Predictors of Parental Accommodation in Pediatric Obsessive-Compulsive Disorder: Findings from the...

NEW RESEARCH

Predictors of Parental Accommodation inPediatric Obsessive-Compulsive Disorder:

Findings from the Pediatric Obsessive-Compulsive Disorder Treatment Study

(POTS) TrialChristopher A. Flessner, Ph.D., Jennifer B. Freeman, Ph.D., Jeffrey Sapyta, Ph.D.,Abbe Garcia, Ph.D., Martin E. Franklin, Ph.D., John S. March, MD, Edna Foa, Ph.D.

Objective: Few studies have examined predictors of parental accommodation (assessed withthe Family Accommodation Scale–Parent Report) among families of children with obsessive-compulsive disorder (OCD). No studies have examined this phenomenon using empiricallyderived subscales of the Family Accommodation Scale–Parent Report (i.e., Caregiver Involve-ment, Avoidance of Triggers). Method: Ninety-six youths (and their families) were includedin the present study. Parents were asked to complete the Family Accommodation Scale–ParentReport. Families also completed several additional measurements assessing child- andparent-level variables of interest. Regression analyses were used to examine potentialpredictors of accommodation. Results: Results support prior research suggesting that ac-commodation is ubiquitous among the families of children with OCD. Analyses revealed thatseveral child-level (i.e., compulsion severity, oppositional behavior, and frequency of washingsymptoms) and one parent-level (i.e., symptoms of anxiety) predictors work jointly to providesignificant predictive models of parental accommodation. Conclusions: Clinicians andresearchers should be aware of the impact of specific child- and parent-level variables onfamily accommodation in pediatric OCD and in turn their implications for treatmentcompliance, adherence, and, by extension, outcome. Study limitations warrant replication andextension of these findings; in particular, researchers may seek to obtain a better understand-ing of how the various facets of parental accommodation may differentially affect treatment.J. Am. Acad. Child Adolesc. Psychiatry, 2011;50(7):716–725. Key words: accommodation,child, obsessive-compulsive disorder, predictors

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O bsessive-compulsive disorder (OCD) runs along-term and impairing course and af-fects 1.5 to 2.2 million children in the

United States (2% to 3% prevalence rate).1,2 Pe-diatric OCD is associated with marked impair-ment in functioning,3-6 and most of these chil-dren also meet diagnostic criteria for at least oneother psychiatric disorder (e.g., 75% to 84%).7

Because of the burden this disorder places onchildren and their families, it is important toexamine variables that may be influential in itsetiology, maintenance, and treatment.

Researchers have suggested that, within thecontext of the family, OCD demonstrates a bidi-
rectional relation. That is, families influence and
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are affected by OCD behaviors.8 More specifi-ally, the relation between specific parentingehaviors and OCD has been examined9-24;ithin this growing body of research, the phe-

omenon of parental accommodation has gar-ered the most research attention. The term ac-ommodation is often defined as participation ofamily members in an individual’s OCD-relatedituals (e.g., aiding in ritual completion, facilitat-ng avoidance of situations).9,12 Several studies

have found high rates of accommodation amongthe families of individuals with OCD20,24 anda significant, positive correlation between ac-commodation and family dysfunction,9,11,12,18,20

symptoms of anxiety and depression (as reported

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PREDICTORS OF PARENTAL ACCOMMODATION

by patients and family members),9,11 and symp-tom severity.9,12,18,20 Collectively, however, littleresearch has examined accommodation in chil-dren,10,14,15,18,24,25 and yet it is at this develop-mental stage when accommodation might exertits most pernicious effects.

In a recent study of 110 adults with OCD, onlyOCD severity and cleaning or contaminationsymptoms were associated with accommoda-tion.26 The investigators posited that patientspresenting with particular OCD symptoms (i.e.,washing/cleaning) might require modification toexisting treatment protocols. Peris et al.20 exam-ined correlates of accommodation using the Fam-ily Accommodation Scale–Parent Report (FAS-PR) in families of 65 children and adolescentswith OCD. Parental involvement in children’srituals, as assessed with the Total Involvementsubscale constructed by the investigators (con-sisting of items 1 to 9 from the FAS-PR) demon-strated a significant, positive correlation withOCD symptom severity and parental symptomsof psychopathology. Similarly, Storch et al.18

demonstrated that parental accommodationshows a positive relation to symptom severityand internalizing and externalizing symptoms(broadly defined by parent report on the ChildBehavior Checklist). The study by Peris et al.also highlights the potential importance of ex-amining not only the relation between child-and parent-level variables and accommoda-tion, but also distinct yet related facets ofparental accommodation.

Several limitations are noteworthy to thesestudies of accommodation in childhood OCD20,18

and highlight the unique contribution of thepresent study to the literature. First, previousstudies have used a 13-item version of theFAS-PR that, until recently, had not been vali-dated for use in the families of children withOCD or in a parent-report format.27 Furthermore,the decision by Peris et al.20 to construct sub-scales (i.e., Total Involvement, Child Conse-quences) for the FAS-PR was based on clinicalrather than empirical evidence. A recent factoranalysis and examination of the scale’s psycho-metric properties has suggested that a 12-itemversion of the FAS-PR consisting of two subscalesis most appropriate.27 In that study, Flessner etal. 27 found that the FAS-PR consists of twodistinct yet related subscales assessing parentalinvolvement in their child’s OCD-related rituals
(Involvement in Compulsions) and the family’s
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avoidance of stimuli that may elicit OCD-relatedbehaviors (Avoidance of Triggers). Importantly,the items constituting these empirically derivedsubscales are markedly different from those pro-posed by Peris et al..20 Second, Peris et al. are the

nly researchers to examine the relation betweenarent-level variables and accommodation inome form. For example, the relation with otherarent-level variables (e.g., symptoms of depres-ion, trait anxiety) remains unexamined. Third,o study has examined the role of specificymptom dimensions (i.e., washing/cleaning,rdering, checking, etc.) on parental accommo-ation of childhood OCD. The present studyims to address each of these limitations torior research.

A recent study by Merlo et al.28 found thatdecreased parental accommodation was associatedwith improved treatment response to cognitive-behavior therapy (CBT) for childhood OCD. Al-though using an unvalidated version of the FAS-PR, these preliminary findings suggest thatunderstanding variables that may influence thedegree to which parents accommodate theirchild’s OCD-related rituals may have importanttreatment implications. In turn, becaue increasedscores on the Involvement in Compulsions andAvoidance of Triggers subscales will affect totalaccommodation, understanding potentiallyunique variables that may influence these facetsof parental accommodation may provide addi-tional information regarding areas in need ofmore careful assessment (e.g., child’s degree ofoppositional behavior, specific symptom profiles,etc.) during the therapeutic process. Therefore,the primary aim of this study was to examinepotential predictors of accommodation in thefamilies of children with OCD using child- andparent-level variables. This study is the first toexamine the role various demographic and phe-nomenological (including symptom dimensions)variables play in predicting accommodation, asassessed with a newly validated, 12-item FAS-PRand two empirically derived facets of accommo-dation (i.e., Involvement in Compulsions andAvoidance of Triggers).

METHODParticipantsParticipants were recruited as part of a larger study,the Pediatric OCD Treatment Study (POTS), examin-ing the efficacy of CBT alone, pharmacotherapy alone
(i.e., sertraline), and combined therapy compared with
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placebo for the treatment of youths (7 to 17 years ofage) with OCD.29 The background, rationale, andprocedures for the POTS have been described else-where.30 Informed consent was obtained.

Inclusion and exclusion criteria for the POTS havebeen documented in detail elsewhere.29,30 To be in-cluded in the present study, parents of participantswere also required to have completed the 12-itemFAS-PR (i.e., omitting one or fewer items). In total, 96youths met inclusion criteria for the study and hadcompleted the relevant measurements at baseline. Thesample was 51% girls (n � 49) and predominantlyCaucasian 93.8% (n � 90). Participants’ ages rangedfrom 7 to 17 years (mean � 11.6, standard deviation �2.7). According to data obtained by administration ofthe Anxiety Disorder Interview Schedule for Chil-dren,31 generalized anxiety disorder (36.5%, n � 35),specific phobia (29.2%, n � 28), attention-deficit/hy-peractivity disorder (i.e., combined, inattentive, orhyperactive type; 20.8%, n � 20), tic disorder (17.7%,n � 17), separation anxiety disorder (15.6%%, n � 15),and oppositional defiant disorder (8.3%, n � 8) wereamong the most common comorbid diagnoses.

InstrumentsChild Measurements of Psychopathology.Children’s Yale-Brown Obsessive-Compulsive Scale(CY-BOCS).32 The CY-BOCS is a 10-item clinician-administered instrument assessing OCD obsessions(scores from 0 to 20), compulsions (scores from 0 to 20),and total symptom severity (scores from 0 to 40) inyouths. The scale demonstrates good psychometricproperties.32 To increase specificity for facets of symp-tom severity that may predict parental accommoda-tion, the CY-BOCS Obsessions and Compulsions sub-scale scores were used rather than the CY-BOCS totalscore.Multidimensional Anxiety Scale for Children(MASC). The MASC is a 39-item self-report scaleassessing anxiety in children and demonstrates goodpsychometric properties.33,34

Child Depression Inventory (CDI).35 The CDI is a27-item self-report scale assessing depression in childrenand demonstrates good psychometric properties.35

Conners’ Parents Rating Scale–Revised: Long(CPRS).36 The CPRS-Revised: Long is an 80-itemparent-report measurement assessing domains of rel-evance to attention-deficit/hyperactivity disorder anddemonstrates good psychometric properties.36 For thepresent study, to provide an index of child opposi-tional behavior, only the Oppositional subscale wasused.Obsessive-Compulsive Inventory–Child Version(OCI-CV).37 The OCI-CV is a 21-item child-reportmeasurement designed to assess symptom dimensionsof OCD. The scale demonstrates good psychometric
properties.37 In lieu of individual symptom-level data
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from the CY-BOCS, the Ordering, Washing, Checking,and Hoarding subscales of the OCI-CV were used forthe present study because these subscales mirrorsymptoms profiles used by Stewart et al.26 in examin-ing accommodation in the families of adults withOCD. Also, to provide a better comparison with prioradult research (e.g., report of affected individuals),38

the child-report version of the OCI rather than theparent-report version was used.Parent Measurements of Psychopathology/Behavior.Family Accommodation Scale–Parent Report.11 The

AS-PR is a 12-item parent-report scale assessing pa-ental accommodation of the child’s OCD-related rit-als. Recent evidence has suggested that a 12- rather

han 13-item version of the FAS-PR demonstrates atable factor structure, excellent internal consistency� � 0.90), good convergent validity, and adequateiscriminant validity.27 In addition, the scale consists

of two separate yet related (r � 0.55) subscales assess-ing the degree to which caregivers are involved in theirchild’s OCD symptoms (i.e., Involvement in Compul-sions, � � 0.80) and avoid certain situations or triggersfor their child’s OCD-related rituals (i.e., Avoidance ofTriggers, � � 0.80).Brief Symptom Inventory (BSI).39 The BSI is a 53-itemself-report measurement assessing parental psychiatricstatus (within the previous week) and demonstratesgood psychometric properties.39 For the present study,only the Anxiety subscale of the BSI was used toprovide measurements of current anxiety symptom-atology (to complement trait anxiety, described below)and parental psychopathology that may be relevant topredicting accommodation.Beck Depression Inventory (BDI).40 The BDI is a

1-item self-report scale assessing symptoms of de-ression and demonstrates good psychometricroperties.41

Yale-Brown Obsessive-Compulsive Scale–Self Report(YBOCS-SR). The YBOCS-SR is a parent self-reportinstrument modeled after a clinician-administered in-strument, the Y-BOCS. The original version of theY-BOCS demonstrates good psychometric proper-ties.42,43 For the present study, the YBOCS-SR demon-strated excellent internal consistency (� � 0.93).State-Trait Anxiety Inventory-Trait (STAI-Trait).44

The STAI is a 40-item self-report instrument assessingsymptoms of anxiety at the present time (20 items, State)and generally (20 items, Trait). The original STAIdemonstrates good psychometric properties.44 In thelarger study (i.e., POTS), only the STAI-Trait wasadministered. For this study, the STAI-Trait demon-strated excellent internal consistency (� � 0.90).

ProcedureEntrance into the larger study29 took an average of 2 to3 weeks and proceeded through four entry gates:
telephone screening, review of youth- and parent-


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report measurements, consent and assessment of allinclusion and exclusion criteria, and baseline assess-ment and randomization to treatment condition. Allmeasurements reported in the present study and sub-sequently used in data analysis were obtained at thebaseline assessment.Data Analytic Plan. Recent empirical evidence hassuggested that accommodation may consist of at leasttwo related facets.27 Therefore, the present study usedthree empirically derived dependent (outcome) measure-ments of accommodation: Total Accommodation(FAS-PR total score), Involvement in Compulsions, andFamily Avoidance. To account for possible missing data(i.e., one item not completed), total and subscale scoreswere calculated by obtaining the mean of availablescores. This value was then used as the outcome mea-surement for subsequent regression analyses.

Based on prior OCD research and theoretical con-siderations, 16 variables were chosen as possible can-didate predictors of accommodation. These variablesfell within the domains of child- or parent-level vari-ables. Child-level variables included age, gender, CDItotal score, MASC total T score, CY-BOCS Obsessionand Compulsion total scores, CPRS Oppositionalsubscale T score, and OCI-CV symptom dimensionscores (i.e., Checking, Hoarding, Ordering, and Wash-ing). Parent-level variables included BDI total score,YBOCS-SR Obsession and Compulsions total scores,STAI-Trait total score, and BSI Anxiety total score.Participants with more than 20% missing data for anyvariable were excluded from that variable’s analyses.For example, a participant with missing CDI totalscore data but no other missing data was excludedonly from analyses involving the CDI. The amount ofmissing data (e.g., �20%) was calculated for eachvariable. Results were 0% for CY-BOCS, 6.3% forMASC, 3.1 % for CDI, 9.5% for CPRS Oppositionalscale, 5.2% for OCI-CV, 1% for BDI, 7.3% for YBOCS-SR, 6.3% for BSI Anxiety, and 6.3% for STAI-Trait.

Before developing final regression models, the distri-bution of the study’s outcome measurements was exam-ined. Preliminary analysis suggested that only Avoid-ance of Triggers scores deviated from assumptions ofnormality (i.e., positively skewed). Therefore, a logarith-mic (log) transformation was conducted resulting innormally distributed log-transformed Avoidance ofTriggers scores. Next, the relations between the afore-mentioned variables and dependent measurementswere examined using parametric tests to inform modelbuilding. Variables were evaluated using Pearson (i.e.,continuous) and point-biserial (i.e., dichotomous) cor-relation coefficients. In turn, variables were evaluatedto test for possible colinearity.

Linear multiple regression analyses were employedto develop this study’s primary regression models(N � 3; Total Accommodation, Involvement in Com-pulsions, and Avoidance of Triggers). Identical proce-
dures were used to determine each outcome measure- s


ment’s final regression model and were modeled afterwork conducted by Stewart et al.38 examining familyaccommodation in adults with OCD. Variables dem-onstrating � levels lower than 0.1 based on preliminary

earson and point-biserial correlations (Table 1) wereelected as candidate predictors. Potential moderatorsere removed by eliminating potentially redundant

ariables, which were defined as those within the sameonceptual grouping (e.g., obsessions-compulsions, anx-ety-depression), with baseline intercorrelations higherhan 0.50. Selection of the appropriate variable from theseroupings was based on theoretical considerationsnd/or previous research findings. For example, CY-OCS Compulsions rather than Obsessions was includedecause it was anticipated that parents would be more

ikely to accommodate overt symptoms of the disorder.orrelational analyses provide some support for thisypothesis. All unique candidate predictors were en-

ered into the regression model. Only those variableschieving an � values less than or equal to 0.05 werencluded in the final regression model. Those variablesot obtaining this threshold were removed and theegression analysis was rerun to reveal the final regres-ion model. After building the models, distribution ofesiduals was examined to test for assumption of nor-ality. Residuals were plotted against predicted values

o test for equality of variance assumptions, and Cook Das used to identify potential outliers.

RESULTSDescriptive DataTable 2 presents descriptive data for children andtheir parents. Children presented with moderateto severe symptoms of OCD and reported symp-toms of anxiety and depression falling within thenormative range.35,45 According to parent report,children demonstrated slightly to mildly atypicaloppositional behavior.36 On parent self-report,minimal symptoms of OCD, anxiety (current andtrait), and depression were noted. In addition,data suggested moderate to severe parental ac-commodation assessed as unitary (FAS-PR totalscore) and binary (Involvement in Compulsions,Avoidance of Triggers) constructs.

Frequency and descriptive data collected us-ing the FAS-PR (Table 3) indicated that 99% (n �95) of parents reported engaging in at least oneaccommodating behavior to some extent and77.1% (n � 74) reported engaging in at least one

f these behaviors daily. A significant proportionf parents reported reassuring their child63.5%), participating in their child’s OCD rituals32.3%), or assisting their child in avoiding anx-ety-provoking situations (33.3%) on a daily ba-
is. Interestingly, despite the frequency of some
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form of accommodation, a substantial proportionof parents reported they never avoided goingplaces (57.3%) or modified leisure activities(52.1%) because of their child’s symptoms.

Predictive Models of Parental AccommodationTotal Accommodation. Preliminary analyses re-vealed 11 (of 16) possible predictors of totalaccommodation. Because of intercorrelations(see Data Analytic Plan), CY-BOCS Obsessions,CDI total score, BDI total score, and STAI-Traitwere removed as possible predictors (Table 1).The remaining child- and parent-level vari-ables (n � 7) were entered into a regressionanalysis to reveal two statistically significantpredictors (CY-BOCS Compulsion total, p �.04; BSI Anxiety, p � .05). To further testwhether these variables remained significantpredictors of total accommodation, they werere-entered into a subsequent regression analy-sis. Each variable remained a significant pre-dictor (p � .002 and p � .004, respectively).

The final regression model (F � 12.23, p �.001) accounted for 23.0% of the variance in TotalAccommodation scores. The model’s adjusted R2

TABLE 1 Pearson Correlation Coefficients for Candidate

FAS Total p

Child-level variablesCY-BOCS Obsession total 0.24 .023CY-BOCS Compulsion total 0.36 �.001MASC total (T score) 0.24 .026CDI total 0.21 .051CPSR Oppositional subscale 0.36 .001OCI-CV Checking 0.16 .150OCI-CV Hoarding �0.02 .839OCI-CV Ordering 0.24 .025OCI-CV Washing 0.34 .001Age �0.12 .270Gender 0.16 .122

Parent-level variablesBDI total score 0.24 .025YBOCS-SR Obsession total 0.16 .146YBOCS-SR Compulsion total 0.21 .050BSI Anxiety 0.37 .001STAI-Trait 0.19 .075

Note: Boldface items indicate that the variable was placed into the initial reChild Depression Inventory; CPRS � Conners’ Parent Rating Scale; CYAccommodation Scale; MASC � Multidimensional Scale for ChildrenAnxiety Inventory; YBOCS-SR � Yale-Brown Obsessive Compulsive Sc

(taking into account number of variables in the B

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model) was 21.2%. Statistical tests showed noviolations of normality or equality of varianceassumptions, and Cook D suggested the absenceof influential outliers.Involvement in Compulsions. Analyses revealednine possible predictors of involvement in com-pulsions. Because of intercorrelations, CY-BOCSObsessions and BDI total score were removed.The remaining variables (n � 7) were enteredinto the regression analysis and revealed twostatistically significant predictors (CPSR Opposi-tional subscale, p � .02; OCI Washing, p � .04).These variables were re-entered into the regres-sion model and were found to remain significantpredictors (p � .001 and p � .004, respectively) ofinvolvement in compulsions.

The final regression model (F � 11.66, p �.001) accounted for 23.2% of the variance inInvolvement in Compulsions scores. The model’sadjusted R2 was 21.3%. Statistical tests revealed

o violations of normality or equality of variancessumptions, and Cook D suggested the absencef influential outliers.voidance of Triggers. Analyses revealed eightossible predictors of avoidance of triggers.

ictor Variables

Involvement inCompulsions p

Avoidance ofTriggers p

0.24 .018 0.12 .2610.32 .002 0.29 .0040.24 .063 0.20 .0640.20 .060 0.17 .1080.39 <.001 0.20 .0740.21 .052 0.09 .427

�0.07 .543 0.05 .6400.22 .037 0.24 .0230.34 .001 0.24 .025

�0.16 .131 �0.09 .4130.13 .213 0.19 .07

0.14 .206 0.21 .0480.12 .286 0.12 .2600.8 .103 0.18 .1000.25 .019 0.32 .0020.15 .162 0.15 .155

n analysis. BDI � Beck Depression Inventory; BSI � Brief Symptom; CDI �

S � Children’s Yale-Brown Obsessive Compulsive Scale; FAS � Family-CV � Obsessive Compulsive Inventory-Child Version; STAI � State Traitlf Report; Inventory.

Pred

gressio-BOC

; OCI

ecause of intercorrelations, BDI total score




was removed. The remaining variables (n � 7)were entered into the regression equation andrevealed two predictors (CY-BOCS Compul-sion total, p � .04; BSI Anxiety, p � .05). Uponentering thr two variables into the final regres-sion, each remained a significant predictor (p �.01 and .01, respectively).

The final regression model (F � 8.61, p � .001)accounted for 17.0% of the variance in Avoidanceof Triggers scores. The model’s adjusted R2 was15.0%. Statistical tests revealed no violations ofnormality or equality of variance assumptions,and Cook D suggested the absence of influentialoutliers.

DISCUSSIONThis is the first study to examine possible child-

TABLE 2 Descriptive Statistics for Present Sample

Measurement Mean (SD)

Child measurements of psychopathologyCY-BOCS total 24.5 (4.2)

Obsession total score 11.8 (2.4)Compulsion total score 12.7 (2.2)

MASC total (T score) 53.9 (12.4)CDI total scorea 9.6 (7.50)CPRS Oppositional subscale (T score) 60.4 (13.9)OCI-CV checking frequencya 2.2 (1.7)OCI-CV hoarding frequencya 2.1 (2.0)OCI-CV ordering frequencya 2.3 (1.9)OCI-CV washing frequencya 2.43 (2.1)

Parent measurements of psychopathologyFAS total scorea 2.6 (0.8)Involvement in compulsionsa 3.1 (0.9)Avoidance of triggers (log

transformed)a2.1 (0.9)

BDI total scorea 10.1 (9.2)YBOCS-SR total score 5.4 (6.7)

Obsession total score 2.9 (3.6)Compulsion total score 2.5 (3.6)

BSI Anxietya 0.6 (0.7)STAI-Trait 43.6 (9.8)

Note: BDI � Beck Depression Inventory; BSI � Brief Symptom Inventory;CDI � Child Depression Inventory; CPRS � Conners’ Parent RatingScale; CY-BOCS � Children’s Yale-Brown Obsessive CompulsiveScale; FAS � Family Accommodation Scale; MASC � Multidimen-sional Scale for Children; OCI-CV � Obsessive Compulsive Inventory–Child Version; SD � standard deviation; STAI � State Trait AnxietyInventory; YBOCS-SR � Yale-Brown Obsessive Compulsive Scale-SelfReport.

aRaw score mean values are presented.

and parent-level predictors of various facets of



parental accommodation (i.e., total accommoda-tion, involvement in compulsions, avoidance oftriggers) using demographic, symptom (i.e., ob-sessions, compulsions) and phenomenological(i.e., symptom dimension) data in children withOCD. The findings support prior research sug-gesting that accommodation is a ubiquitous phe-nomenon in these families.18,20,28 These data alsosuggest that child- and parent-level variablesincluding compulsion severity, washing/clean-ing symptoms, oppositional behavior, and paren-tal anxiety work jointly to provide significantpredictive models of accommodation.

Compulsion severity (CY-BOCS Compulsion)and parental anxiety (BSI Anxiety) accounted forapproximately 23% of the variance in predictingtotal accommodation. These findings demonstratesimilarities (i.e., parental psychopathology andOCD symptoms as predictors of accommodation)and differences (i.e., specific role of washing/con-tamination symptoms and child oppositional be-havior as predictors of parental involvement incompulsions) to the one previous study to examinepredictors of accommodation in families of chil-dren with OCD.20 Differences in methodologymay account for discrepancies between thesestudies. The present study used a larger sampleand a validated version of the FAS-PR usingempirically derived subscales. Only one of thetwo variables (i.e., compulsion severity) predict-ing total accommodation is closely related topredictors of accommodation found in the fami-lies of adults with OCD.38 Perhaps particularsymptom dimensions may be of less importancein predicting total accommodation during child-hood, whereas symptom severity is relevantacross the life span. It should be noted thatwashing symptoms were predictive of involve-ment in compulsions. Future research shouldexamine possible developmental differences inmodels of accommodation in children, adoles-cents, and adults with OCD.

The present study’s findings in relation to theinfluence of parental anxiety on total accommo-dation is particularly interesting because it sug-gests that addressing accommodation may be-come increasingly important as a parent’s ownlevel of anxiety increases. Clinically, this makessense: anxious parents may be more resistant tothe principles underlying CBT and, more specif-ically, exposure with response prevention. Expo-sure with response prevention tasks are designed
intentionally to increase a child’s anxiety. This
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TABLE 3 Frequency and Descriptive Statistics for Family Accommodation Scale for Individual Items

Item Never (1)Mild: 1–3

Times/Month (2)Moderate: 1 or 2Times/Week (3)

Severe: 3–6Times/Week (4)

Extreme: Daily(5) Mean (SD)

Involvement in Compulsions subscale1. How often did you reassure the patient? 2 (2.1%) 6 (6.3%) 13 (13.5%) 14 (14.6%) 61 (63.5%) 4.31 (1.06)2. How often did you participate in behaviors related to

the patient’s compulsions?22 (22.9%) 12 (12.5%) 15 (15.6%) 16 (16.7%) 31 (32.3)% 3.23 (1.57)

3. How often did you provide items for the patient’scompulsions?

42 (43.8%) 12 (12.5%) 14 (14.6%) 6 (6.3%) 21 (21.9%) 2.49 (1.62)

4. Has the patient become distressed/anxious when youhave not provided assistance?

12 (12.5%) 22 (22.9%) 30 (31.3%) 16 (16.7%) 15 (15.6%) 3.00 (1.25)

5. Has the patient become angry/abusive when youhave not provided assistance?

34 (35.4%) 16 (16.7%) 23 (24.0%) 13 (13.5%) 10 (10.4%) 2.47 (1.37)

6. Has the patient spent more time completing ritualswhen you have not provided assistance?

39 (40.6%) 17 (17.7%) 21 (21.9%) 15 (15.6%) 4 (4.2%) 2.25 (1.26)

Avoidance of Triggers subscale1. How often did you assist the patient in avoiding

things that might make him/her anxious?14 (14.6%) 13 (13.5%) 19 (19.8%) 17 (17.7%) 32 (33.3%) 3.42 (1.45)

2. Have you avoided doing things, going places, orbeing with people because of the patient’s OCD?

55 (57.3%) 18 (18.8%) 14 (14.6%) 2 (2.1%) 7 (7.3%) 1.83 (1.20)

3. Have you modified your family routine because of thepatient’s symptoms?

30 (31.3%) 28 (29.2%) 25 (26.0%) 9 (9.4%) 4 (4.2%) 2.26 (1.13)

4. Have you had to do some things for the family thatare usually the patient’s responsibility?

38 (39.6%) 26 (27.1%) 22 (22.9%) 5 (5.2%) 4 (4.2%) 2.06 (1.11)

5. Have you modified your work schedule because ofthe patient’s needs?

45 (46.9%) 23 (24.0%) 19 (19.8%) 6 (6.3%) 3 (3.1%) 1.95 (1.10)

6. Have you modified your leisure activities because ofthe patient’s needs?

50 (52.1%) 23 (24.0%) 14 (14.6%) 4 (4.2%) 5 (5.2%) 1.86 (1.14)

Note: OCD � obsessive-compulsive disorder.

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elevation in the child’s anxiety level may lead toan increase in parental anxiety (e.g., seeing theirchild in distress) and thus compromise treatmentcompliance and/or adherence. This finding isparticularly intriguing in light of preliminaryempirical evidence suggesting that changes inparental accommodation demonstrate a positiveimpact on treatment outcome using CBT forchildhood OCD.28 Because these investigatorsused an unvalidated version of the FAS-PR,replication of their findings is warranted. How-ever, the findings described in the present studymay suggest that clinicians and researchersshould examine the development of individual-ized (modular) interventions for children whoseparents present with elevated anxiety symptoms.For example, researchers may wish to examinethe utility of a brief structured intervention de-signed to manage parents’ level of anxiety (e.g.,perhaps in response to their child’s reaction toexposure-based assignments) and/or during thetreatment process. In turn, it will be important toexamine potential symptom-level cutoffs thatbest predict parental accommodation and in turnaffect treatment outcome.

It is also important to understand the factorsthat exert influence on separate yet related facetsto accommodation. For example, compulsion se-verity and parental symptoms of anxiety ac-counted for approximately 17% of the variance inavoidance of triggers. These results are nearlyidentical to and likely provided the greatestinfluence on total accommodation. Conversely,parents’ report of their child’s oppositional be-havior (e.g., CPRS Oppositional) and OCD-related washing/contamination symptoms weredistinct and significant predictors of involvementin compulsions. It would be interesting to re-examine the impact of not only total accommo-dation but also involvement in compulsions andawareness of triggers on treatment outcome inpediatric OCD. These domains may be differen-tially related to treatment outcome. If this werethe case, findings from the present study sug-gest that different adjuncts to treatment may benecessary (e.g., addressing a child’s opposi-tional behavior versus addressing a parent’sincreased anxiety). Clearly, additional researchis warranted.

Several limitations of the present study mustbe noted. First, this study did not examinewhether changes in involvement in compulsions
and/or avoidance of triggers affected treatment


utcome. As a result, it is unclear whether one ofhese two related facets to accommodation is

ost germane to improving treatment efficacy orhether a more unitary approach to addressing

ccommodation would prove more useful (i.e.,otal accommodation). Second, the models de-cribed in the present report account for a rela-ively small amount (e.g., 23%) of the variance inarental accommodation. Conversely, the modeleveloped by Peris et al.20 explained 43% of theariance. Methodologic differences (e.g., smallerample, use of a 13-item rather than 12-itemAS-PR, using CY-BOCS/YBOCS total scoresather than individual subscales) between thesewo studies may account for some of these dis-repancies. In turn, the models described earliereave room for the likelihood that other candi-ate predictors not assessed in the present studyay also be important for understanding factors

ffecting accommodation. For example, recentvidence has suggested there may in fact be aink between anxious parenting behaviors andpecific candidate genes.46,47 Future research

should examine the possible relation betweengenes and parenting behavior because this mayaid in improving therapeutic interventions.Third, the present study employed a child-reportmeasurement of OCD symptom dimensions (i.e.,OCI-CV) rather than a symptom checklist used inmany other studies. Therefore, caution should beused in interpreting results related to particularsymptom dimensions and their effect on variousfacets of accommodation.

Empirical evidence has suggested that de-creased parental accommodation is associatedwith better CBT outcomes in children withOCD,28 although the directionality of these ef-fects has yet to be established. In conjunctionwith this study’s findings, these results are sup-portive of the more formal assessment of paren-tal accommodation and suggest that cliniciansand researchers should be aware of the impactthat specific child- and parent-level variableshave on parental accommodation. More broadly,these findings also point to the potential impor-tance of assessing parents’ involvement in theirchild’s OCD-related rituals and their avoidanceof triggers for OCD. This latter point is particu-larly interesting because the current gold stan-dard for the assessment of OCD symptom sever-ity in children, the CY-BOCS, does not includeeither domain in the calculation of symptom
severity. Future research may examine whether
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FLESSNER et al.

the failure to assess these domains inadvertentlyresults in misleadingly lower scores on the CY-BOCS. Research of this nature may help elucidatethe importance of these domains/subscales inthe assessment and treatment of children withOCD. Ultimately, the line of research will pro-vide clinical scientists with a better understand-ing of accommodation, childhood OCD, and fac-tors that may influence the pathogenesis andtreatment of this debilitating disorder. &

Accepted March 29, 2011.

Drs. Flessner, Freeman, and Garcia are with the Bradley/HasbroChildren’s Research Center and Alpert School of Medicine at BrownUniversity. Drs. Sapyta and March are with Duke University MedicalCenter. Drs. Franklin and Foa are with the University of PennsylvaniaSchool of Medicine.

The Pediatric OCD Treatment Study (POTS) was supported by Na-tional Institute of Mental Health (NIMH) grants R01 MH55126 (E.B.F.)and R01 MH55121 (J.S.M.). Sertraline and matching placebo wereprovided to the POTS under an independent educational grant fromPfizer Inc. (J.S.M.).

The authors thank the many research assistants who supported the
coordination and acquisition of data for this study.
apy outcome: a prospective study with obsessive-compulsive andagoraphobic outpatients. J Consult Clin Psychol. 1999;67:658-665.

JOURN

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The authors dedicate this study to the memory of Henrietta L. Leonard, M.D.

Disclosure: Dr. Garcia has received research support from the Na-tional Institute of Mental Health (NIMH) and the National Institutes ofHealth (NIH). Dr. Freeman has received research support from theNIMH. Dr. Franklin has received research support from the NIMH andthe Tourette Syndrome Association. Dr. March has served as aconsultant for Bristol-Myers Squibb, Eli Lilly and Co., Johnson andJohnson, MedAvante, Pfizer, Scion, Psymetrix, and Vivus. He holdsequity in MedAvante. He receives royalties from MultiHealth Systems,Guilford Press, and Oxford University Press. He has received studydrugs from Eli Lilly and Co. and Pfizer for NIMH-funded clinical trials.He receives research support from the NIMH and the NationalAlliance for Research on Schizophrenia and Depression (NARSAD).Dr. Foa has received research support from Pfizer, Solvay, Eli Lilly andCo., SmithKline Beecham, GlaxoSmithKline, Cephalon, Bristol-MyersSquibb, Forest, Ciba Geigy, Kalo-Duphar, and the American Psychi-atric Association. She has served on speakers’ bureaus for Pfizer,GlaxoSmithKline, Forest, the American Psychiatric Association, andJazz. She has served as consultant for Acetelion. Drs. Flessner andSapyta report no biomedical financial interests or potential conflicts ofinterest.

Correspondence to Christopher A. Flessner, Ph.D., Bradley/HasbroChildren’s Research Center, 1 Hoppin Street, Suite 204, CoroWest, Providence, RI 02903; e-mail: [email protected]

0890-8567/$36.00/©2011 American Academy of Child andAdolescent Psychiatry

DOI: 10.1016/j.jaac.2011.03.019

REFERENCES1. Valleni-Basile LA, Garrison CZ, Jackson KL, et al. Frequency of

obsessive-compulsive disorder in a community sample of youngadolescents. JAm Acad Child Adolesc Psychiatry. 1995;34:128-129.

2. Zohar AH. The epidemiology of obsessive-compulsive disorderin children and adolescents. Child Adolesc Psychiatr Clin NorthAm. 1999;8:445-461.

3. Adams G, Waas G, March J, Smith M. Obsessive-compulsivedisorder in children and adolescents: the role of the schoolpsychologist in identification, assessment, and treatment. SchoolPsychol Q. 1994;9:274-294.

4. Cooper M. Obsessive-compulsive disorder: effects on familymembers. Am J Orthopsychiatry. 1996;66:296-304.

5. Leonard HL, Lenane M, Swedo SE. Obsessive-compulsive disor-der. Child Adolesc Psychiatr Clin North Am. 1993;2:655-665.

6. Toro J, Cervera M, Osejo E, Salamero M. Obsessive-compulsivedisorder in childhood and adolescence: a clinical study. J ChildPsychol Psychiatry. 1992;33:1025-1037.

7. Geller DA, Biederman J, Griffin S, Jones J, Lefkowitz TR. Comor-bidity of juvenile obsessive-compulsive disorder with disruptivebehavior disorders. J Am Acad Child Adolesc Psychiatry. 1996;35:1637-1646.

8. March J. Cognitive-behavioral psychotherapy for children andadolescents with ocd: A review and recommendations for treat-ment. J Am Acad Child Adolesc Psychiatry. 1995;34:7-18.

9. Amir N, Freshman M, Foa E. Family distress and involvement inrelatives of obsessive-compulsive disorder patients. J AnxietyDisord. 2000;14:209-217.

10. Barrett P, Shortt A, Healy L. Do parent and child behavioursdifferentiate families whose children have obsessive-compulsivedisorder from other clinic and non-clinic families? J Child PsycholPsychiatry. 2002;43:597-607.

11. Calvocoressi L, Lweis B, Harris M, et al. Family accommodation inobsessive-compulsive disorder. Am J Psychiatry. 1995;152:441-443.

12. Calvocoressi L, Mazure C, Kasl SV, et al. Family accommodationof obsessive-compulsive symptoms. J Nerv Ment Dis. 1999;187:636-642.

13. Chambless D, Steketee G. Expressed emotion and behavior ther-

14. Derisley J, Libby S, Clark S, Reynolds S. Mental health, coping andfamily-functioning in parents of young people with obsessive-compulsive disorder and with anxiety disorders. Br J Psychiatry.2005;44:439-444.

15. Hibbs ED, Hamburger S, Lenane M, et al. Determinants ofexpressed emotion in families of disturbed and normal children.J Child Psychol Psychiatry. 1991;32:757-770.

16. Insel TR, Hoover C, Murphy DL. Parents of patients with obsessive-compulsive disorder. Psychol Methods. 1983;13:807-811.

17. Leonard HL, Swedo SE, Lenane M, et al. A 2- to 7-year follow-upstudy of 54 obsessive-compulsive children and adolescents. ArchGen Psychiatry. 1993;50:429-439.

18. Storch EA, Geffken GR, Merlo LJ, et al. Family accommodation inpeditric obsessive-compulsive disorder. J Clin Child AdolescPsychol. 2007;36:207-216.

19. Valleni-Basile LA, Garrison CZ, Jackson K. Family and psychos-ocial predictors of obsessive compulsive disorder in a communitysample of young adolescents. J Child Fam Stud. 1995;4:193-206.

20. Peris TS, Bergman RL, Langley A, Chang S, McCracken JT,Piacentini J. Correlates of accommodation of pediatric obsessive-compulsive disorder: parent, child, and family characteristics. JAm Acad Child Adolesc Psychiatry. 2008;47:1173-1181.

21. Ehiobuche I. Obsessive-compulsive neurosis in relation to paren-tal child-rearing patterns amongst the Greek, Italian, and Anglo-Australian subjects. Acta Psychiatr Scand Suppl. 1988;344:115-120.

22. Merkel WT, Pollard CA, Wiener RL, Staebler CR. Perceivedparental characteristics of patients with obsessive compulsivedisorder, depression, and panic disorder. Child Psychiatry HumDev. 1993;24:49-57.

23. Steketee G. Disability and family burden in obsessive-compulsivedisorder. Can J Psychiatry. 1997;42:919-928.

24. Mariaskin M, Curry JF, March J, Franklin M, Foa E, Team P-IR.Family Accommodation and Emotion Socialization in Child-hood Obsessive-Compulsive Disorder. Philadelphia: Associationfor Behavioral and Cognitive Therapies; 2007.

25. Leonard HL, Lenane MC, Swedo SE, Rettew DC, Gershon ES,Rapoport JL. Tics and Tourette’s disorder: a 2- to 7-year follow up
of 54 obsessive-compulsive children. Am J Psychiatry. 1992;149:1244-1251.


mailto:[email protected]


26. Stewart SE, Beresin C, Haddad S, Stack DE, Fama J, Jenike M.Predictors of accommodation in obsessive-compulsive disorder.Ann Clin Psychiatry. 2008;20:65-70.

27. Flessner CA, Sapyta J, Freeman JB, et al. Examining the FactorStructure and Psychometric Properties of the Family Accommo-dation Scale–Parent Report (FAS-PR). J Psychopathol Behav As-sess. 2011;33:38-46.

28. Merlo LJ, Lehmkuhl HD, Geffken GR, Storch EA. Decreasedfamily accommodation associated with improved therapy out-come in pediatric obsessive-compulsive disorder. J Consult ClinPsychol. 2009;77:355-360.

29. Pediatric OCD Treatment Study Team [POTS]. Cognitive-behaviortherapy, sertraline, and their combination with children andadolescents with obsessive-compulsive disorder: the PediatricOCD Treatment Study (POTS) randomized controlled trial.JAMA. 2004;292:1969-1976.

30. Franklin M, Foa E, March JS. The Pediatric Obsessive-CompulsiveDisorder Treatment Study: rationale, design, and methods. JChild Adolesc Psychopharmacol. 2003;13(suppl 1):39-51.

31. Silverman WK, Albano AM. Anxiety Disorders Interview Schedulefor DSM-IV. San Antonio: Psychological Corporation; 1996.

32. Scahill L, Riddle MA, McSwiggan-Hardin M, et al. Children’sYale-Brown Obsessive-Compulsive Scale: reliability and validity.J Am Acad Child Adolesc Psychiatry. 1997;36:844-852.

33. March JS. Multidimensional Anxiety Scale for Children. NorthTonawanda, NY: Multi-Health Systems; 1998.

34. Wood JJ, Piacentini JC, Bergman RL, McCracken J, Barrios V.Concurrent validity of the anxiety disorders section of the anxietydisorders interview schedule for DSM-IV: child and parent ver-sions. J Clin Child Adolesc Psychol. 2002;31:335-342.

35. Kovacs M. Children’s Depression Inventory Manual. NorthTonawanda, NY: Multi-Health Systems; 1992.

36. Conners CK, Sitarenios G, Parker J, Epstein J. The revised
Conners’ Parent Rating Scale: factor structure, reliability, andcriterion validity. J Abnorm Child Psychol. 1998;26:257-268.


37. Foa E, Kozak M, Salkovskis PM, Coles ME, Amir N. Thevalidation of a new obsessive compulsive disorder scale: theObsessive-Compulsive Inventory. Psychol Assess. 1998;10:206-214.

38. Stewart SE, Beresin C, Haddad S, Egan Stack D, Fama J, Jenike M.Predictors of family accommodation in obsessive-compulsivedisorder. Ann Clin Psychiatry. 2008;20:65-70.

39. Derogatis L, Melisaratos N. The Brief Symptom Inventory: anintroductory report. Psychol Med. 1983;13:595-605.

40. Beck AT, Ward CH, Mendelson M, Mock J, Erbaugh J. Aninventory for measuring depression. Arch Gen Psychiatry. 1961;4:561-571.

41. Beck A, Steer R, Garbin M. Psychometric properties of the beckdepression inventory: twenty five years of evaluation. Clin Psy-chol Rev. 1988;8:77-100.

42. Goodman WK, Price LH, Rasmussen SA, et al. Yale-BrownObsessive Compulsive Scale. I. Development, use, and reliability.Arch Gen Psychiatry. 1989;46:1006-1011.

43. Goodman WK, Price LH, Rasmussen SA, et al. Yale-BrownObsessive-Compulsive Scale. II. Validity. Arch Gen Psychiatry.1989;46:1012-1016.

44. Spielberger CD, Gorsuch RL, Lushene R, Vagg PR, Jacobs GA.Manual for the State Trait Anxiety Inventory. Palo Alto: ConsultingPsychologists Press; 1983.

45. March J. Multidimensional Anxiety Scale for Children. NorthTonawanda, NY: Multi-Health Systems; 1997.

46. Bakermans-Kranenburg MJ, van Ijzendoorn MH. Oxytocin recep-tor (OXTR) and serotonin transporter (5-HTT) genes associatedwith observed parenting. Soc Cogn Affect Neurosci. 2008;3:128-134.

47. Van Ijzendoorn MH, Bakermans-Kranenburg MJ, Mesman J.Dopamine system genes associated with parenting in the
context of daily hassles. Genes Brain Behav. 2008;7:403-410.
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