The present study examined whether change in FA over the course of family-based CBT was significantly associated with treatment response for pediatric OCD. Consistent with others (e.g., Barrett et al., 2004
; Waters et al., 2001
), levels of FA decreased from pre- to post-treatment. Additionally, change in FA from baseline to post-treatment was significantly associated with parent- and clinician-rated symptom severity at post-treatment, even when controlling for pre-treatment symptom severity.
Unfortunately, the mechanism by which FA relates to symptom severity remains unclear. Children with more severe symptoms typically display higher rates of functional impairment (Piacentini et al., 2003
), so it is possible that increased FA results from the attempts to minimize child distress and impairment. Clinical experience suggests that parents become distressed by seeing their child suffer, as is common for children with OCD (Piacentini et al., 2003
). Thus, many parents attempt to “help” by accommodating; however, the provision of FA can exacerbate OCD symptoms. As a result, it is possible that FA directly leads to increases in symptom severity. Parents are typically unaware of this and will continue to accommodate their child until they are educated about the negative consequences of doing so. Other parents recognize that FA exacerbates symptoms in the long run, but feel pressured to utilize a short-term “fix.”
Results indicated that participation in family-based CBT is associated with a significant decrease in FA, and that this decrease is associated with positive treatment outcome. Given that the primary goals of CBT for OCD are to expose the child to anxiety-provoking situations and to prevent ritual engagement, it is clear that FA contradicts the goals of treatment. Thus, helping parents and siblings to recognize FA, instructing them to decrease FA, and teaching them ways to help the child manage his/her OCD symptoms without accommodating may be particularly effective ways to involve families in treatment. Our clinical experience suggests that targeting FA can lead to decreases in symptom severity and functional impairment, even if the patient is unwilling to participate fully in treatment. These results have important clinical implications, as many children with OCD do not respond fully to treatment. We speculate that family-based CBT targeting FA may be indicated for pediatric OCD patients when high levels of FA are present.
Contrary to predictions, FA was not related to child-rated impairment, but there is an intuitive explanation. We hypothesize that parents who accommodate symptoms allow their child to avoid feared stimuli. Then, because the child does not experience the associated anxiety, s/he may view OCD symptoms as less disruptive than s/he would otherwise. And when parents accommodate their children by completing tasks for them, the child does not experience the penalties of unfinished work. Parents who accommodate their child’s symptoms take on more of the burden, allowing the child to avoid consequences and to feel higher-functioning. This hypothesis is supported by the finding that children’s self-ratings of impairment were not related to clinician-rated symptom severity at baseline or to clinician or parent ratings of symptom severity at post-treatment. When parents decrease FA, the child may experience greater impairment in the short term, until learning to manage these “extra” responsibilities on his/her own. Thus, clinicians should prepare families for increased struggles by explaining that the long-term benefit will likely outweigh the short-term consequences of decreasing FA.
Some limitations of the study should be noted. First, the sample was relatively homogeneous. Second, the lack of a control group (i.e., patients receiving individual therapy without a focus on decreasing FA) precludes us from making causal attributions to the variables under study and prevented us from obtaining blind assessments of outcome. Future research should explore whether family-based CBT is more efficacious than individual CBT for decreasing FA. Third, inter-rater reliability was not calculated for the ADIS or post-treatment CY-BOCS, though we did employ checks in confirming each participant diagnosis. Fourth, although the present study supports the treatment sensitivity and internal consistency of the FAS-PR, the psychometric properties have not been systematically studied. Finally, despite the relative stability of results across parent and clinician reports, the use of a parent-report measure of FA, rather than a more objective measure, may have influenced the results of the current study. Future research should include observational measures of FA.
Despite these limitations, the present study provides a foundation for continued research into the role of FA in pediatric OCD and its responsiveness to treatment. Future studies might examine whether FA is influenced by OCD subtype, presence of comorbidities, family psychopathology, or other family patterns. In addition, given that the relation between FA and OCD symptom severity appears to be bidirectional, more research is needed to clarify the mechanisms of influence. Prospective studies examining FA may help to clarify whether it is best viewed as a risk factor or a consequence of OCD symptom severity. Finally, future studies should examine motivations for FA and compare treatment outcome for children affected by significant levels of FA versus those who are not.