As a clinician specializing in the treatment of pediatric anxiety and OCD, I am very fortunate to have access to so many effective interventions designed to treat the children suffering from these disorders. However, as anyone who works with this population knows, addressing the child’s symptoms is only half the battle. Pediatric OCD and anxiety affect the whole family; however, there is comparatively less emphasis on treating the family component of these problems. This is unfortunate because the way in which family members respond to a child with anxiety and OCD can significantly impact the outcome of these disorders.
In particular, Family Accommodation (FA), or the way in which family members act to relieve a child’s distress or discomfort caused by symptoms of anxiety or OCD, is a critical treatment target for pediatric anxiety and OCD. Contrary to most parents’ intuition, relieving a child’s distress in the face of anxiety or discomfort can actually impede treatment and is associated with greater child and family impairment. A recent review of the literature by Kagan, et al. (2017) found that higher levels of FA were linked to greater child symptoms, more instances of comorbid conditions including depression, higher levels of externalizing behaviors including rage episodes and emotional dysregulation, and lower child insight into their symptoms of anxiety or OCD. In addition, greater FA is also associated with greater overall parent distress and family discord.
Given these findings, I would argue that interventions aimed at reducing FA are just as important as interventions for the individual child suffering with anxiety or OCD. In some cases, FA may even be the primary target for treatment, particularly when a child is refusing treatment altogether. However, addressing FA in treatment can be tricky, and it requires a good understanding of family dynamics, specific child and parent factors that may help or hinder progress, and willingness on all sides (parent, child, and therapist!) to feel some discomfort. Many times, it can be difficult to know how much to push, and how much to back off. In my experience, the following components are helpful when developing a treatment plan for addressing FA:
- Provide a clear rationale for why FA is harmful. First and foremost, the child and parents must all understand the model of fear acquisition and extinction—without understanding how aiding in compulsions, safety behaviors, and avoidance all serve to maintain a child’s distress, family members will more likely focus on the short-term relief brought by accommodations and will be unlikely to give up these behaviors.
- Help identify FA. Some types of accommodation are obvious, like providing excessive reassurance or completing rituals for a child with anxiety or OCD. Many types of accommodation are more subtle, like not making certain demands of a child with anxiety, or trying to help a child logically explain away his or her worries. And to complicate matters more, some things that look like accommodation may not be. Helping families spot accommodations and know what to look for is usually enlightening to everyone. Once they are trained on what FA is and how to spot it, many children and adolescents become better at spotting accommodations than their parents!
- Empathize and reduce parent blame. Help parents understand why they may be engaging in accommodating behaviors, even when they know they shouldn’t. Family accommodation not only relieves the child from distressing feelings, but it also relieves parents from the distress or anger their child might experience if the parent did not accommodate. Therefore, it is highly reinforcing for both child AND parent to continue accommodating, and often this cycle of reinforcement has built up over time, making it difficult to change.
- Make sure children are aligned with parents. If children don’t see their parents as team members, they will be more likely to become angry with their parents for withholding accommodation and may engage in more symptomatic behavior. It is very helpful to externalize OCD as the “bully” against which both child and parents are fighting.
- Avoid the “good cop/bad cop” trap. If there is more than one parent or caregiver, be aware of the tendency for one parent to “rescue” and the other one to be stricter or less tolerant of anxious behavior. This dynamic can undermine not only a successful treatment outcome, but understandably, can cause problems in the parent relationship.
- Include the child whenever possible. In the spirit of aligning parents and child together, discussions of why and how to reduce FA should include all family members to the extent possible. Of course, sometimes this may not be feasible, as when the child is refusing treatment; if the child is very young, it may be wise for the parents (in conjunction with a therapist) to develop the plan to reduce FA and incorporate the use of rewards.
- Find a plan and a pace that works for everyone. I have made the mistake of agreeing to a plan for reducing FA that the child felt was manageable, but for which the parents were unable to enforce. One of the parent factors associated with higher rates of FA is a lower tolerance for distress, so be aware that parents need to feel confident and capable, and at times may need to go slower than the child.
- Prioritize the parent-child relationship. Make sure the reduction of FA is done with empathy and that responses to requests for accommodation are given with compassion. Be sure to encourage parents to carve out time to spend quality time with their child free from discussion of symptoms, and help parents find the balance between being vigilant and hypervigilant.
- Monitor progress. While idiographic measures may be an important part of assessing progress for an individual family, there are also several measures of accommodation in OCD and anxiety that have recently been developed as FA has gained more clinical attention. They include the Family Accommodation Scale—Parent Report (FAS-PR; Flessner, Sapyta, et al., 2011) for OCD, and the Family Accommodation Scale—Anxiety (FASA; Lebowitz et al., 2013) for anxiety. Kagan et al. (2017) provide a nice comparison and analysis of all measures currently available.
Although these guidelines may help in developing a comprehensive treatment plan for a child suffering from anxiety and OCD, by no means are they exhaustive, and each family will present with different, individual considerations. However, with increasingly more focus on the role of family accommodation in the treatment of pediatric anxiety and OCD, it is my hope that we will see better treatment outcomes with longer-lasting gains.