Have we forgotten the children who have a parent with OCD?:
Accommodation and early intervention
Jennifer Jencks, LICSW and Barbara Van Noppen, PhD
Jennifer Jencks, LICSW, is a private practice clinician who has been specializing in the treatment of OCD in children and adolescents utilizing cognitive behavioral therapy for the past 12 years in Providence, RI. She received her MSW from the Smith College School for Social Work, where she is currently a doctoral student. She plans to do her dissertation research on the impact of parental OCD on their children, and she hopes to contribute to the efforts being made to improve interventions with families impacted by OCD.
Barbara Van Noppen, PhD, is an Associate Professor of Clinical Psychiatry and Associate Chair of Education at the Keck School of Medicine, Department of Psychiatry at the University of Southern California (USC). Dr. Van Noppen is internationally known for her development of a Multifamily Behavioral Treatment (MFBT) for OCD and her inclusion of family members in CBT. She has published numerous journal articles and book chapters on this topic. Currently, Dr. Van Noppen is the Co-Director (with Dr. Michele Pato) of the OCD Treatment and Research Program at Keck School of Medicine, USC. Dr. Van Noppen also teaches and supervises psychiatric residents in the use of CBT for a variety of psychiatric conditions.
Understanding the impact of parental mental health issues on children is a priority today. Research on child development has informed us about the kind of environment and parenting styles children need to develop in the healthiest possible manner. There are numerous articles written to report clinical and research findings about the impact of mental illness on parenting behaviors (see Mann and Gregoire, 2000). In particular, the interaction between multiple factors influences the relationship between parents’ psychiatric disorders and children’s development; it is a complex picture. To date, little is known about the effects of parental OCD and what happens to the offspring. One study reported the finding that children with a parent with OCD are more likely than those without a parent with OCD to have social, emotional and behavioral disorders (Black, Gaffney, Schlosser and Gabel, 2003). Yet, the good news is that this is not so for all children. Why is this not discussed more in the literature given the prevalence of OCD? What are the risk factors for certain children? How could we offer earlier and better intervention for those families in need?
Obsessive Compulsive Disorder affects 1 in 50 adults, making it one of the most important disorders to research to gain understanding of how its symptoms impact these adults’ children. The typical symptoms associated with OCD include intrusive, unwanted thoughts, ideas, or images that evoke anxiety (obsessions); and behavioral or mental rituals performed to neutralize the anxiety (compulsions). When the obsessions and compulsions occur, they can disrupt the normal social and productive functioning of an adult. In this way, OCD impacts entire families because, just by the nature of the disorder, OCD symptoms invade the lives of others, not just the person with the diagnosis.
Accommodation is an intuitive way in which family members try to provide support to the person with OCD, but inadvertently this response reinforces the fears that underlie rituals. Accommodation can be defined as readiness to assist or appease others. In terms of OCD, Waters and Barrett (2000) identify the family context as a potential risk factor in the development and maintenance of the disorder. Storch et al. (2007) have published extensively about pediatric OCD and the role of family accommodation with regard to functional impairment and OCD symptom severity. With regard to adults, Van Noppen and Steketee (2009) identified family accommodation as the largest contributor to predicting OCD symptom severity in a series of path analyses. Despite what we know about how parents, spouses and other family members accommodate OCD, there is almost no discussion of what happens for children trying to cope with OCD demands for a parent. Our aim is to get the dialogue going, to understand what is happening and to develop effective family interventions.
The Family Accommodation Scale (FAS-IR, Calvocoressi et al., 1999) is a 12-item clinician-administered measure of the extent to which family members accommodate OCD symptoms in specific ways. The original scale was designed to assess the extent to which adults accommodate a loved one’s OCD by avoiding certain triggers, participating in rituals, providing excessive reassurance, and modifying personal and family routines. We have recently revised this measure so that it can be used to assess the extent to which children accommodate a parent’s OCD symptoms. We will begin to use this measure to identify children and families that need interventions to decrease accommodation and to improve parenting practices which, if left uncorrected, may have a negative impact on a child’s development.
Children can accommodate a parent’s OCD symptoms in a variety of ways. The following is a series of clinical vignettes, each of which describes a different type of accommodation:
Some research suggests that children of parents with OCD may be at higher risk of having anxiety, OCD or OCD-like disorders, or behavioral disturbances due to a genetic-environment interaction. That is, the vulnerability to develop OCD is likely heritable, yet not all kids with parents express OCD. Thus, there must be other factors that affect an individual’s biology. Further research has revealed the resiliency that many children demonstrate when raised under adversity. There is much interest in understanding what promotes resilience, which is a process that guides people to “bounce back” from stressful situations. (Dyer and Mc Guinness, 1996). If we could better define protective factors that reduce the likelihood of children exposed to extreme conditions due to the demands of OCD and develop interventions to assist families with these difficult circumstances, then we would certainly make public health strides.
Interventions aimed at decreasing children’s accommodating behaviors will help both the parent and the child. The parent will be better able to treat their OCD symptoms if they are not being accommodated by the family, and the children will be protected from involvement with the OCD and any disruption it may cause in their day to day life and overall development. The following is a list of interventions which could be offered to support families with a parent diagnosed with OCD:
- Children may offer reassurance to their parents in order to diminish the anxiety they have regarding their obsessions.
“Both of my parents are “germaphobes.” My Dad is afraid of the flu, and my mom is afraid of dirt. They are always sitting us kids down and lecturing us about washing our hands. As soon as we get home from school my mom leads us to the bathroom, and I’m pretty sure she sprays Lysol on our school stuff and shoes. Mom expects us to use hand sanitizer at school during the day, too. When I get home that’s the first thing she asks- not' ‘How was your day?’ but, ‘Did you use your hand sanitizer?’ Now that I’m smarter, I just tell her yes no matter what.”
- Children may avoid doing or saying things that could trigger a parent’s rituals.
“My mother was always afraid we would drown. Whenever we went near water, a pool, the ocean, or whatever, she would make us wear a life preserver or she’d hold our hands tightly. She also had words she would say under her breath. Eventually the other kids and I grew to not like swimming, and said no to friends’ invitations to the beach. It was just easier.”
- Children may participate in a parent’s rituals or complete rituals on his or her behalf.
“It used to take my Dad so long to check the windows and doors in the morning when we were trying to go to school that I just offered to do it for him one day. He was relieved, and next thing I knew I was doing it every day. It was a pain, but at least I got to school on time.”
- Children may help a parent avoid triggering stimuli.
“My mother used to bring me into the bathroom with her in public places. Usually she avoided going, but if she needed to she would ask me to clean the toilet seat with a special spray she carried in her purse, and wipe down the door handles. I didn’t like doing it, but if I refused she would get really upset.”
- Children may make decisions for parents to avoid a parent’s anxiety of not knowing the right choice.
“In restaurants, my step-dad would take so long trying to decide what to eat. He would ask everyone what he should have, and sit staring at the menu for a long time. The waitresses would get impatient. One day my brother just ordered for him, and he said that dinner was the best one he ever had. My brother was proud that he helped, and then started making food choices for him more often.”
- Children may modify their schedules or responsibilities to accommodate their parent’s OCD.
“I clean the bathrooms at home now because my mom just can’t do it. She washes her hands over and over when she even stands in the bathroom, never mind touches anything.”
- Children may complete household tasks for their parent with OCD.
“My Dad fears trash day. My mom says he has to take out the garbage, and you can tell by the look on his face he is really afraid. They yell sometimes, and if my Dad can’t do it my mom ends up taking it out. She stomps her feet and mumbles angry things under her breath. I feel really bad sometimes, and if I get home early enough from school I try to take it out before any of that happens.”
- Parenting education and support. Information on effective parenting practices and why it is important to keep children uninvolved in OCD rituals will help to decrease the impact of OCD symptoms on the child and foster a healthier relationship between the parent and child. Ongoing support, in the form of counseling or support groups, will ensure that parents are able to consistently employ effective strategies and not revert back to engaging their children in their rituals.
- Psychoeducation. Educating children about OCD and ways to support a parent in treatment would offer children a way to help their parents in an age-appropriate manner. Children will benefit from a better understanding of a parent's behavior and how they can help by learning what they can say or do. With this information they will be less vulnerable to becoming engaged in OCD rituals and will feel empowered that they are part of the helping process.
- Multi-family Intervention. Multi-family behavior therapy (MFBT) can be utilized to involve whole families in the treatment of OCD and in a group format. Families would receive support from each other, encouragement to stay in treatment and perform exposure and response prevention exercises effectively, as well as ideas regarding how to minimize the impact of OCD on overall family functioning.
- Creating or expanding a family’s support network. Families impacted by OCD benefit from the support of a well-informed and caring support network. Working with families to develop this network and use it to get through challenging times will also help to prevent children from participating in their parent’s OCD rituals.
- Development of coping skills. Children, in general, are eager to learn and employ new ways to help themselves feel better. The introduction and reinforcement of coping skills will provide them with techniques and strategies they can use when they are experiencing anxiety, depression, or any kind of life stress (including any feelings brought on by living with a parent with OCD). The earlier these skills are introduced the more likely the child is to embrace them and utilize them during challenging times.
In conclusion, greater understanding of the impact of parents’ OCD on their children’s development and mental health outcomes is necessary so that effective interventions can be developed and utilized. Further research on this topic, in conjunction with the research on resiliency factors, are imperative so that we can anticipate which youth are at risk and implement appropriate services and supports. With OCD impacting one out of every fifty adults, effective recognition and intervention practices could have a profound impact on the next generation.
Black, D.W., Gaffney, G. R., Schlosser, S. & Gabel, J. (2003). Children of parents with obsessive-compulsive disorder- 2 year follow-up study. Acta Psychiatry Scand, April 107 (4) 305-13.
Dyer, Janye & McGuiness, Teena (1996). Reslience: Analysis of the concept. Archives of Psychiatric Nursing, Vol X, No. 5 276-282.
Mann, J. & Gregoire, A (2000). The effects of parental mental illness on children. Psychiatry, 1:5, 9-12.
Storch, Eric A., Geffken, Gary R., Merlo, Lisa J., Jacob, Marni L., Murphy, Tanya K., Goodman, Wayne K., Larson, Michael J., Fernandez, Melanie and Grabill, Kristen (2007). Family accommodation in pediatric Obsessive-Compulsive Disorder. Journal of Clinical Child & Adolescent Psychology, 36:2, 207 — 216.
Waters, T.L. & Barrett, P.M. (2000). The role of the family in childhood Obsessive-Compulsive Disorder. Clinical Child and Family Psychiatry Review, Vol. 3, No. 3, 173-184.