Comparing family accommodation in pediatric obsessive-compulsive disorder, anxiety disorders, and nonanxious children

Maternal Accommodation of Adolescent Body Dysmorphic Disorder: Clinical Correlates and Association with Treatment Outcomes

Family accommodation (FA) is widely-recognised as an important clinical phenomenon in obsessive-compulsive disorder (OCD) and anxiety disorders, and is related to poorer treatment outcomes. However, FA has not been quantitatively explored in Body Dysmorphic Disorder (BDD). The aim of this study was to investigate the patterns and correlates of maternal accommodation in adolescent BDD, and its association with treatment outcomes. Participants were 131 adolescents with BDD and their mothers who completed the Family Accommodation Scale-Parent Report (FAS-PR) as part of routine clinical practice in a National and Specialist Service for Young People at the Maudsley Hospital, London. Seventy-six (58%) young people received specialist cognitive behavioural therapy for BDD and had post-treatment data available. All mothers engaged in at least one form of accommodation. Providing reassurance (98.5%) and assisting avoidance (88.5%) were the most commonly endorsed behaviours. Levels of accommodation were positively associated with clinician-rated BDD symptom severity (r = 0.18, p = 0.041) and maternal symptoms of anxiety, depression and stress (r = 0.41, p < 0.001), and negatively associated with child global functioning (r = -0.38, p < 0.001). Maternal accommodation did not predict treatment outcomes (β = 0.055, p > 0.05). The findings indicate that maternal accommodation is common and has important clinical correlates, but does not impact on treatment response. Consequently, the relationship between maternal accommodation and BDD symptoms may differ to that evidenced in paediatric OCD. Future longitudinal research exploring maternal and paternal accommodation, and assessing variables of interest at multiple time-points throughout treatment, is needed to advance understanding of the role of FA in adolescent BDD.

The Pediatric Accommodation Scale: Psychometric Evaluation of a Therapist-Report Format

Anxiety disorders are the most common mental health problem in youth, and accommodation is prevalent among youth with anxiety disorders. The Pediatric Accommodation Scale (PAS) is an interview administered by trained evaluators and a parent-report form (PAS-PR) to assess accommodation and its impact. Both have strong psychometric properties including internal consistency, inter-rater reliability, and data supporting construct validity. The present study evaluates the Pediatric Accommodation Scale - Therapist Report (PAS-TR), a therapist-reported version of the PAS-PR. Participants were 90 youth enrolled in cognitive behavioral therapy for anxiety. Therapists completed the PAS-TR over 16 therapy sessions. Internal consistency at baseline, convergent validity, divergent validity, and parent-therapist agreement were evaluated. Results suggest that the PAS-TR has mixed psychometric qualities suggesting that while not strong prior to the initiation of treatment, the PAS-TR may be a useful measure for therapists to rate accommodation as treatment progresses. Implications for assessment, treatment, and research are discussed.

Family Accommodation and Separation Anxiety: The Moderating Role of Child Attachment

Family accommodation, or changes in parental behavior aimed at avoiding or alleviating child anxiety-related distress, contributes to the severity of anxiety symptoms, and is most strongly associated with separation anxiety. This study examined whether child attachment security, characterized as the degree to which children perceive their parents to be reliable, available, and communicative, moderates the association between family accommodation and separation anxiety symptoms, and whether this moderation is specific to separation anxiety among other anxiety symptoms. In a sample of clinically anxious children (N = 243, 6-12 years), family accommodation was significantly positively associated with separation anxiety symptoms across levels of attachment security. Family accommodation was more strongly associated with parent-reported separation anxiety symptoms in children with lower attachment security compared with those with higher attachment security. No significant moderation effect emerged for other anxiety symptoms. Findings enhance understanding of the role of attachment within family accommodation of child anxiety.

Family Accommodation in Children and Adolescents With Misophonia

Family accommodation (e.g., reassurance, modifying routines, assisting avoidance) has not been explored among youth with misophonia but may have important clinical and intervention implications. We examined family accommodation in 102 children and adolescents with interview-confirmed misophonia and compared its frequency and content to family accommodation in 95 children and adolescents with anxiety disorders. Findings showed that family accommodation was ubiquitous in pediatric misophonia and may be even more frequent than in youth with anxiety disorders. Assisting the child, participating in misophonia-related behaviors, and modifying family routines were endorsed by more than 70% of parents of children with misophonia. Further, compared to parents of children with anxiety disorders, parents of children with misophonia more frequently reported child distress and anger when they did not accommodate. Family accommodation was moderately to strongly associated with misophonia severity even when accounting for co-occurring internalizing and externalizing symptoms and sociodemographic factors. This first study of family accommodation in pediatric misophonia suggests accommodation may be an important clinical feature. A notable study limitation is that the measure of misophonia did not delineate between adaptive versus maladaptive accommodations. Excessive and maladaptive accommodation may be one potential candidate to target in interventions when considered within a broader treatment plan. Importantly, adaptive accommodations should also be considered in day-to-day management if they improve functioning and quality of life.

Family Accommodation and Separation Anxiety: The Moderating Role of Child Attachment

Family accommodation, or changes in parental behavior aimed at avoiding or alleviating child anxiety-related distress, contributes to the severity of anxiety symptoms, and is most strongly associated with separation anxiety symptoms. This study examined whether child attachment security, characterized as the degree to which children perceive their parents to be reliable, available, and communicative, moderates the association between family accommodation and separation anxiety symptoms, and whether this moderator is specific to separation anxiety among other anxiety symptoms. In a sample of clinically anxious youth (N = 243, 6-12 yrs), family accommodation was significantly positively associated with separation anxiety symptoms across levels of attachment security. Family accommodation was more strongly associated with separation anxiety symptoms in children with lower attachment security compared with those with higher attachment security. No significant moderation effect emerged for other anxiety symptoms. Findings enhance understanding of the role of attachment within family accommodation of child anxiety.

Characterizing Accommodations by Parents of Young Children with Autism: A Mixed Methods Analysis

Symptoms of autism influence families' participation in daily activities, but few studies have broadly explored the types of accommodations caregivers make to their family's routines after their child is diagnosed with autism. The current study used a mixed-methods approach to characterize the rate and types of accommodations made by 171 families and the child and family characteristics that predicted accommodations. Most families (91%) endorsed making accommodations in the past year. Lower income, older child age, marginalized racial/ethnic identity, and higher levels of child problem behavior predicted accommodations in a greater number of domains. Thematic analysis illuminated the types of accommodations caregivers made and their motivation for making these lifestyle adjustments. Findings have important implications for parent-mediated interventions and policy.

Mothers' Psychological Control and Accommodation are Associated with More Severe Anxiety in Hispanic Youth

Psychological accommodation and control may help explain the finding that anxiety is more severe and common in Hispanic youth. Research with White samples conceptualizes psychological control as part of an authoritarian parenting style; however, research with Hispanic families suggests that psychological control is more likely to be indicative of a protective parenting style. Based on these findings, we hypothesized that in Hispanic families, psychological control would be related to protective parenting behaviors that ultimately maintain child anxiety. We tested a cross-sectional model hypothesizing that in Hispanic families the link between ethnicity and anxiety would be mediated through psychological control and parental accommodation of child anxiety, a parenting behavior which protects the child from the aversive experiences in the moment but ultimately serves to maintain child anxiety. A sample of mothers (n = 145; 48% Hispanic) and fathers (n = 59; 48% Hispanic) of youth from 8 to 18 years of age completed a survey assessing anxiety and parenting. With Hispanic mothers, the relation between ethnicity (Hispanic/non-Hispanic) and child anxiety was mediated through psychological control and accommodation. With fathers, although control was related to accommodation which, in turn, was related to child anxiety, ethnicity was not associated with control, accommodation, or child anxiety. Findings suggest that the context of parenting behavior should be considered in research, and adaptations of child anxiety treatments should consider ways to allow parents to express their desire to communicate warmth and protectiveness while avoiding negative reinforcement of child anxiety.

Cognitive Behavioral Therapy for Children and Adolescents with Anxiety Disorders

Anxiety disorders are the most common class of psychiatric conditions among children and adolescents. The cognitive behavioral model of childhood anxiety has a strong theoretic and empirical foundation that provides the basis for effective treatment. Cognitive behavioral therapy (CBT), with an emphasis on exposure therapy, is the gold standard treatment for childhood anxiety disorders, with strong empirical support. A case vignette demonstrating CBT for childhood anxiety disorders in practice, as well as recommendations for clinicians, are also provided.

Understanding parental knowledge, attitudes and self-efficacy in professional help-seeking for child anxiety

BACKGROUND

Child anxiety disorders are highly prevalent yet undertreated. As parents are often 'gatekeepers' to children receiving treatment and support, this study aimed to investigate modifiable parental factors affecting professional help-seeking for their children from general practitioners (GPs), psychologists, and paediatricians.

METHODS

In this study, 257 Australian parents of children aged 5-12 years with elevated anxiety symptoms completed a cross-sectional online survey. The survey assessed help-seeking from a GP, psychologist, and paediatrician (General Help Seeking Questionnaire), as well as anxiety knowledge (Anxiety Literacy Scale), help-seeking attitudes (Attitudes Toward Seeking Professional Psychological Help), personal stigma (Generalised Anxiety Stigma Scale) and self-efficacy (Self-Efficacy in Seeking Mental Health Care).

RESULTS

66.9 % of participants had sought help from a GP, 61.1 % from a psychologist, and 33.9 % from a paediatrician. Help-seeking from a GP or psychologist was associated with lower personal stigma (p = .02 and p = .03 respectively). Participants who sought help from a psychologist also had more positive attitudes toward seeking professional support (p = .01). Conversely, knowledge of anxiety disorders and self-efficacy were not associated with help-seeking from any source.

LIMITATIONS

Limitations of the study include the representativeness of our sample (female gender, higher education level); unexplained variance potentially accounted for by other factors (e.g., structural barriers); lack of prior validation of measures in a parent sample.

CONCLUSIONS

This research will inform the development of public health policy and psychoeducation interventions for parents, to reduce personal stigma and increase positive attitudes toward professional help-seeking, in turn improving help-seeking for child anxiety.

The Role of Pediatric Sensory Over-responsivity and Anxiety Symptoms in the Development of Family Accommodations

Sensory over-responsivity (SOR) is linked with elevated anxiety and reduced family wellbeing. Family accommodation of anxiety relates with greater symptom severity and reduced intervention outcome. This study examined the contribution of child SOR and co-occurring anxiety symptoms to family accommodation and its consequences. Ninety families of typically developing children (ages 4-13 years), completed an online survey including the Sensory Profile 2, Screen for Child Anxiety Related Emotional Disorders (SCARED), and Family Accommodation Sensory Scale (FASENS). FASENS scores include frequency of accommodation, child impact, and family impact.Children with elevated anxiety symptoms had significantly higher sensory and FASENS scores. Stepwise linear regression indicated that only SOR symptoms significantly predicted the frequency of sensory family accommodation, while both SOR and anxiety symptoms predicted the impact of family accommodation upon child and family well-being.Both SOR and anxiety symptoms in children predict the impact of sensory family accommodations on child and family well-being.

The Relations between Repetitive Behaviors and Family Accommodation among Children with Autism: A Mixed-Methods Study

Restricted and repetitive behaviors and interests (RRBI) are a significant component in diagnosing autism spectrum disorder (ASD). They often pose the main challenge in day-to-day functions for children with ASD and their families. Research addressing family accommodation behaviors (FAB) in the ASD population is scarce, and associations with the characteristics of the children's behaviors are unclear. This sequential mixed-methods study assessed the correlation between RRBI and FAB within the ASD group to deepen the understanding of parents' subjective experiences regarding their children's RRBI. It included a quantitative phase with a follow-up qualitative study. A total of 29 parents of children with autism (5-13 yr) completed the study questionnaires; a total of 15 also were interviewed regarding their children's RRBI and related FAB. We used the Repetitive Behavior Scale-Revised (RBS-R) to assess RRBI, and the Family Accommodation Scale (FAS-RRB) to assess FAS. In-depth interviews from phenomenological methodology were used in the qualitative phase. We found significant positive correlations between the RRBI and FAB overall and their subscores. Qualitative research supports these findings, adding descriptive examples of the accommodations families make to address the RRBI-related challenges. The results indicate relations between RRBI and FAB and the importance of practically addressing children with autism's RRBI and their parents' experiences. Both affect and are affected by the children's behaviors.

Construct Validation for Toddler-Solicited Maternal Comforting Behavior as Relevant to Family Accommodation and Child Anxiety Risk

Reciprocal parent-child interactions are theorized to play a crucial role in child anxiety development and maintenance. The current study tested whether toddler-solicited maternal comforting behavior in low-threat (mildly challenging and novel) situations may be a unique, early indicator of anxiety-relevant interactions. Controlling for other types of maternal comforting behavior, a path model tested solicited comforting behavior in a low-threat context in relation to both family accommodation (FA) and child anxiety symptoms, which may subsequently continue to predict each other over time. Identifying the emergence of this cycle in early childhood could bolster anxiety development theory and preventative interventions. Mother-child dyads (n = 166) of predominantly non-Hispanic/Latinx European American and socioeconomically diverse backgrounds were assessed at child ages 2, 4, and school-age via laboratory observation and maternal report. A longitudinal path model showed that solicited comforting observed in a low-threat situation at age 2 predicted mother-reported FA and child anxiety symptoms at age 4, above and beyond unsolicited comforting behavior and comforting behavior in a high-threat context. Furthermore, FA and child anxiety were bidirectionally related between age 4 and school-age assessments. Results suggest that toddler-solicited comforting in low-threat situations may be a unique indicator of child-directed anxiogenic family processes. The current study also expands the FA literature by providing empirical evidence for a bi-directional relation between anxiety and accommodation in young children.

A Systematic Review of Therapeutic Process Factors in Mental Health Treatment for Autistic Youth

Understanding the role of therapeutic process factors in treatment change may prove useful for discerning why some autistic youth benefit from psychosocial interventions that target emotional and psychological aspects of mental health, while others do not. The aim of the current study was to synthesize what is currently known about therapeutic process factors in mental health treatment of emotional and psychological challenges for autistic youth, regarding how process factors have been measured in past research, and the relation between process factors and treatment outcome. A systematic review of the literature was conducted to narratively synthesize all articles published up until June 2021. Methodological quality of included studies was appraised. Twenty-five studies met inclusion criteria. Process factors assessed across studies included relational factors; treatment expectations, readiness, and satisfaction; and treatment engagement from youth and their parents. Process-outcome associations were reported for a limited number of constructs. There is a limited, albeit growing, body of high-quality research evaluating the role of process factors in the treatment of mental health issues for autistic youth. Future research should continue to examine process factors in relation to treatment outcome, and validate measures to accurately capture process-related constructs in mental health treatment for this population. Greater understanding of therapy processes can lead to developing evidence-informed strategies that clinicians can implement to promote positive expectations, relationships, and engagement.

Trajectory of Change in Parental Accommodation and Its Relation to Symptom Severity and Impairment in Pediatric OCD

Family accommodation (FA) has been shown to relate to poorer treatment outcomes in pediatric obsessive compulsive disorder (OCD), yet few studies have examined the trajectory of change in FA throughout treatment and its relation to treatment outcomes. This study examined change in FA in relation to change in symptom severity and impairment in 63 youth receiving a family-based intervention for early-onset OCD. FA, symptom severity and functional impairment were assessed at baseline, week 5, week 9, and post-treatment (week 14). Results suggested that changes in FA in the beginning stages of treatment preceded global symptom improvement (but not OCD specific improvement) whereas changes in functional impairment preceded changes in FA. In the latter half of treatment, changes in FA preceded improvement in global and OCD specific symptom severity as well as functional impairment. These findings highlight the importance of reducing FA, especially in the later stages of treatment, in order to optimize treatment outcomes in early-onset OCD.

Change Patterns During Family-Based Treatment for Pediatric Obsessive Compulsive Disorder

Cognitive behavior therapy (CBT) for young people with obsessive compulsive disorder (OCD) has recently been enhanced to target family environment factors. However, the process of change for OCD symptoms and family factors during treatment is not well understood. Uniquely, we explored patterns of change for OCD symptoms and a range of family variables throughout Baseline, Early, Mid, and Late treatment phases of family-based CBT (FCBT) for 15 young people with OCD using multiple informants. We predicted a linear reduction in OCD symptom severity and family accommodation (FA) across treatment phases, however the investigation into other family factor change patterns was exploratory. OCD symptom severity, FA, parental distress tolerance (DT), and conflict all showed significant linear change patterns across treatment phases according to multiple informants. In addition, the largest proportion of change for these variables typically occurred during the first third of treatment, highlighting the importance of identifying participants with and without early gains in future research. Blame also showed a significant linear change pattern, although with small reductions between treatment phases. Preliminary bivariate analyses sought to better understand whether family factor change predicted subsequent OCD severity change or vice versa. Similar patterns emerged across informants, including identification of OCD severity as a significant predictor of change for Blame at subsequent treatment phases. Analyses also showed bi-directional effects for DT and OCD symptoms across informants, where DT predicted OCD severity at subsequent treatment phases and vice versa. These outcomes support further research aimed at understanding the role of family factors in pediatric OCD symptom change.

Frequency and Correlates of Fathers' Accommodation in Pediatric Anxiety Disorders

Previous studies investigating family accommodation (FA) in pediatric anxiety disorders have primarily relied on mothers' reports, while data on FA by fathers remains scarce. We examined the frequency and correlates of fathers' FA of anxious children and compared fathers' and mothers' reports of FA. Participants were 69 parents of treatment-seeking children and adolescents with a primary anxiety disorder. FA was highly prevalent amongst fathers, with the majority of fathers participating in symptom-related behaviors and modifying family routines due to child anxiety. Fathers' accommodation levels were significantly correlated with fathers' reports of child internalizing symptoms, child externalizing symptoms, and fathers' own anxiety symptoms. Fathers' and mothers' reports of FA were moderately correlated, whereas their reports of their respective distress related to the need to accommodate were only weakly correlated. Fathers reported a significantly lower frequency of FA than did mothers. These findings highlight the importance of obtaining reports from both fathers and mothers when assessing FA. Results are particularly relevant to family-focused and parent-based interventions designed to address and reduce FA amongst parents of clinically anxious children.

School-based supports and accommodations among anxious youth in treatment

Within pediatric anxiety, accommodation describes ways caregivers modify their behavior in an effort to alleviate distress shown by anxious youth. In schools, accommodation refers to school-based supports (SBS) placed to increase academic success for students with disabilities. The present study, using school documents provided at treatment, examined the types of SBS provided to youth (N = 76; ages 7-17; mean age 11.07; 47.4 % female) diagnosed with an anxiety disorder. SBS were rated by a panel of youth anxiety experts on the degree to which each SBS promoted (a) approach or (b) avoidance. School documents were coded for the presence of SBS and each SBS received a (a) total approach and (b) total avoidance score. Analyses revealed (a) approach and (b) avoidance promoting SBS were differentially associated with diagnostic status: youth with social anxiety disorder were more likely to be recommended SBS promoting avoidance and youth with a specific phobia were more likely to be recommended SBS promoting approach. Overall, the present study characterizes types of SBS being received by anxious youth and finds that SBS recommended to anxious youth vary in type and quality. Discussion considers the need for observations in schools to further address the merits/demerits of anxiety-related SBS.

Psychometric Properties and Factor Analysis of Family Accommodation Scale For Obsessive Compulsive Disorder-Interviewer-Rated-Thai Version (FAS-T)

Purpose

Obsessive compulsive disorder (OCD) is a longstanding and debilitating psychiatric disorder which is related to a level of distress in family members of patients who suffer from it. The Family Accommodation Scale (FAS) for OCD helps medical personnel have a clearer and deeper understanding of the pattern of family accommodation. This study aimed to translate FAS into Thai and examine its psychometric properties and factor analysis.

Patients and Methods

There were fifty participants who were relatives of OCD patients. Demographic data were collected along with completion of the FAS-T, the Patient Health Questionnaire (PHQ-9), the Pictorial Thai Quality of Life (PTQL), and the Thai Florida Obsessive Compulsive Inventory (FOCI-T), and then analyzed. The severity scales of FOCI-T from 44 OCD patients who had relatives participating in this study were collected from medical records and examined. Psychometric properties and factor analysis of FAS-T were tested.

Results

The average total score of FAS-T was 8.36±8.77 ranging between 0 to 25. The mean scores of FOCI-severity scale in relatives, PHQ-9, PTQL, and FOCI-severity scale in OCD patients, were 1.04±1.97, 4.04±3.73, 52.31±13.99, 8.95±4.36, respectively. The Cronbach’s coefficient alpha of FAS-T was 0.84, which demonstrated good internal consistency. The item-level CVI and scale-level CVI were at an excellent level. The Spearman’s rho between the FAS and FOCI symptom checklist, FOCI severity score, and PHQ-9 PTQL, were weakly correlated which implied acceptable discriminant validity. Exploratory Factor Analysis (EFA) suggested a three-factor solution as participation, modification, and facilitation.

Conclusion

The Family Accommodation Scale for Obsessive–Compulsive Disorder—Interviewer-Rated - Thai version is a psychometrically reliable and valid measure for assessing accommodation in family members of OCD patients.

Short-term outcomes of the Therapist-assisted Online Parenting Strategies intervention for parents of adolescents treated for anxiety and/or depression: A single-arm double-baseline trial

OBJECTIVE

This study aimed to evaluate whether the Therapist-assisted Online Parenting Strategies programme increased parenting behaviours known to be supportive of adolescents experiencing anxiety and/or depression. Secondary parenting outcomes of parental self-efficacy, parental accommodation, carer burden, parent-adolescent attachment, family functioning and parent distress were also examined, along with adolescent outcomes of anxiety and depression symptoms, suicidal ideation and sleep.

METHOD

Seventy-one parents (94.4% females) and their adolescents (73.2% females) aged 12-18 years (Mean = 15.02, SD = 1.56) being treated for depression and/or anxiety in Australia were recruited into a single-arm double-baseline open-label trial. Parents received Therapist-assisted Online Parenting Strategies, which comprised up to nine web-based modules each supplemented with coaching sessions via videoconferencing. Outcomes were analysed using latent growth curve modelling to determine if changes to outcomes at post-intervention (4 month post-second baseline) exceeded changes between two baselines measured 1 month apart.

RESULTS

Sixty-five parents (91.6%) completed at least one module of the online parenting intervention and on average received nine coaching sessions (SD = 2). Parenting behaviours targeted by Therapist-assisted Online Parenting Strategies improved at post-intervention (Cohen's d = 1.16, 95% confidence interval [0.78, 1.51]). Parent-reported parental self-efficacy and parent-adolescent attachment increased (Cohen's d = 1.44 [1.05, 1.82] and 0.39 [0.05, 0.74], respectively), while impairments to family functioning and parent distress decreased (Cohen's d = -0.51 [-0.86, -0.16] and -0.84 [-1.23, -0.44], respectively). Changes to adolescent anxiety, depression and sleep were not significant.

CONCLUSION

The Therapist-assisted Online Parenting Strategies intervention improved self-reported parenting behaviours, parental self-efficacy, parent levels of distress, parent-adolescent attachment, and family functioning in parents with adolescents being treated for anxiety and/or depression. However, significant changes in adolescent mental health and sleep outcomes at post-intervention were not observed. The usefulness of a therapist-supported online parenting programme in addressing a service gap for parents seeking professional help is indicated.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry Number (ACTRN) 12618000290291, prospectively registered on 26 February 2018; https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=368031.

Family Accommodation Scale for Sensory Over-Responsivity: A Measure Development Study

Family accommodation refers to the attempt of family members (most often parents) to prevent their child's distress related to psychopathology. Family accommodation can limit meaningful participation in personal and social routines and activities. Accommodation has been studied extensively in the context of childhood anxiety and has been linked to greater impairment, and poor intervention outcomes. Like anxiety, sensory over-responsivity (SOR) symptoms are associated with heightened distress and thus, may also be accommodated by family members. The current study describes the validation of a new pediatric family accommodation scale for SOR. Parents of 301 children ages 3-13 years completed an online survey, of which 48 had medical or developmental conditions. The survey included the Child Sensory Profile 2 and the newly developed family accommodation scale for sensory over-responsivity (FASENS). Three Sensory Profile 2 scores were analyzed: SOR, sensory under-responsivity and sensory seeking. The FASENS consists of 18 items; 12 describing the frequency of accommodation behaviors and 6 describing the impact of the accommodation on the wellbeing of the family and the child. Results indicated that the FASENS has high internal consistency (α = 0.94) as well as a significant 3-factor confirmatory model fit: (1) accommodations (i.e., avoidance and changes), (2) family impact, and (3) child impact. FASENS scores significantly correlated with SOR symptoms (r = 0.52-0.60, p < 0.001). However, they also correlated with under-responsivity and seeking (r = 0.33-0.42, p < 0.001). Parents of children with health conditions reported significantly higher FASENS scores (p < 0.002), which corresponded with their child's significantly higher sensory scores (p < 0.001). Family accommodations for SOR occur to some extent in the general population, but their prevalence and impact are significantly greater when the child has a health condition, in addition to SOR. Additional research is needed to explore whether these accommodations are adaptive and whether families and children would benefit from learning to reduce them, as with anxiety.

Accommodation of Anxiety in Youth with Autism Spectrum Disorder: Results from the TAASD Study

Objective: Accommodation, or the ways in which families modify their routines and expectations in response to a child's anxiety, is common and interferes with anxiety treatment outcomes. However, little research has examined family accommodation among youth with autism spectrum disorder and anxiety. The current study aimed to (a) identify pre-treatment correlates of accommodation, (b) examine changes in accommodation after treatment, and (c) assess relationships between accommodation and post-treatment anxiety severity.Method: The sample consisted of 167 youth (mean age = 9.90 years; 79.6% male; 18% Latinx) with clinically significant anxiety and a diagnosis of autism spectrum disorder who were enrolled in a randomized clinical trial comparing two cognitive behavioral therapy interventions for anxiety and treatment-as-usual. Participants were evaluated for symptom severity and family accommodation at pre- and post-treatment.Results: Results indicated that clinician-rated anxiety severity and parent-rated externalizing behaviors and autism spectrum disorder severity significantly predicted pre-treatment accommodation. Accommodation significantly decreased from pre- to post-treatment and non-responders showed significantly higher accommodation at post-treatment compared to responders. Finally, youth with higher pre-treatment accommodation had higher post-treatment anxiety.Conclusions: Findings indicate that accommodation for anxiety is common among youth with autism spectrum disorder and anxiety. Furthermore, accommodation is implicated in treatment outcomes and should be targeted in treatment for youth with autism spectrum disorder and anxiety.

The Feasibility of a Parent Group Treatment for Youth with Anxiety Disorders and Obsessive Compulsive Disorder

Cognitive behavioral therapy (CBT) is an effective treatment for children and adolescents with anxiety disorders and obsessive-compulsive disorder (OCD). Yet CBT is insufficiently effective in approximately half of cases in clinical trials and in a substantial number of cases children refuse to participate in CBT sessions altogether. Parent training offers a promising alternative to direct child therapy. The present study examined the feasibility of a group implementation of SPACE (Supportive Parenting for Anxious Childhood Emotions), a novel parent training approach aimed at reducing parent's accommodation of children's anxiety symptoms. Based on parent reports (N = 25), following treatment there was a significant decrease in parental accommodation, in family power struggles and in parental sense of helplessness, as well as a significant reduction in anxiety and OCD symptom severity. Results support the promise of group SPACE treatment and underscore the need for additional clinical trial research.

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.

Overcoming barriers in cognitive-behavioral therapy for youth anxiety and obsessive-compulsive disorder: Addressing parent behaviors

Exposure-based cognitive-behavioral therapy (CBT) is a well-established treatment for anxiety disorders and obsessive-compulsive disorder (OCD) in youth. Although a majority of youth respond to CBT, a substantial portion remain symptomatic and/or experience a return of symptoms after completing a course of treatment. This highlights the need for further improvements to this evidence-based treatment. Given that parent behaviors can negatively influence treatment, addressing parental behaviors in CBT serves as a novel and promising treatment target to improve youth's therapeutic outcomes. The authors review three common parent behaviors that influence anxiety and treatment outcomes: family accommodation, parent anxious behaviors, and management of disruptive behaviors. The authors then discuss each behavior, its effect on anxiety/OCD and treatment, and how to address the behavior within the context of CBT. In doing so, therapeutic learning can be optimized to improve CBT outcomes for youth with anxiety disorders and/or OCD.

Empowering Anxious Parents to Manage Child Avoidance Behaviors: Randomized Control Trial of a Single-Session Intervention for Parental Accommodation

BACKGROUND

A majority of youth who need anxiety treatment never access support. This disparity reflects a need for more accessible, scalable interventions-particularly those that may prevent anxiety in high-risk children, mitigating future need for higher-intensity care. Self-guided single-session interventions (SSIs) may offer a promising path toward this goal, given their demonstrated clinical utility, potential for disseminability, and low cost. However, existing self-guided SSIs have been designed for completion by adolescents already experiencing symptoms, and their potential for preventing anxiety in children-for instance, by mitigating known anxiety risk factors-remains unexplored.

OBJECTIVE

This trial evaluated the acceptability and proximal effects of project EMPOWER: a web-based, self-guided SSI designed to reduce parental accommodation, a parenting behavior known to increase the risk of anxiety in offspring.

METHODS

In total, 301 parents who reported elevated anxiety symptoms with children aged 4-10 years received either project EMPOWER or an informational control (containing psychoeducational materials and resources); parents self-reported their accommodation of child anxiety and overall distress tolerance at baseline and 2-week follow-up.

RESULTS

Relative to control-group parents, those who received the intervention outlined in project EMPOWER reported significant reductions in their accommodation of child anxiety (d_s=0.61; P<.001) and significant increases in their distress tolerance (d_s=0.43; P<.001) from baseline to 2-week follow-up. Additionally, parents rated project EMPOWER as highly acceptable (ie, easy to use, helpful, and engaging) in accordance with preregistered benchmarks.

CONCLUSIONS

Project EMPOWER is an acceptable self-guided SSI for parents of children at-risk for anxiety, which yields proximal reductions in clinically relevant targets.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04453865; https://tinyurl.com/4h84j8t9.

The Role of Parental Beliefs About Anxiety and Attachment on Parental Accommodation of Child Anxiety

This study examined: 1) the relationship between negative parental beliefs about child anxiety (i.e., it is harmful), insecure parental attachment and parental accommodation of child anxiety; 2) whether parental attachment insecurity moderates the effect of negative beliefs about anxiety on parent accommodation; and 3) a path model of parental factors affecting accommodation and child anxiety severity. Participants were 139 parents of children (6-18 years) with a primary anxiety disorder. Parents completed measures of parental accommodation of their child's anxiety, beliefs about child anxiety, and attachment security. Child anxiety diagnosis and severity was determined using semi-structured clinical interviews. Negative beliefs about child anxiety were directly associated with levels of parental accommodation. There was no direct relationship between insecure attachment and accommodation; however anxious attachment moderated the effect of parental beliefs about anxiety on parental accommodation. Among parents with more secure attachment, negative beliefs about anxiety were associated with greater parental accommodation. However, among parents with less secure attachment, accommodation was high regardless of beliefs about anxiety. A path model suggested that negative beliefs about anxiety was related to increased parental accommodation, which in turn was related to increased child anxiety severity. Psychoeducation about the nature of anxiety is likely to be beneficial in helping to reduce accommodation among parents with more secure attachment styles. However, among those with greater anxious attachment, psychoeducation may need to be tailored to focus on corrective information about the impact of treatment processes on the parent-child relationship.

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.

Research Review: Pediatric anxiety disorders - what have we learnt in the last 10 years?

BACKGROUND

Anxiety disorders first emerge during the critical developmental periods of childhood and adolescence. This review synthesizes recent findings on the prevalence, risk factors, and course of the anxiety disorders; and their neurobiology and treatment.

METHODS

For this review, searches were conducted using PubMed, PsycINFO, and clinicaltrials.gov. Findings related to the epidemiology, neurobiology, risk factors, and treatment of pediatric anxiety disorders were then summarized.

FINDINGS

Anxiety disorders are high prevalence, and early-onset conditions associated with multiple risk factors including early inhibited temperament, environment stress, and structural and functional abnormalities in the prefrontal-amygdala circuitry as well as the default mode and salience networks. The anxiety disorders are effectively treated with cognitive behavioral therapy (CBT), selective serotonin reuptake inhibitors (SSRIs), and serotonin-norepinephrine reuptake inhibitors (SNRIs).

CONCLUSIONS

Anxiety disorders are high prevalence, early-onset conditions associated with a distinct neurobiological fingerprint, and are consistently responsive to treatment. Questions remain regarding who is at risk of developing anxiety disorders as well as the way in which neurobiology predicts treatment response.

Psychometric properties of the Chinese version of the family accommodation scale for obsessive-compulsive disorder interviewer-rated

BACKGROUND

Family accommodation (FA) in obsessive-compulsive disorder (OCD) means that the relatives of patients are involved in, help or facilitate patients' ritual behaviors and avoidance, which is a frequent occurrence and underresearched phenomenon in China. Recent studies have suggested that FA is adversely associated with treatment response, contradictory to the goal of cognitive behavior therapy, a contributor to the maintenance of symptoms and increased symptom severity, and associated with low levels of family and social functioning. There is increasing interest and focus on establishing a family-based intervention for OCD treatment based on the inclusion of relatives by decreasing FA. The present study explored the psychometric properties of the Chinese version of the Family Accommodation Scale for OCD Interviewer-Rated (FAS-IR).

METHOD

A total of 109 patients with OCD and 91 primary relatives were assessed in corresponding patient and family measures, and the FAS-IR was administered to relatives by trained interviewers.

RESULTS

More than 90% of the relatives accommodated patients' symptoms with at least one kind of FA behavior over the previous week, and the incidence of extreme or everyday routines was as high as 59.3%. Exploratory factor analysis demonstrated two-factor structure for the whole scale, including (1) modification and facilitation, and (2) participation. Cronbach's alpha was 0.798 for the whole scale, and the interrater and test-retest reliability coefficients were 0.835 (95%CI: 0.603-0.937) and 0.882 (95%CI: 0.685-0.959), respectively. Convergent validity was supported in exploring FA and was associated with symptom severity, level of functional impairment and family functioning related to OCD. The FA was not significantly correlated with depressive symptoms rated by the patients, as evidence of acceptable divergent validity. There was no significant difference in FA total score based on patient gender, patient age, or relationship with patients.

CONCLUSIONS

The Chinese version of the FAS-IR demonstrated excellent psychometric properties for assessing the degree of FA, suggesting that it is a useful and valuable instrument in clinical and research settings.

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.

Caregiver accommodation in adolescents with avoidant/restrictive food intake disorder and anorexia nervosa: Relationships with distress, eating disorder psychopathology, and symptom change

OBJECTIVE

The role of family and caregiver accommodation is a well-defined maintenance factor for anxiety disorders and OCD. Family accommodation for patients with eating disorders is beginning to be described and characterized, but gaps in the literature remain. The current project compares levels of accommodation in families of those with anorexia nervosa (AN) to those with avoidant/restrictive food intake disorder (ARFID). It additionally establishes whether accommodation changes over the course of treatment and the extent to which these changes are related to changes in eating disorder pathology.

METHODS

A total of 39 adolescents with ARFID and 59 with AN presenting to a partial hospitalization program were included, with measures completed at intake and discharge.

RESULTS

Caregivers of adolescents with AN and those with ARFID reported similar levels of accommodation, with the exception of the Reassurance Seeking subscale of the Accommodation and Enabling Scale for Eating Disorders (AESED). Additionally, accommodation decreased significantly from intake to discharge for both patient groups. Intake AESED scores were also significantly related to caregiver distress, and changes in AESED scores were related to decreases in relevant eating disorder psychopathology for both groups.

CONCLUSIONS

The results of the current study highlight the importance of considering family accommodation for ARFID patients and point to the need for future research to capture changes in accommodation over the course of treatment in relation to the delivery of evidence-based interventions and subsequent changes in ED symptoms.

A randomized-controlled examination of the effect of cognitive reappraisal instruction on maternal accommodation of child anxiety symptoms

Parental accommodation plays a key role in the maintenance of child anxiety, yet much of the research to date has been correlational, making it difficult to draw conclusions about underlying mechanisms. Given preliminary evidence that parental beliefs play a role in parental accommodation, the present study sought to experimentally reduce accommodation by targeting parental attitudes about child anxiety. Mothers of children ages 4-9 (N = 47) were randomly assigned to either receive brief instruction in cognitive reappraisal (EXP) or to a control intervention in which they received no instruction (CON). At pre- and post-intervention mothers were presented with bogus information that their child was experiencing varying levels of distress while completing a task in a nearby room. Maternal distress, negative affect and perceived likelihood of accommodation in the context of child distress were measured pre- and post-intervention. EXP mothers reported greater pre- to post-intervention decreases in distress and perceived likelihood of accommodation, compared to CON mothers. EXP and CON mothers showed similar changes in negative affect. Findings from this study provide preliminary experimental evidence that targeting maternal beliefs about child anxiety can result in changes in maternal distress and behavior following exposure to child distress. Implications for prevention and treatment are discussed.

The Role of Paternal Accommodation of Paediatric OCD Symptoms: Patterns and Implications for Treatment Outcomes

Family accommodation (FA) refers to the participation of family members in obsessive-compulsive disorder (OCD) rituals. Most studies have focused on maternal accommodation; consequently, little is known about fathers’ accommodation of OCD. The current study aims to extend the existing literature by examining maternal versus paternal accommodation of OCD symptoms.

The sample consisted of 209 children with OCD (Mean [M] age = 14.1 years) and their parents (N_Mothers = 209, N_Fathers = 209) who had completed the Family Accommodation Scale- Parent Report (FAS-PR). Paired t-test and chi-square analyses were used to compare FA of OCD symptoms between mothers and fathers. Linear regression was used to examine correlates of maternal and paternal FA and its impact on treatment outcomes.

Mothers reported significantly higher levels of daily FA than fathers. Correlates of maternal and paternal accommodation included OCD symptom severity, emotional and behavioral difficulties, and parent psychopathology. Both maternal and paternal FA significantly predicted worse treatment outcomes.

Both mothers and fathers accommodate child OCD symptoms with high frequency, and in similar ways. Although mothers accommodate to a greater extent than fathers, both maternal and paternal involvement in rituals are a significant predictor of the child’s treatment response. Results emphasise the need to consider the whole family system, including fathers, in understanding and treating OCD in children.

Intolerance of Uncertainty and Parental Accommodation: Promising Targets for Personalized Intervention for Youth Anxiety

PURPOSE OF REVIEW

After reviewing predictors of differential outcomes of cognitive behavioral therapy (CBT) for pediatric anxiety, we identify and discuss recent evidence for the role of (a) intolerance of uncertainty (IU) and (b) parental accommodation as meaningful targets for personalized intervention.

RECENT FINDINGS

Few studies to date have identified promising, theory-driven predictors of differential CBT outcomes. Recent findings suggest that increased IU and high levels of parental accommodation are associated with a poorer response to CBT. Several adaptations of CBT and new interventions targeting either IU or parental accommodation have been developed and found to be efficacious in preliminary studies. IU and parental accommodation are promising constructs for personalizing intervention, both in the identification of who will respond to treatment and in the development of targeted intervention. We recommend that future work test if individuals high in IU and/or parental accommodation will respond more optimally to treatments that specifically target these constructs. The results of this future work may help to move the field closer to personalized intervention.

Parent and child emotion and distress responses associated with parental accommodation of child anxiety symptoms

OBJECTIVE

Parental accommodation contributes to the maintenance of child anxiety and related symptoms. The current study examines the contributions of parent and child factors to parental accommodation in a sample of anxious youth.

METHODS

Sixty-four treatment-seeking youth (6-16 years) and their mothers, as well as a subset of fathers (N = 41) reported on parental accommodation, parental distress and emotion regulation, child psychopathology, child externalizing behaviors, and child intolerance of uncertainty.

RESULTS

Parental accommodation was not related to parental distress or emotion regulation. Parents who viewed their child as being more symptomatic (e.g., anxious, externalizing, and intolerant of uncertainty) were more likely to engage in accommodation. For mothers, child anxiety and externalizing symptoms were notable predictors of accommodation.

CONCLUSIONS

Parent perceptions of child symptomology is an important factor significantly related to accommodation behaviors. This finding can be used to inform programming designed to target parental responses to child anxiety and related disorders.

Separation Anxiety Symptom Profiles and Parental Accommodation Across Pediatric Anxiety Disorders

Parental accommodation refers to ways in which caregivers modify their behavior to decrease child distress in the short-term. Accommodation is prevalent among anxious youth and related to decreased treatment and functional outcomes. Although separation anxiety disorder (SAD) is associated with increased accommodation, SAD is not a predictor of treatment response, suggesting that a diagnosis of SAD alone may not be enough to clarify the relationship between accommodation and separation anxiety symptoms within a clinical context. Participants were youth with a primary anxiety disorder (N = 186; aged 7-17) enrolled in an outpatient anxiety clinic. Latent class analysis was used to extract profiles from parent-reported SAD symptoms using the Anxiety Disorders Interview Schedule for DSM-IV/5. Profiles were compared on pre-treatment accommodation. Low, moderate, and interfering SAD classes emerged. Interfering SAD was associated with high accommodation. Results help to clarify the association between SAD and accommodation and has implications for personalized intervention.

Parent-Child Agreement on Family Accommodation Differentially Predicts Outcomes of Child-Based and Parent-Based Child Anxiety Treatment

Objectives: Family accommodation is linked to poor treatment outcomes for childhood anxiety. Progress in research on the role of accommodation in treatment has been hindered by the relatively weak association between child and parent reports on accommodation. In this study, we suggest that parent-child agreement on family accommodation may provide a dependable estimation of this construct, and investigated whether the level of parent-child agreement on family accommodation predicts subsequent treatment outcome. We further examined whether the effect was greater in Supportive Parenting for Anxious Childhood Emotions (SPACE), which directly targets family accommodation, than in individual child-focused cognitive behavioral therapy (CBT).Methods: Participants were 104 children (aged 6-15) with anxiety disorders, and their mothers, randomized to SPACE or CBT. Accommodation was rated by mothers and children before treatment, halfway through treatment, and at treatment end, using respective versions of Family Accommodation Scale-Anxiety. To accurately estimate agreement, we conducted multilevel response surface analysis by polynomial regression, with agreement on accommodation at each time point predicting subsequent child anxiety severity, over the course of treatment.Results: Parent-child agreement and disagreement on accommodation were significant predictors of subsequent anxiety symptom severity. Different results were obtained for SPACE and CBT, suggesting potentially distinct underlying mechanisms.Conclusions: The findings suggest treatment-specific roles of accommodation in SPACE vs. CBT. Multiple-informant assessment of accommodation provides important information, which may have important implications for optimal treatment personalization.

Family accommodation of anxiety in a community sample of children on the autism spectrum

Anxiety is recognised as one of the most common co-occurring conditions for individuals with a diagnosis on the autism spectrum, with approximately 40 % of children on the spectrum receiving a clinical diagnosis of an anxiety disorder. To date, research has tended to focus upon understanding presentation and evaluating treatment, with little focus on assessing systemic factors, such as the way that family members accommodate the anxiety. This study aimed to investigate the relationship between parent and child anxiety levels and child autism characteristics on the four domains of family accommodation; Participation, Modification, Distress, and Consequence. A community sample (n = 132) of parents of children on the spectrum completed questionnaires on their child's autism characteristics and anxiety symptomatology as well as their own levels of anxiety and family accommodation behaviours. Regression models identified specific aspects of child anxiety as well as parent anxiety as predictive of family accommodation, with the child's difficulties with uncertainty being a consistent predictor of all four domains. Clinical and research implications of this study, including the importance of understanding similarities or differences in the nature and consequence of family accommodation in children on the autism spectrum, are discussed.

Family Accommodation in Autism Spectrum Disorder

Family accommodation occurs frequently among families of children with OCD and anxiety disorders, with higher levels of accommodation repeatedly associated with greater symptom severity, lower functioning, and poorer treatment outcomes for children. This is the first examination of family accommodation of restricted and repetitive behaviors (RRBs) in children with autism spectrum disorder (ASD). Parents of children with ASD (N = 86) completed questionnaires assessing their children's RRBs and parental accommodation of these symptoms. Most participants (80%) reported engaging in accommodation at least once a month and family accommodation was significantly positively correlated with RRB severity. These results suggest accommodation of RRBs follows a pattern similar to that reported in obsessive compulsive and anxiety disorders, and highlight avenues for potential parent-based interventions.

Comorbid Psychopathology and the Clinical Profile of Family Accommodation in Pediatric OCD

Family accommodation (FA) has been linked with myriad negative outcomes in pediatric obsessive-compulsive disorder (OCD), but extant literature has yielded differential relationships between FA and clinical variables of interest. Consequently, this study examined the phenomenology, clinical profile, and effects of comorbid psychopathology on FA to better understand these behaviors. A total of 150 youths and their caregivers completed clinician- and self-reported measures at a baseline visit for a larger randomized controlled trial. Sociodemographic variables were not associated with FA, but specific types of OCD symptom clusters were. Higher OC-symptom severity and functional impairment were associated with increased FA. Comorbid anxiety disorders moderated the relationship between OC-symptom severity and FA, but comorbid attention deficit hyperactivity, oppositional defiant, and mood disorders did not. Internalizing and externalizing problems both mediated the relationship between FA and functional impairment. These findings provide clinical implications for important treatment targets and factors that may impact FA.

Comorbidity, Parental Psychopathology, and Accommodation in the Treatment of Pediatric Obsessive-Compulsive Disorder: A Case Study

This article discusses the treatment of a young person with obsessive-compulsive disorder (OCD) characterized primarily by symptoms of physical and mental contamination, as well as religious obsessions. The treatment was complicated by several factors that will be reviewed and addressed. First, this client had a comorbid diagnosis of attention-deficit/hyperactivity disorder. Second, the young client's mother was also diagnosed with OCD and had a significantly anxious presentation. This impacted treatment in two primary ways. One important way treatment was complicated was that the client frequently attempted to manage her mother's emotions by underreporting her own distress at times. The other implication of the mother's diagnosis was that it became difficult to involve her in the treatment of her daughter and reduce her accommodation of her daughter's symptoms. The manner in which these complicating factors were addressed in the successful treatment of this client by adapting evidence-based practice will be presented as a guide for clinicians facing similar challenges.

Relationship between posttraumatic stress symptoms, caregiving response, and parent mental health in youth exposed to single incident trauma

BACKGROUND

Family factors may alter the risk of developing posttraumatic stress disorder (PTSD) or depression in young people after a traumatic event, but it is not clear which modifiable family variables can be addressed in psychological therapies. This study examined the relationships between family factors (Expressed Emotion [EE] and family accommodation) and psychopathology (posttraumatic stress symptoms; PTSS) in young people following a single incident trauma. Potential mediators of these relationships were also investigated.

METHOD

Sixty-six parent-child dyads (aged 8-17 years) were assessed within one month of attending an Emergency Department. Self-reported PTSS and perceived EE were assessed in young people. Parents' own PTSS, mood symptoms, EE, and accommodating behaviours were also assessed.

RESULTS

Cross-sectional analyses revealed that young person-perceived EE, parent-reported emotional over involvement (EOI) and accommodation behaviours significantly predicted higher PTSS in young people. The stress experienced as a consequence of EE mediated the relationship between young person-perceived EOI and PTSS in young people. Parental PTSS and anxiety were positively correlated with EOI and accommodation. Parental PTSS was not significantly associated with symptoms in young people.

CONCLUSIONS

The results support the hypothesis that EE and accommodation are positively associated with PTSS in young people in the month following a potentially traumatic event. Understanding the child in the context of their family environment and relationships offers an important framework for making sense of and facilitating adaptive adjustment following a traumatic event.

Cognitive Predictors of Parental Rescue Behavior and Malleability of Behavior Using a Brief Psychoeducation Intervention

Cognitive factors, such as beliefs that anxiety is harmful, may lead parents to engage excessively in over-controlling parenting practices, such as "rescuing" children from distress. The present study examined whether parental rescue behavior, or the speed at which parents intervened to rescue an increasingly distressed child during an audio paradigm, was associated with beliefs about child anxiety. We also evaluated the impact of psychoeducation on rescue behavior during the audio paradigm. A nonclinical sample of 310 parents was recruited from an online crowdsourcing platform. Findings support the hypothesis that parents' stronger beliefs that anxiety is harmful relate to parents' faster speed of rescue. Additionally, participants who received psychoeducation delayed their rescue responses more than did participants who received benign information. Findings add to the growing body of evidence that cognitive factors contribute to countertherapeutic parent behavior and indicate that psychoeducation can be an important component of family-based child anxiety treatment.

Family accommodation mediates nightmares and sleep-related problems in anxious children

Nightmares are commonly reported in clinically anxious children and are associated with the presence of other sleep-related problems. Family accommodation has been theorized as playing a central role in the sleep-related problems of anxious children, but empirical data is lacking. We examined associations between nightmares, maternal reports of family accommodation, and sleep-related problems in clinically anxious children. We also examined a hypothesized mediational pathway linking nightmares to other sleep-related problems, through increased family accommodation using structural equation modeling. Participants were 277 clinically anxious children (ages 6-17), and their mothers. Nightmares were reported in over three quarters of the children and were linked to higher mother-rated accommodation and to sleep-related problems. Fit indices for the structural equation model were excellent, and data supported the hypothesis that family accommodation mediates the association between nightmares and sleep-related problems in the anxious children. Results provide the first empirical evidence for the role of family accommodation in nightmares and other sleep-related problems in anxious children. Implications for assessment and treatment of childhood anxiety are discussed.

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.

Symptom Insight in Pediatric Obsessive-Compulsive Disorder: Outcomes of an International Aggregated Cross-Sectional Sample

Insight in obsessive-compulsive disorder (OCD) refers to patients' recognition that their obsessions and compulsions are symptoms rather than necessary or natural thoughts and behaviors.¹ It has been estimated that 20% to 45% of youth with OCD exhibit poor or absent insight.^2-4 Identified correlates of poor insight include younger age,^2,3,5,6 increased OCD severity,^2,4,7 impairment,^4,7,8 and family accommodation^2,4; lower intellectual and adaptive functioning³; and greater depressive symptoms.^2,3 Poorer insight has also been associated with reduced response across treatment groups (ie, selective serotonin reuptake inhibitor [SSRI], cognitive behavioral therapy [CBT], combined SSRI plus CBT, or pill placebo).⁹.

A Preliminary Examination of the Link Between Maternal Experiential Avoidance and Parental Accommodation in Anxious and Non-anxious Children

Studies point to parental experiential avoidance (EA) as a potential correlate of maladaptive parenting behaviors associated with child anxiety. However, research has not examined the relationship between EA and parental accommodation of child anxiety, nor the extent to which parental negative beliefs about child anxiety help explain such a relationship. In a sample of mothers (N = 45) of anxious and non-anxious children, the present study investigated the potential link between maternal EA and accommodation of child anxiety and whether this link may be indirectly accounted for via maternal negative beliefs about child anxiety. EA was significantly and positively associated with accommodation of child anxiety, but when negative beliefs about child anxiety were incorporated into the model this direct effect was no longer significant. Findings highlight the contribution of parental emotions and cognitions to behaviors that may exacerbate child anxiety, and may inform treatment and prevention efforts with families of anxious youth.

Cognitive Behavioral Therapy for Childhood Anxiety Disorders: a Review of Recent Advances

PURPOSE OF REVIEW

We review recent research validating cognitive behavioral therapy (CBT) as a first-line intervention for childhood anxiety disorders. We also review recent research aimed at enhancing exposure-based CBT components and adapting CBT to work with specific populations.

RECENT FINDINGS

Exposure-based CBT is a well-established intervention. Different research groups have found positive evidence to augment CBT by evaluating inhibitory learning principles, the role of parents in child treatment, an individualized case formulation, computer and online forms of CBT, and virtual and augmented reality systems for exposure practice. Specific programs have been developed to meet specific needs of preschoolers, adolescents, and children with comorbid autism spectrum disorder and anxiety. Successful adaptations to CBT exist and the field should continue to improve the generalizability, feasibility, and expected benefit of CBT to improve its effectiveness.