**6.1. Pediatric OCD and family accommodation**

A child, age 8, becomes tearful after accidentally touching something in a public area due to worries of becoming severely ill. She cries and asks her mother repeatedly "Am I going to be sick and die?" The child's mother answers the question, "No, that's not possible, you aren't going to become sick from that"; however, the girl appears unsatisfied and continues to ask similar questions. When her mother eventually tells her she already answered the question and attempts to end the conversation, the daughter throws herself onto the floor and begs her mother to answer again. The mother knows from past experience that when she answers her daughter, she is likely to calm down sooner and experience relief. However, she has also observed that her daughter seems to ask more frequently for reassurance and seems to want her mother to repeat the answer more times. What is this mother's best choice in this situation?

family members attempt to change the system. Thus, parents can often feel powerless to intervene and feel compelled to continue accommodation even if they realize it may exacerbate

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In an effort to understanding the family processes that contribute to accommodation, researchers have explored the correlates and predictors of this phenomenon. Within the 96 families involved in the POTS cited above, more severe rituals, oppositional behavior, and higher frequency of washing symptoms in children contributed to increased parental accommodation. Parental anxiety was also identified as a relevant factor, which suggests that as parents' anxiety increases, they may have a harder time setting boundaries and disengaging from requests to participate in rituals [53]. A study of 65 children and their families (ages 8–17) also demonstrated that child symptom severity as well as parent anxiety, parent hostility, and parent psychopathology correlate with accommodation. Additionally, higher family conflict was associated with more accommodation-related distress and worse consequences when not accommodating while higher family organization was associated with the less accommodation-related distress [57]. Thus, without addressing family or parent-related factors, cognitive behavioral therapy can be compromised and lead to less beneficial outcomes. A prospective, longitudinal study found that parental accommodation (measured at intake) was the strongest predictor of OCD symptom severity at intake and 2-year follow-up, again demonstrating the impact of family factors on pediatric OCD [54]. This study analyzed data from an ongoing, prospective study, the Brown Longitudinal Obsessive Compulsive Disorder Study (BROWNS), to examine the predictive value of parental accommodation (assessed at intake) on OCD symptom severity at intake and 2 years after intake after controlling for factors such as child age, anxiety, and depression [59]. Results revealed, as discussed above, that parental accommodation at a single point in time may have a strong influence on predicting future OCD symptom severity. Potentially, family accommodation patterns become so entrenched that they are maintained over time due to the potential short-term effects of sudden accommodation changes (child becoming agitated and expressing distress). Thus, unless intervention directly targets family factors, one may expect parental accommodation

to remain a strong predictor of future OCD symptoms and outcome.

**7. Assessment practice guidelines**

Addressing family accommodation in treatment can substantially impact treatment outcomes in children with OCD [46, 58]. In a study of 50 youth and families who participated in family-based cognitive behavioral therapy, family accommodation was common among the participants and was associated with symptom severity before treatment [46]. Decreases in family accommodation during treatment predicted treatment outcome even when controlling for pretreatment OCD severity. Accordingly, treatment protocols for OCD are increasingly

The 2012 evidence-based practice parameters published by the American Academy of Child Adolescent Psychiatry detail assessment recommendations for pediatric OCD symptoms [17].

emphasizing reduction of family accommodation as an important therapeutic factor.

symptoms over time.

It is common for pediatric and adult individuals with OCD to involve close family members in OCD-related behaviors in some capacity [51, 52]. Accommodation refers to family members' modification of their own behavior in order to assist in their child's OCD-related rituals [53–55]. This may occur in a variety of forms including participating in rituals themselves (e.g., washing their hands excessively at their child's request or listening to repeated confessions of their child), facilitating avoidance of situations (e.g., picking child up early from school or removing knives in home if child has aggressive obsessions), and providing reassurance (e.g., saying nothing bad is going to happen in response to child asking about a harm-related fear).

Research suggests that the majority of families engage in accommodation on a regular basis. An analysis of the Pediatric OCD Treatment Study (POTS) explored the prevalence of family accommodation as well as whether there are child or parent factors that are related to a tendency toward accommodation. The POTS is a randomized controlled trial that investigated the effectiveness of cognitive behavioral therapy alone, medication alone, and the combination of therapy and medication, compared to a placebo control condition in children (ages 7–17) with OCD and their families [56]. In a subset of 96 individuals who completed the Family Accommodation Scale Parent Report (FAS-PR), 99% of parents reported engaging in at least one accommodating behavior to some extent and 77.1% reported engaging in at least one accommodating behavior daily [53]. More than half of parents reassured their child (63.5%), while about a third participated in their child's OCD rituals (32.33%) and assisted in avoiding triggering situations (33.3%) on a daily basis [53]. These results are comparable to other studies that have explored the prevalence of accommodation in pediatric OCD [46, 57].

Parents typically accommodate with their child's best interests at heart in hopes of alleviating distress, assisting with management of OCD symptoms, and/or improving family functioning. Accommodation often does result in short-term relief and can appear helpful when, for example, a child ceases tantruming after receiving reassurance. In reality, OCD symptoms are actually maintained as rituals are negatively reinforced and the child learns they cannot handle their fears without compulsions. Family accommodation has been shown to be associated with symptom severity pretreatment for children and adolescents with OCD, further evidence that this practice actually worsens rather than solves the problem [46, 57, 58]. Yet, children eventually come to expect family participation in rituals and become agitated when family members attempt to change the system. Thus, parents can often feel powerless to intervene and feel compelled to continue accommodation even if they realize it may exacerbate symptoms over time.

In an effort to understanding the family processes that contribute to accommodation, researchers have explored the correlates and predictors of this phenomenon. Within the 96 families involved in the POTS cited above, more severe rituals, oppositional behavior, and higher frequency of washing symptoms in children contributed to increased parental accommodation. Parental anxiety was also identified as a relevant factor, which suggests that as parents' anxiety increases, they may have a harder time setting boundaries and disengaging from requests to participate in rituals [53]. A study of 65 children and their families (ages 8–17) also demonstrated that child symptom severity as well as parent anxiety, parent hostility, and parent psychopathology correlate with accommodation. Additionally, higher family conflict was associated with more accommodation-related distress and worse consequences when not accommodating while higher family organization was associated with the less accommodation-related distress [57]. Thus, without addressing family or parent-related factors, cognitive behavioral therapy can be compromised and lead to less beneficial outcomes. A prospective, longitudinal study found that parental accommodation (measured at intake) was the strongest predictor of OCD symptom severity at intake and 2-year follow-up, again demonstrating the impact of family factors on pediatric OCD [54]. This study analyzed data from an ongoing, prospective study, the Brown Longitudinal Obsessive Compulsive Disorder Study (BROWNS), to examine the predictive value of parental accommodation (assessed at intake) on OCD symptom severity at intake and 2 years after intake after controlling for factors such as child age, anxiety, and depression [59]. Results revealed, as discussed above, that parental accommodation at a single point in time may have a strong influence on predicting future OCD symptom severity. Potentially, family accommodation patterns become so entrenched that they are maintained over time due to the potential short-term effects of sudden accommodation changes (child becoming agitated and expressing distress). Thus, unless intervention directly targets family factors, one may expect parental accommodation to remain a strong predictor of future OCD symptoms and outcome.

Addressing family accommodation in treatment can substantially impact treatment outcomes in children with OCD [46, 58]. In a study of 50 youth and families who participated in family-based cognitive behavioral therapy, family accommodation was common among the participants and was associated with symptom severity before treatment [46]. Decreases in family accommodation during treatment predicted treatment outcome even when controlling for pretreatment OCD severity. Accordingly, treatment protocols for OCD are increasingly emphasizing reduction of family accommodation as an important therapeutic factor.
