Family accommodation in obsessive-compulsive and anxiety disorders: a five-year update

Obsessive-Compulsive Disorder in Children and Adolescents

Obsessive-compulsive disorder (OCD) in children and adolescents is a neurobehavioral condition that can lead to functional impairment in multiple domains and decreased quality of life. We review the clinical presentation, diagnostic considerations, and common comorbidities of pediatric OCD. An overview of the biological and psychological models of OCD is provided along with a discussion of developmental considerations in youth. We also describe evidence-based treatments for OCD in childhood and adolescence, including cognitive behavioral therapy (CBT) with exposure and response prevention (ERP) and pharmacotherapy. Finally, research evaluating the delivery of CBT in different formats and modalities is discussed, and we conclude with suggestions for future research directions.

Maternal Depressive Symptoms and Offspring Internalizing Problems: A Cross-Lagged Panel Network Analysis in Late Childhood and Early Adolescence

The present study investigated the relations between maternal depressive symptoms and internalizing problems in offspring during late childhood and early adolescence, examining sex differences using symptom network analysis. A total of 885 Chinese youths in late childhood (n = 497, 38.6% girls; age = 9.58 years, SD = 0.24) and early adolescence (n = 388, 48.5% girls; age = 11.30 years, SD = 0.24) and their mothers (Mage = 37.34 years, SD = 5.42) were recruited. Cross-lagged panel network (CLPN) analysis was used to explore bridge symptoms (i.e., symptoms connecting two or more mental disorders) and identify transmission pathways between maternal depressive symptoms and offspring's internalizing problems at these two developmental stages. The CLPN results revealed that in late childhood, the bridge connections in the network model were boys feeling worried to mothers feeling distractible, and girls feeling worried to mothers feeling powerless. In early adolescence, the bridge connections were boys experiencing depressed mood to mothers feeling powerless, and mothers feeling bad to girls experiencing depressed mood. These findings highlight the network-level relations between maternal depressive symptoms and offspring internalizing problems. They provide insights into the developmental differences and similarities in symptoms during these periods and suggest ways to break the vicious cycle of psychopathology between mothers and their children.

The significant others' responses to trauma scale (SORTS): applying factor analysis and item response theory to a measure of PTSD symptom accommodation

Background: Symptom accommodation by family members (FMs) of individuals with posttraumatic stress disorder (PTSD) includes FMs' participation in patients' avoidance/safety behaviours and constraining self-expression to minimise conflict, potentially maintaining patients' symptoms. The Significant Others' Responses to Trauma Scale (SORTS) is the only existing measure of accommodation in PTSD but has not been rigorously psychometrically tested.Objective: We aimed to conduct further psychometric analyses to determine the factor structure and overall performance of the SORTS. Method: We conducted exploratory and confirmatory factor analyses using a sample of N = 715 FMs (85.7% female, 62.1% White, 86.7% romantic partners of individuals with elevated PTSD symptoms).Results: After dropping cross-loading items, results indicated good fit for a higher-order model of accommodation with two factors: an anger-related accommodation factor encompassed items related largely to minimising conflict, and an anxiety-related accommodation factor encompassed items related primarily to changes to the FM's activities. Accommodation was positively related to PTSD severity and negatively related to relationship satisfaction, although the factors showed somewhat distinct associations. Item Response Theory analyses indicated that the scale provided good information and robust coverage of different accommodation levels.Conclusions: SORTS data should be analysed as both a single score as well as two factors to explore the factors' potential differential performance across treatment and relationship outcomes.

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.

The Importance of Practicing at Home During and Following Cognitive Behavioral Therapy for Childhood Anxiety Disorders: A Conceptual Review and New Directions to Enhance Homework Using Mhealth Technology

Practicing newly acquired skills in different contexts is considered a crucial aspect of Cognitive Behavioral Therapy (CBT) for anxiety disorders (Peris et al. J Am Acad Child Adolesc Psychiatry 56:1043-1052, 2017; Stewart et al. Prof Psychol Res Pract 47:303-311, 2016). Learning to cope with feared stimuli in different situations allows for generalization of learned skills, and experiencing non-occurrence of the feared outcome helps in developing non-catastrophic associations that may enhance treatment outcomes (Bandarian-Balooch et al. J Behav Ther Exp Psychiatry 47:138-144, 2015; Cammin-Nowak et al. J Clin Psychol 69:616-629, 2013; Kendall et al. Cogn Behav Pract 12:136-148, 2005; Tiwari et al. J Clin Child Adolesc Psychol 42:34-43, 2013). To optimize treatment outcome, homework is often integrated into CBT protocols for childhood anxiety disorders during and following treatment. Nevertheless, practicing at home can be challenging, with low motivation, lack of time, and insufficient self-guidance often listed as reasons for low adherence (Tang and Kreindler, JMIR Mental Health 4:e20, 2017). This conceptual review provides an overview of (1) how existing CBT childhood programs incorporate homework, and empirical evidence for the importance of homework practice, (2) evidence-based key elements of practice, and (3) how mHealth apps could potentially enhance practice at home, including an example of the development and application of such an app. This review therefore sets the stage for new directions in developing more effective and engaging CBT-based homework programs for childhood anxiety disorders.

Study protocol for a randomized controlled trial of supportive parents - coping kids (SPARCK)-a transdiagnostic and personalized parent training intervention to prevent childhood mental health problems

BACKGROUND

To meet the scientific and political call for effective prevention of child and youth mental health problems and associated long-term consequences, we have co-created, tested, and optimized a transdiagnostic preventive parent-training intervention, Supportive parents - coping kids (SPARCK), together with and for the municipal preventive frontline services. The target group of SPARCK is parents of children between 4 and 12 years who display symptoms of anxiety, depression, and/or behavioral problems, that is, indicated prevention. The intervention consists of components from various empirically supported interventions representing different theorical models on parent-child interactions and child behavior and psychopathology (i.e., behavioral management interventions, attachment theory, emotion socialization theory, cognitive-behavioral therapy, and family accommodation intervention). The content and target strategies of SPARCK are tailored to the needs of the families and children, and the manual suggests how the target strategies may be personalized and combined throughout the maximum 12 sessions of the intervention. The aim of this project is to investigate the effectiveness of SPARCK on child symptoms, parenting practices, and parent and child stress hormone levels, in addition to later use of specialized services compared with usual care (UC; eg. active comparison group).

METHODS

We describe a randomized controlled effectiveness trial in the frontline services of child welfare, health, school health and school psychological counselling services in 24 Norwegian municipalities. It is a two-armed parallel group randomized controlled effectiveness and superiority trial with 252 families randomly allocated to SPARCK or UC. Assessment of key variables will be conducted at pre-, post-, and six-month follow-up.

DISCUSSION

The current study will contribute with knowledge on potential effects of a preventive transdiagnostic parent-training intervention when compared with UC. Our primary objective is to innovate frontline services with a usable, flexible, and effective intervention for prevention of childhood mental health problems to promote equity in access to care for families and children across a heterogeneous service landscape characterized by variations in available resources, personnel, and end user symptomatology.

TRIAL REGISTRATION

ClinicalTrials.gov ID: NTCT05800522.

Partner symptom accommodation in generalized anxiety disorder: a preliminary examination of correlates with symptoms and cognitive behavioural therapy outcome

BACKGROUND

Symptom accommodation is suggested to maintain anxiety pathology and interfere with treatment effectiveness for anxiety and related disorders. However, little is known about symptom accommodation in generalized anxiety disorder (GAD).

AIM

This study investigated the associations between romantic partner symptom accommodation, GAD symptoms, intolerance of uncertainty (IU), relationship satisfaction, and cognitive behavioural therapy (CBT) outcomes from the perspective of the person with GAD.

METHOD

One hundred and twelve people with GAD participated in group CBT and completed measures at pre- and post-treatment.

RESULTS

All participants endorsed that their partner engaged in symptom accommodation to some extent, and the most commonly endorsed type was providing reassurance. Greater self-reported partner symptom accommodation was associated with greater GAD symptoms, chronic worry severity, IU, and relationship satisfaction at baseline. Partner symptom accommodation was found to significantly decrease over treatment; however, less improvement in symptom accommodation from pre- to post-treatment was associated with worse treatment outcomes.

DISCUSSION

This study is the first to show that partner symptom accommodation is prevalent in adults with GAD and to elucidate the presentation and frequency of behaviours. The findings provide preliminary evidence that targeting partner symptom accommodation in treatment may improve CBT outcomes.

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.

Randomized trial comparing standard versus light intensity parent training for anxious youth

OBJECTIVE

To examine the efficacy of the parent-led intervention Supportive Parenting for Anxious Childhood Emotions (SPACE) relative to a low-dose version of the protocol among children and adolescents with clinically significant anxiety and/or obsessive-compulsive disorder (OCD).

METHOD

68 youth (7-17) with anxiety/OCD and their parents were randomized to receive 12 weekly telehealth SPACE sessions (SPACE-Standard) or bibliotherapy plus 4 telehealth sessions over 12 weeks (SPACE-light). After screening, assessments were conducted via videoconferencing at baseline, post-treatment, and one-month follow-up. Independent evaluators were blind to treatment condition.

RESULTS

Treatment condition did not predict whether a participant responded to the intervention (SPACE-Standard = 70%; SPACE-Light = 68%), nor was treatment condition a predictor of anxiety severity, parent-reported anxiety, or parent-/child-reported functional impairment at post-treatment or one-month follow-up. Youth in SPACE-Light self-reported higher post-treatment anxiety than youth in SPACE-standard, though this was no longer significant at one-month follow-up. Parent-reported family accommodation total change scores were associated with anxiety severity at post-treatment across both arms.

CONCLUSION

This is the second randomized controlled trial (RCT) evaluating SPACE and provides further support for the efficacy of this intervention both in standard and low-dose formats. This study provides support for parent-led anxiety treatment targeting family accommodation as a primary mechanism of change and extends evidence of efficacy to a more clinically diverse sample.

TRIAL REGISTRATION

ClinicalTrials.gov Registry: NCT04922502.https://classic.

CLINICALTRIALS

gov/ct2/show/NCT04922502.

The role of family accommodation in child posttraumatic stress symptoms and functional impairment in the context of cognitive behavioral therapy

BACKGROUND

Caregiver behaviors such as family accommodation (FA) are negatively reinforced by reduced distress in the short term, but ultimately maintain symptoms. It is important to explore the role of FA on symptoms and impairment. The current study examined the relationship among FA, posttraumatic stress symptoms (PTSS), and functional impairment in a sample of children and their caregivers who completed trauma treatment.

METHOD

Participants included 183 children and their caregivers (M age = 7.89; 55.19 % female; 73.22 % non-Hispanic; 51.37 % White). Data consisted of parent-reported measures collected at baseline, post-treatment, and 12-month follow-up from a randomized control trial (RCT) comparing Stepped Care CBT for Children after Trauma and Trauma-Focused Cognitive Behavior Therapy (TF-CBT). Correlational, mediation, and hierarchical linear regression analyses were conducted to test the interrelationships among FA, child PTSS, and child functional impairment.

RESULTS

FA was significantly, positively associated with total PTSS and functional impairment at baseline. Baseline FA partially mediated the relationship between baseline total PTSS and baseline functional impairment. Lastly, greater pre- to post-treatment changes in FA were mostly associated with relevant outcome variables at post-treatment and 12-month follow-up.

LIMITATIONS

Study limitations include use of a single informant, cross-sectional data analysis, lack of differentiation among trauma types, concerns regarding generalizability.

CONCLUSION

Assessing FA may be a helpful tool in better understanding how child PTSS relates to functional impairment following exposure to trauma. This study is clinically relevant it offers insight on the relationship among FA, PTSS, and functional impairment for families involved in trauma treatment.

Family accommodation in PTSD: Proposed considerations and distinctions from the established transdiagnostic literature

Accommodation is widely documented and studied among internalizing disorders; however, the conceptualization and study of accommodation in the context of posttraumatic stress disorder (PTSD) is relatively nascent. PTSD entails many diagnostic criteria-including exposure to a distinct Criterion A event, emotional numbing, and anger-that may uniquely influence accommodation and merit special consideration. Our aim was to review the impact of accommodation in PTSD, compare and contrast accommodation in PTSD to other disorders with a strong empirical evidence base regarding accommodation, and highlight considerations unique to PTSD and associated implications for accommodation. We conclude by providing considerations for future research and practice.

Brief Report: Family Accommodation is Associated with the Impact of Childhood Anxiety in Autism

Anxiety is commonly experienced by children on the autism spectrum, and can negatively impact their lives. Family accommodation has been linked to the impact of anxiety on the child's life in non-autistic children. This study tested whether the same relationship holds for children on the autism spectrum. A community sample (n = 118) of parents of children on the spectrum completed questionnaires on their child's autism characteristics and severity and impact of their child's anxiety, their own anxiety and family accommodation behaviours. Family accommodation was associated with the impact of child anxiety, over and above anxiety severity of the child and parent. Findings support the involvement of parents in psychosocial support for children on the autism spectrum experiencing anxiety.

A Wearable Artificial Intelligence Feedback Tool (Wrist Angel) for Treatment and Research of Obsessive Compulsive Disorder: Protocol for a Nonrandomized Pilot Study

BACKGROUND

Obsessive compulsive disorder (OCD) in youth is characterized by behaviors, emotions, physiological reactions, and family interaction patterns. An essential component of therapy involves increasing awareness of the links among thoughts, emotions, behaviors, bodily sensations, and family interactions. An automatic assessment tool using physiological signals from a wearable biosensor may enable continuous symptom monitoring inside and outside of the clinic and support cognitive behavioral therapy for OCD.

OBJECTIVE

The primary aim of this study is to evaluate the feasibility and acceptability of using a wearable biosensor to monitor OCD symptoms. The secondary aim is to explore the feasibility of developing clinical and research tools that can detect and predict OCD-relevant internal states and interpersonal processes with the use of speech and behavioral signals.

METHODS

Eligibility criteria for the study include children and adolescents between 8 and 17 years of age diagnosed with OCD, controls with no psychiatric diagnoses, and one parent of the participating youths. Youths and parents wear biosensors on their wrists that measure pulse, electrodermal activity, skin temperature, and acceleration. Patients and their parents mark OCD episodes, while control youths and their parents mark youth fear episodes. Continuous, in-the-wild data collection will last for 8 weeks. Controlled experiments designed to link physiological, speech, behavioral, and biochemical signals to mental states are performed at baseline and after 8 weeks. Interpersonal interactions in the experiments are filmed and coded for behavior. The films are also processed with computer vision and for speech signals. Participants complete clinical interviews and questionnaires at baseline, and at weeks 4, 7, and 8. Feasibility criteria were set for recruitment, retention, biosensor functionality and acceptability, adherence to wearing the biosensor, and safety related to the biosensor. As a first step in learning the associations between signals and OCD-related parameters, we will use paired t tests and mixed effects models with repeated measures to assess associations between oxytocin, individual biosignal features, and outcomes such as stress-rest and case-control comparisons.

RESULTS

The first participant was enrolled on December 3, 2021, and recruitment closed on December 31, 2022. Nine patient dyads and nine control dyads were recruited. Sixteen participating dyads completed follow-up assessments.

CONCLUSIONS

The results of this study will provide preliminary evidence for the extent to which a wearable biosensor that collects physiological signals can be used to monitor OCD severity and events in youths. If we find the study to be feasible, further studies will be conducted to integrate biosensor signals output into machine learning algorithms that can provide patients, parents, and therapists with actionable insights into OCD symptoms and treatment progress. Future definitive studies will be tasked with testing the accuracy of machine learning models to detect and predict OCD episodes and classify clinical severity.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05064527; https://clinicaltrials.gov/ct2/show/NCT05064527.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/45123.

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.

Understanding the support needs of parents of children with obsessive-compulsive disorder: a qualitative descriptive study in the UK

INTRODUCTION

Caring for a child with obsessive-compulsive disorder (OCD) can be extremely difficult, yet evidence-based support strategies for parents/carers are limited. A detailed understanding of parent support needs is an important first step in intervention development and qualitative research with this focus is currently lacking. In this study, the viewpoints of parents and professionals were used to understand support needs and preferences when caring for a child with OCD. This qualitative descriptive study formed part of a wider UK-based project aimed at developing better support for parents of children with OCD.

METHOD

Individual semi-structured interviews (and an optional one-week journal) with a purposive sample of parents of children and young people (CYP) with OCD, aged 8-18, and focus groups (or individual interviews where preferred) with a purposive sample of professionals supporting CYP with OCD. Data comprised transcripts of audio-recorded interviews and focus groups, and text from journals. Analysis was informed by the Framework approach involving inductive and deductive coding, supported by NVivo 12.0 software. Co-production methods were adopted throughout the research process, including the involvement of a parent co-researcher and charity collaborators.

RESULTS

Interviews were undertaken with 20 parents, of which 16 completed a journal. Twenty-five professionals took part in a focus group or interview. Five key themes relating to parent support challenges and support needs/preferences were identified (1) Coping with the impact of OCD; (2) Getting help for my child; (3) Understanding parents' role; (4) Making sense of OCD; (5) Joined-up care.

CONCLUSION

Parents caring for children with OCD have clear caregiver support needs which are currently not being met. Through triangulation of parent and professional accounts, this study has identified parent support challenges (e.g., emotional impact of OCD, visibility of caring role, misunderstanding about OCD) and support needs/ preferences (e.g., headspace/respite, compassion/sensitivity, guidance on accommodation) to lay the vital foundations for the development of effective parent support interventions. There is now an urgent need to develop and test an intervention to support parents in their caregiving role, with the aim of preventing and/or reducing their levels of burden and distress and ultimately, improving their quality of life.

Characteristics and predictors of family accommodation in Turkish individuals with obsessive-compulsive disorder

BACKGROUND

Family accommodation (FA) is associated with disease severity and response to treatment rates in patients with obsessive-compulsive disorder (OCD) and is therefore particularly important in this patient group. This study investigated the structure of FA and associated factors in a Turkish society sample.

METHODS

The study was carried out with 92 patients diagnosed with OCD for at least 1 year, who applied to Alanya ALKU Training and Research Hospital psychiatry outpatient clinic between February 2021 and March 2022. Sociodemographic data form, Family Accommodation Scale-Patient Form (FAS-PF), Dimensional Obsessive-Compulsive Scale (DOCS), Beck Depression Inventory (BDI), Beck Anxiety Inventory (BAI) and Acceptance and Action Questionnaire (AAQ-II) were applied to all of the cases. Relatives filled out the Sociodemographic Data.

RESULTS

The mean age of the patients was 32.11 ± 11.56 years. Sixty-nine (75%) of the patients were women. Fifty (54.3%) patients weremarried. All participants reported FA behavior at least once in the previous week. FA exhibited no significant variation by sex (p = 0.679)or marital status (p = 0.256). Significant positive correlation was determined between DOCS-T (r = 0.370, p < 0.001), AAQ-II (r = 0.261, p = 0.013), BDI (r = 0.235, p = 0.024) and BAI (r = 0.342, p = 0.001) scores and the FAS-PF. In the regression analysis, only OCD disease severity predicted FA [(β = 0.295, p = 0.036, 95% confidence interval (95% CI) = 0.02 to 0.55)]. Higher FA scores were obtained in this study (23.93 ± 15.28) compared to previous research in Western societies (14.3 ± 15.2).

DISCUSSION

Clinicians should consider FA in the examination of OCD patients. High FA values for both frequency and severity suggestthat interventions directed toward FA may be associated with more positive outcomes in outpatient Turkish patients with OCD.

Exploring the experiences and responses of siblings living with a brother or sister with obsessive compulsive disorder

OBJECTIVES

The impact of having a child with diagnosed obsessive-compulsive disorder (OCD) can reportedly cause significant disruption to caregiver routines and negatively affect their mental health. Less is known about the impact to other first-degree relatives such as siblings due to limited research. It should not be assumed that findings in the caregiver literature can simply be applied to siblings. This study, therefore, aimed to explore the experiences and responses of cohabiting siblings of a brother or sister with an OCD diagnosis.

METHOD

Eight participant siblings were recruited from a UK specialist OCD NHS clinic and interviewed via telephone about their experiences co-habiting with a brother or sister with OCD. Interviews were transcribed and subjected to interpretative phenomenological analysis (IPA).

RESULTS

Two superordinate themes of 'OCD as a dangerous dictator' and the 'unifying/polarising influence of OCD on relationships' were interpreted from the eight participant experiences. Siblings spoke to OCD creating a dictatorial environment characterised by sibling loss, helplessness and adjustment. This fragile domestic environment seemingly pushed non-anxious siblings to the periphery of the family or conversely centralised their position through parentification.

CONCLUSIONS

Many of the sibling experiences of frustration, distress avoidance, helplessness and symptom accommodation are mirrored in the burgeoning caregiver literature. Longitudinal studies are required to track sibling experiences over the course of their siblings OCD journey and expand our knowledge in this area. Counselling services, sibling support groups and inclusion in family assessment, formulation and treatment are possible avenues of exploration for siblings of those with an OCD diagnosis.

Clinical Considerations for an Evidence-Based Assessment for Obsessive-Compulsive Disorder

Obsessive-compulsive disorder (OCD) is an impairing mental health disease, generally beginning in childhood, affecting up to ∼3% of the population. Using evidence-based assessments (EBAs) is the starting point for the accurate diagnosis and treatment of OCD. EBAs consist of structured and semistructured clinician-administered interviews, parent-report and child-report, and self-report for adults. This article details the practical application, psychometric properties, and limitations of available assessments to determine the presence of OCD and evaluate OCD symptom severity. The following reviews measurement of constructs relevant to OCD (ie, insight, family accommodation, impairment) and details considerations for best clinical interview practices.

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.

Early Identification and Intervention in Pediatric Obsessive-Compulsive Disorder

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

Parent-Led Cognitive Behavioural Therapy for Children with Autism Spectrum Conditions. A Pilot Study

This article reports on a pilot study of a parent-only cognitive behavioural therapy (CBT) programme for parents of children with autism spectrum disorders (ASD) and anxiety difficulties. Twenty-one parents of anxious children with ASD (5-11 of age) completed the From Timid to Tiger intervention. Parent outcome measures were assessed at post-intervention and at 3-month follow-up. Analysis indicated significant reductions in both parent and clinician reports of child anxiety symptoms. Specifically, 38% of children were free of their primary diagnosis at treatment end and this increased to 57% when measured at 3-month follow-up. Positive gains were evidenced regarding parents' ability to manage their child's anxiety without accommodating to it. The results provide preliminary evidence of parent-only CBT programs for children with ASD.

Context matters: criticism and accommodation by close others associated with treatment attitudes in those with anxiety

BACKGROUND

Many people with anxiety do not seek therapy due to negative views of treatment. Although close others (e.g. romantic partners, family members, close friends) are highly involved in treatment decisions, the role of specific relational behaviours in treatment ambivalence has yet to be studied.

AIMS

This study examines the relationship between social predictors (perceived criticism and accommodation of anxiety symptoms by close others) and treatment ambivalence.

METHOD

Community members who met diagnostic criteria for an anxiety-related disorder (N = 65) and students who showed high levels of anxiety (N = 307) completed an online study. They were asked to imagine they were considering starting cognitive behavioural therapy (CBT) for their anxiety and complete a measure of treatment ambivalence accordingly. They then completed measures of perceived criticism and accommodation by close others. Linear regression was used to examine the predictive value of these variables while controlling for sample type (clinical/analogue) and therapy experience.

RESULTS

Greater reactivity to criticism from close others and greater accommodation of anxiety symptoms by close others were associated with greater treatment ambivalence in those with anxiety. These predictors remained significant even when controlling for therapy history and sample type.

CONCLUSIONS

When it comes to treatment attitudes, relational context matters. Clients demonstrating ambivalence about starting therapy may benefit from discussion about the impact of their social environment on ambivalence.

Unpacking parental accommodation: Relationship to parent distress tolerance and cognitive styles

Accommodation, or changes to parent behaviors or routines to avoid or alleviate child distress related to psychopathology, is one maladaptive parent response that is common in anxiety disorders and associated with poor youth outcomes. Little is known about the processes in parents that contribute to accommodation. Thus, the current study examined how accommodation relates to parent distress tolerance and cognitive styles. The present study utilized data from 295 parents (289 female) of children ages 4-10 who were recruited for a randomized trial of an internet-based single-session intervention targeting parent accommodation (NCT04453865). Results indicate a positive relationship between parent rumination and worry and accommodation, highlighting the influence of parent cognitive processes on their tendency to accommodate. In addition, results suggest a positive relationship between reduced parent distress tolerance and greater accommodation, and this relationship may be influenced by other factors. Future research that uses multiple methods of assessment will add to effective interventions for parent accommodation that can be used to improve youth outcomes.

Clinical, demographic and theory-derived maintaining factors as moderators of treatment outcome in internet-delivered cognitive behavioural therapy for children and adolescents with social anxiety disorder

Internet-delivered cognitive behavioural therapy (ICBT) is an efficacious treatment for social anxiety disorder (SAD) in youth. However, we have limited knowledge about patient characteristics that may be associated with better (or worse) treatment outcome. Particularly concerning factors suggested to be involved in the maintenance of SAD (e.g., anticipatory anxiety and post-event processing). The aim of the current study was to evaluate possible predictors and moderators of the effect of ICBT in a randomised controlled trial where children and adolescents (N = 103; 10-17 years) with SAD received either ICBT or internet-delivered supportive therapy, ISUPPORT. Examined variables were pre-treatment levels of social anxiety, depression symptoms, putative maintaining factors as well as demographic variables like age and gender. Latent growth curve models were used to examine predictors and moderators of changes in youth and clinician rated social anxiety symptoms, from pre-treatment to 3-month follow-up. Baseline depression symptoms moderated the outcome, with higher depression scores being associated with greater reduction of SAD symptoms in ICBT compared to ISUPPORT. More difficulties at baseline with anticipatory anxiety, post-event processing, focus of attention and safety behaviours predicted greater reduction of SAD symptoms, regardless of treatment condition. No other clinical or demographic variable predicted or moderated the outcome. In summary, baseline depression severity may be an important moderator of ICBT, but the preliminary finding needs replication in sufficiently powered trials.

Early intervention in obsessive-compulsive disorder: From theory to practice

Obsessive-compulsive disorder (OCD) is frequent and often disabling. Yet, correct diagnosis and appropriate treatment implementation are usually delayed, with undesirable consequences. In this paper we review the rationale for early intervention in OCD and provide recommendations for early intervention services. Two scenarios are discussed, i.e., subclinical (prodromal) obsessive-compulsive symptoms (OCS) and full-blown OCD. Although the typical patient with OCD reports a long history of subclinical OCS, longitudinal studies suggest most individuals with OCS in the community do not convert to full-blown OCD. Thus, research on "at risk" phenotypes for OCD and how they should incorporate different risk factors (e.g., polygenic risk scores) are badly needed. For this specific scenario, preventative treatments that are cheap, well tolerated and highly scalable (e.g., lifestyle interventions) are of major interest. On the other hand, increasing evidence suggests OCD to be a progressive disorder and the severity and duration of illness to be associated with both biological changes and increased clinical complexity, including greater number of physical and psychiatric comorbidities, increased family accommodation and worse treatment response. Therefore, prompt identification and early treatment implementation for full-blown OCD are also critical for ethical, clinical and therapeutic reasons. Based on the existing findings, we argue that, regardless of focusing on subclinical OCS or clinical OCD, early intervention services need to target a childhood age group. In addition to delivering well established treatments to people with full-blown OCD early on their illness, early intervention services also need to provide psychoeducation for patients, families and teachers.

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.

The global assessment of OCD

Obsessive Compulsive Disorder (OCD) is a common mental disorder that often causes great sufferance, with substantial impairment in social functioning and quality of life and affects family and significant relationships. Notwithstanding its severity, OCD is often not adequately diagnosed, or it is diagnosed with delay, leading often to a long latency between onset of the OCD symptoms and the start of adequate treatments. Several factors contribute to the complexity of OCD's clinical picture: early age of onset, chronic course, heterogeneity of symptoms, high rate of comorbidity with other psychiatric disorders, slow or partial response to therapy. Therefore, it is of primary importance for clinicians involved in diagnosing OCD, to assess all aspects of the disorder. This narrative review focuses on the global assessment of OCD, highlighting crucial areas to explore, pointing out the clinical features which are relevant for the treatment of the disorder, and giving an overview of the psychometric tools that can be useful during the screening procedure.

Parent training for dependent, yet abled, young adults

The term Failure to launch (FTL) has been used to describe abled adults who do not work, do not attend school, and live with- and at the expense of-their parents. FTL can be beneficially addressed through parent training, a treatment method that is rarely used with adults (i.e., individuals past the age of majority). The authors first review the goals of parent training programs offered to parents of adults. The review demonstrates that these goals dovetail with key aspects of FTL. The authors then describe a new parent training approach for parents of individuals with FTL, based on SPACE (Supportive Parenting for Anxious Childhood Emotions). They highlight five key components of SPACE-FTL: Psychoeducation, Reducing Parental Accommodation, Increasing Parental Support, De-Escalation, and Engaging Supporters. The authors conclude by discussing SPACE-FTL in relation and comparison to other parent training programs and their components.

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.

Family accommodation in pediatric anxiety: Relations with avoidance and self-efficacy

Pediatric anxiety disorders are common, impairing, and chronic when not effectively treated. A growing body of research implicates family accommodation in the maintenance of pediatric anxiety. The present study aimed to quantify previously untested relations among family accommodation and two theoretically linked constructs: avoidance and self-efficacy. Eighty youths between ages 8 and 17 (53 with anxiety disorders, 27 non-anxious controls) completed measures of family accommodation and self-efficacy. In addition, avoidance was assessed using two distinct measures of avoidance: a clinician rating of real-world behaviors and a laboratory task-based index. As predicted, youths with anxiety disorders reported greater family accommodation than non-anxious controls. Across the sample, greater family accommodation was associated with greater avoidance, as measured using both clinician rating and the laboratory task, as well as with lower self-efficacy. In an exploratory mediation model, self-efficacy partially mediated the relation between family accommodation and clinician-rated avoidance; however, it did not mediate the relation between family accommodation and task-based avoidance. Considering the robust association between family accommodation and anxiety in youths, this addition to our understanding of related cognitive and behavioral factors provides important preliminary insight, which can guide future research on potential targets for early identification and intervention for pediatric anxiety.

Clinician Perspectives on the Impact of COVID-19 on the Treatment of Adults and Youth with Anxiety

We describe the perceptions of mental health clinicians practicing in the United States about the effects of the COVID-19 pandemic on the presentation and treatment course of active clients with anxiety. Clinician participants reported on client symptomology at the beginning of treatment, just before (prior to March 2020), and at a mid-pandemic timepoint (December 2020/January 2021). An initial sample of 70 clinicians responded to a survey assessing their clients' overall anxiety severity, anxiety sensitivity, pathological uncertainty, family accommodation, and avoidance levels. Of these, 54 clinician responses were included in study analyses, providing detailed clinical information on 81 clients. Findings suggest that the COVID-19 pandemic was associated with increases in anxiety severity in the majority of clients; overall, clinicians reported that 53% of clients had symptoms worsen due to COVID-19 and that only 16% experienced improvement of symptoms during treatment. Those who had lower levels of avoidance pre-pandemic and those who increased their frequency of treatment were more likely to experience increases in anxiety severity by the mid-pandemic timepoint. Further research is needed to understand the extended effects of the COVID-19 pandemic on anxiety symptomology and treatment.

Determinants of family functioning in caregivers of persons with obsessive-compulsive disorder

BACKGROUND

Obsessive-compulsive disorder (OCD) is known to cause significant burden to patients and their caregivers. However, there is limited data on its impact on family functioning, especially from families with an adult member having OCD.

METHODS

Four hundred subjects, which included treatment-seeking adult OCD patients (n = 200) and their caregivers (n = 200) were recruited. Patients were evaluated using the Mini International Neuropsychiatric Interview (MINI) and the Yale-Brown Obsessive-Compulsive Scale (YBOCS). Caregivers were evaluated using the MINI, the Caregiver Strain Index (CSI), the Hamilton Anxiety Rating Scale (HAM-A), the Hamilton Depression Rating Scale (HAM-D), the Socio-Occupational Functioning Assessment Scale (SOFAS), the Family Accommodation Scale (FAS) and the Connor-David Resilience scale (CD-RISC) in a cross-sectional interview. Family functioning was measured using the OCD Family Functioning (OFF) Scale. Structural equation modeling (SEM) was carried out to evaluate the relationships between the patient and caregiver variables to predict family functioning.

RESULTS

From the best-fitting path model, we ascertained that OCD symptoms did not have a direct relationship with family dysfunction. Their effects were in turn was mediated by family accommodation, anxiety, caregiver stress/burden and depression. "Contamination & washing" was the only significant symptom dimension within the model. Caregiver resilience was found to predict only their individual functioning, and not family functioning.

LIMITATIONS

Study sample included patients from a tertiary care OCD service, only one caregiver from each patient's family was interviewed.

CONCLUSIONS

Evaluating family functioning, addressing it as part of interventional modules for patients and caregivers may help improving treatment outcomes.

Family-based cognitive behavioural therapy versus family-based relaxation therapy for obsessive-compulsive disorder in children and adolescents: protocol for a randomised clinical trial (the TECTO trial)

BACKGROUND

Cognitive behavioural therapy (CBT) is the recommended first-line treatment for children and adolescents with obsessive-compulsive disorder (OCD), but evidence concerning treatment-specific benefits and harms compared with other interventions is limited. Furthermore, high risk-of-bias in most trials prevent firm conclusions regarding the efficacy of CBT. We investigate the benefits and harms of family-based CBT (FCBT) versus family-based psychoeducation and relaxation training (FPRT) in youth with OCD in a trial designed to reduce risk-of-bias.

METHODS

This is an investigator-initiated, independently funded, single-centre, parallel group superiority randomised clinical trial (RCT). Outcome assessors, data managers, statisticians, and conclusion drawers are blinded. From child and adolescent mental health services we include patients aged 8-17 years with a primary OCD diagnosis and an entry score of ≥16 on the Children's Yale-Brown Obsessive-Compulsive Scale (CY-BOCS). We exclude patients with comorbid illness contraindicating trial participation; intelligence quotient < 70; or treatment with CBT, PRT, antidepressant or antipsychotic medication within the last 6 months prior to trial entry. Participants are randomised 1:1 to the experimental intervention (FCBT) versus the control intervention (FPRT) each consisting of 14 75-min sessions. All therapists deliver both interventions. Follow-up assessments occur in week 4, 8 and 16 (end-of-treatment). The primary outcome is OCD symptom severity assessed with CY-BOCS at end-of-trial. Secondary outcomes are quality-of-life and adverse events. Based on sample size estimation, a minimum of 128 participants (64 in each intervention group) are included.

DISCUSSION

In our trial design we aim to reduce risk-of-bias, enhance generalisability, and broaden the outcome measures by: 1) conducting an investigator-initiated, independently funded RCT; 2) blinding investigators; 3) investigating a representative sample of OCD patients; 3) using an active control intervention (FPRT) to tease apart general and specific therapy effects; 4) using equal dosing of interventions and therapist supervision in both intervention groups; 5) having therapists perform both interventions decided by randomisation; 6) rating fidelity of both interventions; 7) assessing a broad range of benefits and harms with repeated measures. The primary study limitations are the risk of missing data and the inability to blind participants and therapists to the intervention.

TRIAL REGISTRATION

ClinicalTrials.gov : NCT03595098, registered July 23, 2018.

Non-violent resistance and family accommodation: A trans-diagnostic solution to a highly prevalent problem

The goal of this study is to integrate two areas in recent clinical theory, research, and practice: family accommodation and non-violent resistance (NVR). Family accommodation describes changes that family members make to their own behavior, to help their relative who is dealing with psychopathology to avoid or alleviate distress related to the disorder. Rapidly growing research on family accommodation has established its high prevalence and negative impact across disorders and the life span. NVR is a trans-diagnostic treatment approach that helps parents to cope with child externalizing, internalizing, and other problems in non-escalatory ways. This study reviews empirical research on family accommodation and NVR, and argues that the anchoring function of NVR, a central concept reflecting the stabilization of the parent-child relationship, may provide a uniquely suited framework for reducing family accommodation across disorders and development. The study discusses how the anchoring function may be applied to promote accommodation reduction through a detailed description of SPACE (Supportive Parenting for Anxious Childhood Emotions), an NVR-informed treatment for childhood anxiety and obsessive-compulsive disorder.

Family Accommodation of Symptoms in Adults With Obsessive-Compulsive Disorder: Factor Structure and Usefulness of the Family Accommodation Scale for OCD-Patient Version

For individuals with obsessive-compulsive disorder (OCD), family accommodation of symptoms, such as over-reassurance, participation in rituals, or facilitation of avoidance, is one of the key factors associated with symptom severity, maintenance, and related impairment. Most studies have assessed accommodation behaviors based on reports from family members or other loved ones. Recently, a patient-rated questionnaire, the Family Accommodation Scale for OCD-Patient Version (FAS-PV) was developed to assess family accommodation from the patient's perspective. This study investigated the factor structure of the FAS-PV and clinical variables associated with patient-reported family accommodation in a sample of 151 treatment-seeking adults with OCD. A confirmatory factor analysis suggested that a 4-factor model best characterized the scale, with the following factors: (1) participation in symptoms, (2) avoidance of OCD triggers, (3) taking on responsibilities, and (4) modifying responsibilities. Internal consistency was high for the total score and for scores on the 4 subscales of the FAS-PV. Approximately 87% of the sample reported accommodation behaviors at some level. Family accommodation was positively correlated with OCD symptom severity and functional disability, and partially mediated the associations between these 2 factors, so that greater OCD severity was associated with greater accommodation, which, in turn, was associated with greater disability. Our findings parallel those of studies that have employed other versions of the FAS and suggest that the FAS-PV is a useful tool for assessing family accommodation of OCD symptoms from the patient's perspective.

Comorbidities in Obsessive-Compulsive Disorder Across the Lifespan: A Systematic Review and Meta-Analysis

Comorbidities are seen with obsessive-compulsive disorder (OCD) across the lifespan. Neurodevelopmental comorbidities are common in young children, followed by mood, anxiety, and obsessive-compulsive related disorders (OCRDs) in children, adolescents and adults, and neurological and degenerative disorders in the elderly. Understanding comorbidity prevalence and patterns has clinical and research implications. We conducted a systematic review and meta-analysis on comorbidities in OCD across the lifespan, with the objective to, first, estimate age-wise pattern and prevalence of comorbidities with OCD and, second, to examine associations of demographic (age at assessment, gender distribution) and clinical characteristics (age of onset, illness severity) with comorbidities. Four electronic databases (PubMed, EMBASE, SCOPUS, and PsycINFO) were searched using predefined search terms for articles published between 1979 and 2020. Eligible studies, across age, reported original findings on comorbidities and had an OCD sample size of ≥100. We excluded studies that did not use standardised diagnostic assessments, or that excluded patients on the basis of comorbidity. We adhered to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. The review protocol has been registered on the International Prospective Register of Systematic Reviews. A comorbidity rate of 69% was found in a pooled sample of more than 15,000 individuals. Mood disorders (major depressive disorder), anxiety disorders (generalised anxiety disorder), neurodevelopmental disorders (NDDs) and OCRDs were the commonest comorbidities. Anxiety disorders prevailed in children, mood disorders in adults, whereas NDDs were similarly prevalent. Higher comorbidity with any psychiatric illness, NDDs, and severe mental disorders was seen in males, vs. females. Illness severity was inversely associated with rates for panic disorder, tic disorders, OCRDs, obsessive compulsive personality disorder, and anorexia nervosa. This systematic review and meta-analysis provides base rates for comorbidities in OCD across the lifespan. This has implications for comprehensive clinical evaluation and management planning. The high variability in comorbidity rates suggests the need for quality, multi-centric, large studies, using prospective designs. Systematic Review Registration: Unique Identifier: CRD42020215904.

Clinical Update: The Role of Family Accommodation in Youth Anxiety Treatment Outcomes

Over the past several years, family accommodation (FA) has gained increasing recognition for its role in child and adolescent anxiety disorders. Recent clinical trials highlight the importance of assessing and addressing FA within the context of treatment, with findings showing that FA is a significant predictor of treatment success. This clinical update was prompted by such findings, and specifically findings from a study by Zilcha-Mano and colleagues (2020) which suggest that the level of agreement between child- and parent-reports of FA has differential effects on outcomes for child- and parent-based treatments. In this article we aim to provide (1) a brief overview of the research pointing to the reduction of FA as a critical ingredient of youth anxiety treatment, and (2) a summary and in-depth discussion of the study by Zilcha-Mano et al. (2020) that speaks to the potential importance of leveraging multi-informant reports of FA. With regard to the latter aim, we offer preliminary suggestions for how clinicians might incorporate measures of FA into their practice to maximize benefits for anxious youth and their families. We also offer suggestions for how future research can build on these novel findings, advance methods of FA assessment, and promote its clinical utility.

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.

Knowledge and competency standards for specialized cognitive behavior therapy for adult obsessive-compulsive disorder

Obsessive-Compulsive Disorder (OCD) is a leading cause of disability world-wide (World Health Organization, 2008). Treatment of OCD is a specialized field whose aim is recovery from illness for as many patients as possible. The evidence-based psychotherapeutic treatment for OCD is specialized cognitive behavior therapy (CBT, NICE, 2005, Koran and Simpson, 2013). However, these treatments are not accessible to many sufferers around the world. Currently available guidelines for care are deemed to be essential but insufficient because of highly variable clinician knowledge and competencies specific to OCD. The phase two mandate of the 14 nation International OCD Accreditation Task Force (ATF) created by the Canadian Institute for Obsessive Compulsive Disorders is development of knowledge and competency standards for specialized treatments for OCD through the lifespan deemed by experts to be foundational to transformative change in this field. This paper presents knowledge and competency standards for specialized CBT for adult OCD developed to inform, advance, and offer a model for clinical practice and training for OCD. During upcoming ATF phases three and four criteria and processes for training in specialized treatments for OCD through the lifespan for certification (individuals) and accreditation (sites) will be developed based on the ATF standards.

Therapist-Led, Internet-Delivered Treatment for Early Child Social Anxiety: A Waitlist-Controlled Evaluation of the iCALM Telehealth Program

Despite recent advances in the treatment of early child social anxiety, the broad accessibility of brick-and-mortar services has been limited by traditional barriers to care, and more recently by new obstacles related to efforts to slow the spread of COVID-19. The present waitlist-controlled trial examined the preliminary efficacy of a family-based behavioral parenting intervention (i.e., the iCALM Telehealth Program) that draws on Parent-Child Interaction Therapy and videoconferencing to remotely deliver clinician-led care for anxiety in early childhood. Young children (3-8 years) with a diagnosis of social anxiety disorder (N = 40; 65% from ethnic/racial minority backgrounds) were randomly assigned to iCALM or waitlist. Intent-to-treat analyses found that at post, independent evaluators classified roughly half of the iCALM-treated children, but only 6% of waitlist children, as "Responders" (Wald test = 4.51; p = .03). By Post, iCALM led to significantly greater reductions than waitlist in child anxiety symptoms, fear, discomfort, and anxiety-related social impairment, and also led to greater improvements in child soothability. By 6-month follow-up, the percentage of iCALM-treated children classified as "Responders" rose to roughly 60%. Exploratory moderation tests found iCALM was particularly effective in reducing life impairments and parental distress among families presenting with higher, relative to lower, levels of baseline parental accommodation. The present findings add to a growing body of research supporting the promise of technology-based strategies for broadening the portfolio of options for delivering clinician-led mental health services.

Family accommodation in eating disorders: a preliminary examination of correlates with familial burden and cognitive-behavioral treatment outcome

Previous research suggests caregivers of individuals with eating disorders (EDs) may attempt to reduce family strain by engaging in accommodation and enabling behaviors to avoid conflict or alleviate stress of the affected individual. Moreover, families often reorganize life around the ED, reinforcing ED behaviors and exacerbating family dysfunction and caregiver distress. However, limited research has examined how accommodation relates to caregivers' distress, family functioning, and treatment outcomes. The current study provides an initial evaluation of these associations among treatment-seeking individuals with EDs and their family members. Forty family members of individuals receiving cognitive behavioral therapy for EDs in a residential treatment setting completed the Accommodation and Enabling Scale for Eating Disorders (AESED) and measures of anxiety (Patient-Reported Outcomes Measurement Information System anxiety scale) and family functioning (Family Assessment Device; FAD) at the time of their family member's treatment admission. Eighteen patients completed the Eating Disorder Examination-Questionnaire (EDE-Q) at admission and discharge. AESED scores were positively associated with family member anxiety, FAD roles, FAD behavioral control, and higher patient EDE-Q global scores at discharge. Findings provide preliminary evidence that greater family accommodation not only relates to poorer family functioning, but uniquely relates to worse ED treatment outcome.

Behavioral interventions for infant sleep problems: the role of parental cry tolerance and sleep-related cognitions

STUDY OBJECTIVES

This study tested whether parental cry tolerance (PCT) and distress-attribution cognitions predict outcomes of behavioral interventions for infant sleep problems. It additionally examined intervention effects on these parental factors.

METHODS

Participants were 91 infants aged 9-18 months (61% boys) with sleep-related problems and their parents. Families were randomized to 1 of 2 behavioral interventions for infant sleep problems: Checking-in or Camping-out. Assessments were completed at baseline and 1-month post-treatment. Infant sleep was assessed using actigraphy and parent reports on the Brief Infant Sleep Questionnaire. PCT was measured using the Intervention Delay to Infant Crying Video laboratory paradigm, and parental distress-attribution cognitions were assessed via the Infant Sleep Vignettes Interpretation Scale.

RESULTS

Higher PCT and lower parental distress-attribution cognitions at baseline predicted greater improvement in parent-reported sleep problems post-treatment, and higher PCT additionally predicted larger reductions in the number of reported nighttime awakenings. Moreover, PCT increased, and distress-attribution decreased, following the interventions.

CONCLUSIONS

Parent factors both predict and are predicted by behavioral interventions for infant sleep problems. This study's findings suggest that parents with low cry tolerance and high distress-attribution cognitions derive less benefit from these interventions and may thus require augmented care.

CLINICAL TRIAL REGISTRATION

Registry: ClinicalTrials.gov; Name: Interventions for sleep problems in early childhood; URL: https://clinicaltrials.gov/ct2/show/NCT01489215;Identifier: NCT01489215.

Evaluation of a parent-led cognitive behaviour therapy programme in routine clinical practice: A controlled trial

Parent-led cognitive behavioural therapy for child anxiety disorders have garnered a growing evidence base. However, it is unclear how such approaches translate into routine clinical practice. The current study aims to evaluate the effectiveness of an 8-session treatment (From Timid to Tiger) in reducing child anxiety and behavioural difficulties, as well as family accommodation. The parents of 71 children (aged 4-11) were assigned to the treatment or a waitlist control. Parent report measures were completed pre-treatment, at treatment-end, and at 3-month follow-up. Parents assigned to the waitlist were assessed 8 weeks after the initial assessment. Findings indicated that parents who attended the group reported significant reductions in child anxiety and behavioural difficulties. In addition, the parents in the treatment group reported a reduction in family accommodation compared to those in the waitlist. The current control trial provides tentative evidence of the use and effectiveness of such parent-led approaches in addressing child anxiety difficulties commonly seen in routine clinical practice. PRACTITIONER POINTS: Parent-led approaches are effective treatments in managing child anxiety difficulties. Very little research to date has assessed the effectiveness of such approaches in routine clinical practice. The From Timid to Tiger program is a brief parent-led CBT intervention. The programme was effective in reducing child anxiety and behavioural difficulties. Parents also reported a reduction in behaviours related to family accommodation. Such programmes show promise and can be used in routine clinical practice.

Specialty knowledge and competency standards for pharmacotherapy for adult obsessive-compulsive disorder

Obsessive-compulsive disorder (OCD) affects approximately one person in 40 and causes substantial suffering. Evidence-based treatments can benefit many; however, optimal treatment can be difficult to access. Diagnosis is frequently delayed, and pharmacological and psychotherapeutic interventions often fail to follow evidence-based guidelines. To ameliorate this distressing situation, the International OCD Accreditation Task Force of the Canadian Institute for Obsessive-Compulsive Disorders has developed knowledge and competency standards for specialized treatments for OCD through the lifespan. These are foundational to evidence-based practice and will form the basis for upcoming ATF development of certification/accreditation programs. Here, we present specialty standards for the pharmacological treatment of adult OCD. We emphasize the importance of integrating pharmacotherapy with clear diagnosis, appreciation of complicating factors, and evidence-based cognitive behavioral therapy. Clear evidence exists to inform first- and second-line pharmacological treatments. In disease refractory to these initial efforts, multiple strategies have been investigated, but the evidence is more equivocal. These standards summarize this limited evidence to give the specialist practitioner a solid basis on which to make difficult decisions in complex cases. It is hoped that further research will lead to development of a clear, multi-step treatment algorithm to support each step in clinical decision-making.

Parental accommodation of symptoms in adolescents with chronic pain

Chronic pain in adolescents can be highly impairing. Parental reactions to their child's pain are important factors influencing pain perception and pain-related impairment in children and adolescents. The present study aimed to examine parental accommodation of pain symptoms using the Inventory of Parent Accommodations of Children's Symptoms (IPACS) to provide empirical support for the utility of this measure in parents of adolescents with chronic pain. We examined the prevalence, nature, and correlates of accommodation behaviors in 66 adolescents with chronic pain and their parents using the IPACS. All parents reported some level of accommodation of their child's pain symptoms. After controlling for pain severity, parental accommodation was associated with functional impairment. In addition, parental accommodation mediated the link between parental catastrophizing reactions to pain and child impairment and between child anxiety and depressive symptoms and child impairment. The IPACS appears to be a useful measure of parental accommodation of pain. Parental accommodation should be included as an intervention target when necessary. It is important to educate families about the negative consequences that can be related to excessive accommodation of pain symptoms and to provide effective resources to manage the impact of chronic pain and replace accommodation with more adaptive pain coping strategies.

Better Together: A Review and Recommendations to Optimize Research on Family Involvement in CBT for Anxiety and Related Disorders

Anxiety and related disorders (ARDs) occur in an interpersonal context. Individuals with ARDs respond well to individual cognitive behavioral therapy (CBT); however, there is room for improvement. As such, family members may be included to "enhance" treatment outcomes, yet findings from studies examining family involvement in CBT for ARDs are equivocal. The present paper (a) identifies methodological considerations for explaining inconsistent outcomes among CBT for ARDs with family involvement, and (b) reviews factors that affect outcomes of CBT for ARDs with family involvement including levels of involvement in treatment (e.g., number, duration, and spacing of sessions) and characteristics of who is involved in treatment (e.g., family member cognitions and cultural factors). Limitations of the literature and recommendations for future research are discussed. Researchers should focus on conducting studies that can test not whether but for whom and how family involvement can contribute to improved outcomes above and beyond individual CBT for ARDs.