬁculty tolerating the child’s distress or stronger iden-

tiﬁcation with the child’s experience. [ 19, 30 ]

ACCOMMODATION IN AD

Studies have highlighted the impact of childhood AD

on family functioning, but generally do not focus specif-

ically on accommodation. [31–33] One study systemati-

cally examined accommodation among children with

AD. [15] Accommodation was found to be highly preva-

lent and associated with child symptom severity. Sepa-

ration anxiety had the highest levels of accommodation,

and speciﬁc phobia had the lowest. School-related anx-

iety and worried preoccupation were the most powerful

dimensional predictors of accommodation. As in OCD,

providing reassurance was the most frequent form of

accommodation in AD. Most parents reported experi-

encing distress resulting from accommodation and neg-

ative consequences of not accommodating the child’s

symptoms. Among the negative consequences, exacer-

bation of the child’s distress was most common and the

child becoming angry/abusive was frequently noted.

To summarize, high levels of family accommodation

have been consistently reported in childhood OCD and

more recently in AD. To date, there have been no com-

parisons of family accommodation between these clinical

groups. Derisley et al. [33] compared general family func-

tioning in children with OCD and AD and a nonclinical

group. They reported both clinical groups had poorer

family functioning than normal controls but did not ﬁnd

differences between family functioning in OCD and AD.

Comparing family accommodation in childhood

OCD and AD can increase our understanding of the role

that family factors play in the development and mainte-

nance of childhood psychopathology. This knowledge

could help clinicians shape appropriate treatments. In-

terventions targeting family accommodation have al-

ready shown promising results in treating OCD or AD

in children who decline treatment, children too young

for cognitive behavior therapy, and children who fail to

respond to it. [34–37]

We directly compared maternal reports of accommo-

dation across OCD and AD and a comparison NA group.

Mothers also reported on their child’s OCD and anxi-

ety symptom severity. We hypothesized that parents of

children with OCD and AD would endorse more ac-

commodation, greater distress related to accommoda-

tion, and more severe behavioral consequences of not

accommodating than parents of NA children. Further,

Depression and Anxiety 1020 Lebowitz et al.

TABLE 1. Demographic characteristics of children ( N=87)

AD ( n=31) OCD ( n=26) NA ( n=30) F/χ2/tvalue Partial η2/η2

Age ( M/SD ) 11.13 (2.2) 12.07 (3.0) 12.13 (2.8) 1.347 .031 Sex ( n/%) 0.828 .098 Females 15 (48.4) 14 (53.8) 18 (60.0)Males 16 (51.6) 12 (46.2) 12 (40.0)

AD, anxiety disorders; OCD, obsessive-compulsive disorder; NA, nonanxious.

we hypothesized a signiﬁcant positive relationship be-

tween accommodation and anxiety symptom severity in

all three groups.

MATERIALS AND METHOD

PARTICIPANTS

Participants were mothers of children, aged 7–17, who met DSM- IV-TR criteria for a primary diagnosis of either OCD ( n=26) or AD ( n=31), and mothers of NA children ( n=30). The three groups did not differ signiﬁcantly on age ( F[2,84] =1.347, P=0.26, η2=.031) or sex of the child ( χ2[2] =0.828, P=0.66, η2=.098) . All moth- ers completed an in-person evaluation, during which all measures forthe present study were collected. The Institutional Review Board ap-proved the study and participants provided written informed consent.Demographic characteristics are summarized in Table 1.

PROCEDURE AND MEASURES

Children in the OCD group presented at an OCD Specialty Clinicat a major medical center in the United States and diagnosis wasconﬁrmed with the Children’s Yale-Brown Obsessive Compulsive Scale (CYBOCS). [38] CY-BOCS is a semistructured, clinician-administered inventory of pediatric OCD symptoms and severity and yields a totalscore, from 0 to 40, and subscale scores. A total score of 16 or higher was required for inclusion in the study. Experienced clinicians trained by one of the authors of the measure administered the CY-BOCS.The CY-BOCS is widely used and yields reliable and valid scores forOC symptom severity. [39] Scores for this sample fell within the severe OCD symptom range ( M=27.50, SD =3.8). Children in the AD group presented at Programs for Anxiety Dis-orders in two major medical centers and diagnoses were conﬁrmedwith the Anxiety Disorders Interview Schedule for Children: Parent Ver- sion (ADIS-P). [40] Children did not meet criteria for OCD. ADIS-P is a semistructured interview designed to assess DSM-IV AD and otherpsychiatric disorders. A clinical psychologist or postgraduate clini-cal psychology student administered the interviews. ADIS-P has highinter-rater reliability [41] and is the gold standard for establishing AD diagnoses. In the AD group, 40% of children met criteria for a singleAD diagnosis, 47% ﬁt two diagnoses, and 13% ﬁt three diagnoses.The most common AD was generalized anxiety (41%), followed byseparation anxiety (31%), speciﬁc phobias (16%), and social phobia(12%).The NA group comprised nontreatment-seeking individuals recruited from the community with no history of OCD, AD, or otherpsychiatric diagnosis. The Screen for Childhood Anxiety RelatedEmotional Disorders–Parent Report (SCARED-PR) [42] was used to screen for anxiety concerns. Subjects whose total SCARED scoreexceeded 12, well below cutoff for clinical anxiety, were excludedfrom the NA group.

FAMILY ACCOMMODATION

Mothers in the OCD group completed the 13 items from the Fam- ily Accommodation Scale (FAS) by Calvocoressi et al. [14] These items have frequently been used in self-report form and have demonstratedexcellent psychometric qualities. [17,18,43] Items were rated on a 5- point Likert-type scale ranging from 0 ( never )to4( daily ). An overall Accommodation score was calculated based on the ﬁrst nine itemsincluding Participation (ﬁve items) and modiﬁcation (four items). Ad-ditional items assess Distress related to accommodation (one item) andnegative Consequences of not accommodating (three items). Internal consistency for the FAS accommodation items was high ( α=.861). Mothers in the AD group completed the Family Accommodation Scale–Anxiety (FASA). [15] FASA closely mirrors the FAS items but was adapted to measure accommodation to anxiety rather than OCDsymptoms. The FASA yields the same overall Accommodation scoreand subscale scores of Participation, Modiﬁcation, Distress, and Con-sequences as the FAS. The FASA has good internal consistency andconvergent and divergent validity and is sensitive to detecting fam-ily accommodation among various childhood ADs. [15] Mothers in the NA group also completed FASA. Although the children did not haveclinically signiﬁcant anxiety, FASA items are better suited to the gen-eral population of children (who presumably experience anxiety someof the time) than the FAS items, which are OCD speciﬁc. The FASAAccommodation items displayed adequate internal consistency for theAD ( α=.870) and NA ( α=.725) groups.

ANXIETY SYMPTOM SEVERITY

All mothers completed the SCARED-PR [42] to obtain a measure of the child’s anxiety symptoms. Forty-one items were rated on a three-point scale. A SCARED-PR total score and the four subscale scores ofPanic/Somatic, Generalized Anxiety, Separation Anxiety, Social Anx-iety, and School Anxiety were calculated. The SCARED-PR differen-tiates between clinically anxious and NA children. [44] Internal consis- tency of the SCARED-PR total score was adequate for the OCD, AD, and NA groups ( α=.923, .941, .739, respectively).

RESULTS

FAMILY ACCOMMODATION

Accommodation was highly prevalent in both clinical

groups. Most mothers of AD (61%) and OCD (69%)

children reported daily participation in symptoms, com-

pared to 23% of NA mothers. Daily modiﬁcation of

routines and schedules was reported by mothers of AD

(19%) and OCD (27%) children, whereas no mothers of

NA children reported daily modiﬁcations. Sixteen per-

cent of AD mothers and 23% of OCD mothers reported

both daily participation and modiﬁcations. Two mothers

(one OCD and one NA) reported no accommodating be-

haviors at all. Item-by-item comparisons of the AD and

Depression and Anxiety Research Article: Accommodation in Childhood OCD and Anxiety 1021

TABLE 2. Accommodation and anxiety levels in the three study groups ( N=87)

AD M(SD )n=31 OCD M(SD )n=26 NA M(SD )n=30 F-Value Partial η2

FASA/FAS Accommodation 15.39 (8.9) a 18.77 (9.0) a 5.57 (3.9) b 23.411 * .358 Participation (total) 9.87 (5.3) a 11.92 (5.7) a 4.47 (3.0) b 18.676 * .308 Providing reassurance 3.12 (1.11) 3.11 (1.36) 2.03 (1.21) - -Providing items 1.35 (1.64) 2.3 (1.66) 0.73 (1.04) - -Participating in symptoms 2.25 (1.52) 2.5 (1.6) 0.7 (0.65) - -Assisting avoidance 2.0 (1.5) 2.46 (1.6) 0.83 (1.01) - -Avoiding things/places 1.12 (1.28) 1.53 (1.36) 0.16 (0.46) - -Modiﬁcation (total) 5.52 (5.0) a 6.85 (4.4) a 1.10 (1.2) b 17.174 * .290 Modifying family routines 1.48 (1.41) 1.88 (1.39) 0.03 (0.18) - -Doing things in place of child 1.61 (1.35) 1.46 (1.3) 0.9 (0.95) - -Modifying work schedule 1.19 (1.35) 1.69 (1.46) 0.1 (0.3) - -Modifying leisure activities 1.22 (1.4) 1.8 (1.29) 0.06 (0.25) - - Parent distress 1.65 (1.3) a 2.35 (1.4) a 0.30 (0.6) b 24.050 * .364 Consequences (total) 5.10 (3.7) a 6.08 (3.8) a 1.20 (1.6) b 18.967 * .311 Child becomes distressed 1.8 (1.42) 2.5 (1.36) 0.56 (0.67) - -Child is angry/abusive 1.32 (1.44) 1.57 (1.6) 0.26 (0.58) - -Child anxiety worsens 1.96 (1.47) 2.0 (1.46) 0.36 (0.61) - -

SCARED-PR Total Anxiety 37.23 (18.8) a 30.92 (13.8) a 5.27 (3.9) b 45.848 * .522 Panic/Somatic 8.42 (7.3) a 4.85 (5.5) b 0.53 (0.7) c 16.759 * .285 General Anxiety 10.71 (4.6) a 9.96 (3.7) a 2.20 (2.5) b 47.518 * .531 Separation Anxiety 8.42 (7.3) a 4.85 (5.5) b 1.10 (1.5) c 14.096 * .251 Social Anxiety 10.74 (5.7) a 8.54 (4.2) a 1.13 (1.3) b 43.123 * .507 School Anxiety 3.35 (2.7) a 2.65 (2.1) a 0.17 (0.5) b 21.522 * .339

FAS, Family Accommodation Scale; FASA, Family Accommodation Scale-Anxiety; SCARED-PR, Screen for Childhood Anxiety Related EmotionalDisorders—Parent Report; AD, anxiety disorders; OCD, obsessive compulsive disorder; NA, nonanxious.a,b,c Means sharing superscripts are not signiﬁcantly different. * P-value <.001.

OCD groups on all the FAS/FASA questions revealed no

differences in the distribution of answers to any of the

accommodation items ( P>.17 for all χ2tests). The high-

est rated accommodating behavior across all groups was

providing reassurance (MOCD = 3.1, MAD = 3.1, MNA =

2). The lowest rated items in the AD and OCD groups

were avoiding things/places and doing things instead of the

child , respectively, and in the NA group modifying leisure

activities .

A series of analyses of variance (ANOVAs) examined

the effect of group on maternal reports of overall Accom-

modation, and the subscales of Participation, Modiﬁca-

tion, Distress, and Consequences. Signiﬁcant Fscores

were followed by least signiﬁcant difference (LSD) tests

to determine where differences occurred. A Bonferroni

correction was applied to avoid inﬂation of the type I

error rate. Means and standard deviations are reported

in Table 2. A priori power analysis indicated the number

of participants necessary to achieve power of 0.8 to de-

tect an overall group difference with an effect size of f=

0.35 is 84, whereas the necessary sample size to achieve

power of 0.8 to detect a difference between the two clin-

ical groups with an effect size of d= 0.8 is 52; hence the

study was adequately powered.

There was a signiﬁcant main effect for group on Ac-

commodation ( F[2,84] = 23.411, P< .001, partial η2=

.358) and the subscales of Participation ( F[2,84] =

18.676, P < .001, partial η2= .308), Modiﬁcation

( F[2,84] = 17.174, P< .001, partial η2= .290), Distress

( F[2,84] =24.050, P<.001, partial η2=.364), and Con-

sequences ( F[2,84] =18.967, P<.001, partial η2=.311).

Post hoc LSD tests did not reveal any signiﬁcant

differences between the two clinical groups for overall

accommodation, participation, or modiﬁcation. These

groups did not differ signiﬁcantly with regard to distress

from accommodation or negative consequences of not

accommodating.

Mothers of AD and OCD children had signiﬁcantly

higher scores than the NA group across all accommoda-

tion measures including overall accommodation and the

subscales of participation and modiﬁcation ( P< .001).

Finally, mothers of children with OCD or AD reported

signiﬁcantly greater distress resulting from accommoda-

tion ( P< .001) and more negative consequences of not

accommodating, compared to mothers of NA children

( P< .001).

ANXIETY SYMPTOM SEVERITY

A series of ANOVAs examined the effect of group on

mothers’ reports of their child’s anxiety symptoms based

on the SCARED-PR total, Panic/Somatic, Generalized

Anxiety, Separation Anxiety, Social Anxiety, and School

Anxiety scores. Signiﬁcant F scores were followed by

Depression and Anxiety 1022 Lebowitz et al.

LSD tests to determine where differences occurred. A

Bonferroni correction was applied to avoid inﬂation of

the type I error rate. The means and standard deviations

are reported in Table 2.

A signiﬁcant main effect existed for group on total

score ( F[2,84] = 45.848, P< .001, partial η2= .522),

and the Panic/Somatic ( F[2,84] =16.759, P<.001, par-

tial η2= .285), Generalized Anxiety ( F[2,84] = 47.518,

P < .001, partial η2 = .531), Separation Anxiety

( F[2,84] = 14.096, P< .001, partial η2= .251), Social

Anxiety ( F[2,84] = 43.123, P< .001, partial η2= .507),

and School Anxiety ( F[2,84] = 21.522, P< 0001, partial

η2= .339) subscales.

Post hoc LSD tests revealed that children with AD

were rated higher on panic/somatic symptoms and sep-

aration anxiety than children with OCD ( Ps<.05). The

AD and OCD groups were not signiﬁcantly different on

overall anxiety, generalized anxiety, social anxiety, and

school anxiety ( Ps> .05).

Children with AD and OCD were rated as experienc-

ing more overall anxiety (both Ps<.001), panic/somatic

symptoms ( P< .001 and .020, respectively), generalized

anxiety ( Ps< .001), separation anxiety ( P< .001 and

.040, respectively), social anxiety ( Ps < .001), and school

anxiety (both Ps< .001) than NA children.

RELATION BETWEEN ACCOMMODATION AND

ANXIETY SEVERITY

A series of correlations explored the relation between

overall accommodation on the FAS/FASA and dimen-

sions of child anxiety on the SCARED-PR scores. There

was a signiﬁcant positive correlation between overall Ac-

commodation and overall anxiety ( r= .426, P= .017)

and school anxiety ( r=.431, P=.016) for the AD group.

For the OCD group, total Accommodation was signiﬁ-

cantly correlated with overall anxiety ( r=.465, P=.017)

and general anxiety ( r= .654, P< .001). There were no

signiﬁcant correlations between overall Accommodation

and dimensions of child anxiety for the NA group (all

P s> .1).

DISCUSSION

This study directly compared maternal reports of fam-

ily accommodation among children with OCD, AD, and

a comparison group of NA children. The study aimed to

investigate whether patterns of accommodation, factors

that maintain it and its relation to symptoms of child anx-

iety are similar or different among these groups. Over-

all ﬁndings highlight family accommodation as a phe-

nomenon that applies broadly and in a similar manner

in childhood AD and OCD.

PATTERNS OF ACCOMMODATION

Accommodation was highly prevalent among moth-

ers of children with OCD and AD. Examinations of the

subdomains of accommodation indicated that mothers

of children with OCD and AD frequently participate in

their children’s symptoms. Participation includes verbal

reassurance, facilitating avoidance, providing items, and

parental avoidance. Mothers of children with OCD and

AD also reported modifying their routines because of the

child’s symptoms (e.g., changing family/work schedules,

altering leisure activities, and completing the child’s re-

sponsibilities). These data suggest that family accommo-

dation, a construct well studied in OCD, is also impor-

tant to consider among children with AD, among whom

it has been less extensively studied.

There were no signiﬁcant differences between OCD

and AD in parent participation, modiﬁcation, and over-

all accommodation. These results are in line with an ear-

lier comparison of family functioning in pediatric OCD,

AD, and NA children. [33] Parents of OCD and AD chil-

dren reported greater use of avoidance strategies than

parents of NA children, with no signiﬁcant differences

between the clinical groups. However, not all studies

found similar patterns in families of OCD and AD chil-

dren. Parents of OCD children were observed to provide

less praise for autonomy and display less conﬁdence in

their child’s ability relative to parents of AD, externaliz-

ing, or NA children. [45] Other studies have highlighted

less autonomy granting as a feature of parental behavior

in AD. [46] Clearly, more research is necessary to deepen

the understanding of the similarities and differences in

parental behavior in OCD and AD. The current study

highlights the similarities, at least with regard to family

accommodation.

Comparisons of accommodation between clinical

children and NA children supported the study hypothe-

ses. Mothers of AD or OCD children reported more

overall accommodation, participation, and modiﬁcation

than mothers of NA children, for whom infrequent ac-

commodation was reported. An obvious interpretation

is that lower rates of accommodation of NA children

simply reﬂect NA children being less anxious. But the

results of this study also highlight another interesting

possibility. A strong and signiﬁcant correlation existed

between child anxiety severity and overall accommoda-

tion in both clinical groups. No such correlation was

found in the NA group. Perhaps parents of NA chil-

dren are less responsive to their child’s anxiety, even

when it manifests. Given the strong data supporting

the link between accommodation and impairment, it is

plausible that when parents are not overly responsive,

the child is less likely to develop clinically signiﬁcant

anxiety. Although tantalizing in its implications for pre-

ventive efforts, conﬁdence in this interpretation is tem-

pered by the truncated range of anxiety scores in the

NA group and by the lack of longitudinal data on these

families. Further research should investigate the possi-

bility that less-accommodating parenting may serve as

a protective factor in lowering risk for developing a full

blown AD.

The ﬁndings suggest that accommodation is an im-

portant element to consider in assessing families of

children with AD or OCD. The practice parameters

for treatment of childhood OCD call for evaluating

Depression and Anxiety Research Article: Accommodation in Childhood OCD and Anxiety 1023

family accommodation as part of standard assessments

and a similar recommendation may be appropriate for

AD. [47] The ﬁndings also indicate that FASA adequately

captures the phenomenon, and effectively distinguishes

between clinical and nonclinical patterns of accommo-

dation.

FACTORS THAT MAINTAIN ACCOMMODATION

Mothers in the OCD and AD groups reported similar

consequences of not accommodating their child’s symp-

toms. Both groups reported the child frequently becom-

ing angry or abusive and described a short-term wors-

ening of the child’s symptoms. Accommodation may be

fueled or reinforced by short-term relief from the aver-

sive experience of parenting a child under emotional

duress. The results might reﬂect the circuitous relation-

ship between anxiety and accommodation, regardless of

the particular stimuli that trigger the emotional distress.

Clinically, understanding the cycle of anxiety and ac-

commodation may be important for aiding families in

overcoming AD or OCD. Parents appear to respond to

children’s distress with greater accommodation, despite

the accommodation causing them signiﬁcant personal

distress. The accommodation provides children with

short-term relief, negatively reinforcing the displays of

distress. The continued reliance on parent accommo-

dation may further undermine the children’s ability or

willingness for self-regulation and coping with the symp-

toms, further perpetuating the cycle. Parents may beneﬁt

from work that would better prepare them for dealing

with the child’s distress or from cognitive restructuring

of the thoughts they have when the child is distressed;

children may beneﬁt from treatments that replace the re-

liance on parent accommodation with self-efﬁcacy; and

reducing accommodation may show both parents and

child that the cycle can in fact be mitigated.

RELATION BETWEEN ACCOMMODATION AND

ANXIETY SYMPTOM SEVERITY

Consistent with previous research, accommodation

was associated with increased overall anxiety symptom

severity, but only for the clinical groups. As mentioned

earlier, the relation between overall anxiety severity and

family accommodation did not hold in the NA group.

In the AD group only, the school anxiety SCARED-PR

subscale was also associated with degree of accommo-

dation and in the OCD group, the generalized anxiety

subscale correlated positively with family accommoda-

tion.

LIMITATIONS

Some limitations of this study should be noted.

First, we examined family accommodation based on

maternal report only. Earlier studies in both OCD

and AD have indicated that mothers are the primary

“accommodators” [29] and parents tend to agree on over-

all family functioning, [48] but paternal perspective could

enhance the report. Second, FAS/FASA include rel-

atively broad statements describing forms of accom-

modation, not detailed qualitative descriptions. This is

strength in allowing for the direct comparison this study

undertook but also limits the subtlety of the information

received. It is plausible, for example, that although both

OCD and NA mothers “provide items” to accommo-

date their children, the kinds of items may be different.

Indeed, there are likely differences within the different

ADs as well. This relates to another limitation. Although

the sample size permitted between-group comparisons,

it was not sufﬁcient to investigate accommodation within

the various AD, particularly given the typically high co-

morbidity in these disorders. An additional limitation is

the absence of clinical and psychosocial data relating to

mothers in this study and of broader clinical data on the

children, apart from anxiety symptoms. Such informa-

tion would greatly enrich the clinical picture and our

understanding of the potentially causal role of family

accommodation (FA) for the course of AD. These lim-

itations may be addressed in future research, some of

which is already underway.

IMPLICATIONS FOR TREATMENT

The results of the current study highlight the impor-

tance of assessing the presence and extent of family ac-

commodation in youth with OCD or AD. Parents should

be educated on the potentially negative implications of

FA. In particular, providing reassurance is very common

across both AD and OCD, and parents will need alter-

native strategies for coping effectively with their chil-

dren’s distress. Prospective longitudinal studies will in-

vestigate the causal role of FA in the development of AD

but the current data already point to the need for inter-

ventions that effectively reduce accommodation. Further

studies are needed to assess the efﬁcacy of the SPACE

program, [36] which focuses on this aim.

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