Pediatric OCD, Its Effects on Family Functioning​, and Treatments

• compulsive hand washing
• fretting over whether or not the door is locked and the oven and stove burners are turned off
• counting cracks in the pavement and tiles on the floor in order to ensure some unnamed tragedy doesn’t befall a loved one

By now the signs of obsessive-compulsive disorder (OCD) are so woven into the popular consciousness as to be recognizable to the layperson, though the expected image of an OCD sufferer is usually that of a tightly-wound adult, rarely that of a child. But as OCD usually revolves around daily life – activities such as bathing, eating, being with family members – its symptoms exhibited by a child can be particularly disruptive within a family context. It can fray the delicate fabric of home life and leave parents and siblings stuck between conflicting impulses of compassion and understanding and rage and frustration.

With discussions of this disorder generally centered on its impact on the individual, pediatric OCD can have a tremendous negative impact on a child’s immediate and extended families. Kids with OCD often develop coercive strategies as a means of imposing and demanding accommodation behaviors by those around them, such as insisting parents take part in or facilitate ritual completion or insisting that they either engage in or refrain from certain behaviors based on the child’s OCD-related fears. It is precisely how parents and other family members respond to the child’s OCD symptoms that have tremendous implications as to how symptoms are maintained¹.

Study Results

A recent study examined individual perspectives of obsessive-compulsive disorder, specifically its repercussions on family functioning, including emotional and occupational parental burden. Impairment on proper familial functioning was reported to be more extensive at the time of worst OCD severity, with mothers more affected than fathers (nearly half of mothers and one-third of fathers reported daily impairment). Emotional repercussions in all family members included stress and anxiety, followed by frustration or anger in siblings and sadness in parents².

In another study on coercive and disruptive behaviors by pediatric OCD sufferers (i.e., accommodation of/forced participation in rituals; demands to perform actions instead of the child or to refrain from certain behaviors; compulsive behaviors on the part of the child that negatively impact others) and their effect on families, 99% of responders reported encountering coercive/disruptive behaviors, with most responders reporting that physical violence and/or the threat of violence were exhibited in some of the cases. The primary victims of such behaviors were mothers (95%) and with fathers (57%); siblings (49%) were also frequent targets. Indeed, most responders agreed that increased family accommodation actually increased coercive behaviors, which in turn drives further accommodation³.

Faced with such daunting, abnormal scenarios on a daily basis, it shouldn’t be surprising that the first impulse by family members would be to quickly smooth things over by giving in to the child’s demands, though studies have indicated that accommodation can not only increase the severity of obsessive-compulsive symptoms and lower the child’s levels of functioning, but can weaken the OCD sufferer’s response to treatment⁴. Perhaps counter-intuitively, a recent study indicated that parents who report higher levels of intra-family conflict had a more difficult time refraining from accommodation⁵. And antagonistic responses such as avoidance, teasing, and demanding discontinuation of obsessive-compulsive symptoms at will have likewise been shown to have detrimental effect on the pediatric OCD sufferer and have been shown to be positively associated with parental psychopathology⁶.

Effective Treatments

A 2012 study on family-focused cognitive behavioral therapy (FCBT) on pediatric OCD patients against varying levels of familial functioning underscored the importance of family dynamics on clinical outcomes: families with lower levels of parental blame and family conflict and higher levels of cohesion were more likely to have a child who responded to FCBT compared with families who experienced higher levels of dysfunction prior to treatment, with the former having a 93% response rate and the later having only a 10% response rate⁷.

Family Inclusive Treatment (FIT) models for pediatric OCD also bring family members into the treatment process and can focus on cognitive behavioral therapy (CBT) and psychoeducation about obsessive-compulsive disorder as well as skills training specific to family interactions. Common goals include working with families to reduce symptom accommodation and on exposure “coach” training, during which patients are asked to deliberately provoke obsessive fears and then resist engaging in associated compulsions, allowing patients to learn to tolerate their anxiety and ultimately reduce the urge to ritualize.

These exposures will often have a family member present as a means of the OCD sufferer avoiding the distress provoked by the exercise, as well as providing family members with a more sophisticated understanding of the principal of exposure and enhancing treatment compliance. Findings have shown that FIT is associated with highly robust effects on OCD psychopathology and that FITs which specifically targeted family accommodation of symptoms were associated with larger positive effects on functioning than treatments that did not include this element⁸.