Elsevier

Clinical Psychology Review

Volume 45, April 2016, Pages 34-44
Clinical Psychology Review

A meta-analysis of family accommodation and OCD symptom severity

https://doi.org/10.1016/j.cpr.2016.03.003Get rights and content

Highlights

  • This meta-analysis synthesized an overall effect size (ES) across 41 studies.

  • The ES for family accommodation and OCD symptom severity was r = .42.

  • This is the first meta-analysis to examine purported moderators of this ES.

  • The number of items used in the family accommodation measures moderated the ES.

  • Despite adequate power, no sample-dependent variables significantly moderated the ES.

Abstract

Family accommodation in obsessive–compulsive disorder (OCD) is characterized by myriad behaviors, such as modifying family routines, facilitating avoidance, and engaging in compulsions to reduce obsessional distress. It has been linked to various deleterious outcomes including increased functional impairment and poorer treatment response for OCD. Although extant literature suggests a linear relationship between family accommodation and OCD symptom severity, the magnitude and statistical significance of this association has been inconsistent across studies, indicating that moderators may be influencing this relationship. The present study examined this relationship using meta-analytic techniques, and investigated sample-dependent (age, gender, comorbid anxiety/mood disorders) and methodological (administration method and number of items used in family accommodation measure, informant type, sample size, publication year) moderators. Forty-one studies were included in the present meta-analysis, and the overall effect size (ES) for the correlation between family accommodation and OCD symptom severity was moderate (r = .42). Moderator analyses revealed that the number of items on the family accommodation scale moderated the ES. No other sample-dependent or methodological characteristics emerged as moderators. In addition to being the first systematic examination of family accommodation moderators, these results highlight the moderate relationship between family accommodation and OCD severity that is influenced by measurement scales. Findings may be used to guide clinical care and inform future investigations by providing a more nuanced understanding of family accommodation in OCD.

Section snippets

Family accommodation in OCD

Family accommodation can manifest in various forms including modifying family routines, engaging in the patient's compulsions, and facilitating avoidance of OCD triggers (Calvocoressi et al., 1995). For instance, a parent or partner may engage in excessive hand washing rituals to assuage the patient's contamination fears, or excessively reassure the patient that the stove is turned off and the house will not burn down. Although family members often engage in these behaviors in hopes of

Present study

Based on these identified gaps in the literature, the purpose of this meta-analysis was to identify a summary effect of the correlation between family accommodation and OCD symptom severity; considering extant findings, a positive correlation is expected between these variables. Given the importance of moderators, this meta-analysis will also examine potential sample-dependent (e.g., age) and methodological (e.g., family accommodation measure) moderator variables to determine their effects on

Selection of studies

Potential studies for inclusion in the meta-analysis were searched and obtained up to September 20, 2015 and evaluated by two personnel. Studies must have included objective, quantitative measures of both family accommodation and OCD symptom severity; studies solely presenting qualitative descriptions of family accommodation in OCD were excluded (e.g., Lebowitz, Vitulano, & Omer, 2011). Studies investigating family accommodation outside of OCD were discarded. Case report/series with sample

Statistical analyses

All data were analyzed through Comprehensive Meta-Analysis (CMA; Borenstein, Hedges, Higgins, & Rothstein, 2005).

Included studies

An initial search of the literature elicited 326 potential studies for inclusion in the meta-analysis. Fig. 1 outlines the steps and rationale for inclusion and exclusion of studies. Appendix A displays the 41 studies that met full inclusion criteria for the meta-analysis, which resulted in a total sample of 2509 participants. The total sample included in the meta-analysis had a mean age of 20.45 years and was 50% male.

Inter-rater reliability for coding study characteristics

There was excellent agreement for all categorical (κs = 0.95–1.00) and

Sample-dependent moderators

When examining the effect of age, both pediatric (k = 26, r = .44, 95% CI [.37, .51], z = 10.34, p < .001) and adult (k = 15, r = .38, 95% CI [.29, .46], z = 7.92, p < .001) studies exhibited significant moderate effects separately. Although accommodation appeared to be descriptively larger among pediatric OCD studies, there was no statistically significant difference in the relationship between family accommodation and OCD severity by categorical age groups, Q(1)btwn = 1.36, p = .24. When examining mean

Publication bias and sensitivity analyses

Upon visual inspection of the funnel plot (Fig. 3), the studies were generally observed to fall symmetrically around the mean. However, Egger's test for bias was significant (p = .02), suggesting that publication bias may be present. Using Duval and Tweedie's Trim and Fill procedure, one study was imputed to the right of the mean effect, eliciting an unbiased effect size of r = .40, 95% CI [.36, .43]. Using the Rosenthal's Fail-safe N (Rosenthal, 1979), there would need to be 4395 unretrieved

Discussion

This meta-analysis provides support for a medium effect size for the correlation between family accommodation and OCD symptom severity, suggesting that increased symptomology is associated with higher levels of accommodating behaviors. The effect size for this correlation is comparable to the effect size found in Strauss et al. (2015), albeit slightly larger (r = .42 versus r = .35). Although it is unclear which direction of causality is present, the relationship is likely bidirectional. On one

Conclusions

Family accommodation is a salient phenomenon that negatively impacts both the individual with OCD and the family. Because the extant literature has produced mixed findings, the present study sought to identify the strength of the association between family accommodation and OCD severity and to determine whether sample-dependent characteristics or methodological factors influenced the association between family accommodation and OCD symptom severity. Building from the preliminary meta-analysis

References (70)

  • T.S. Peris et al.

    Correlates of accommodation of pediatric obsessive–compulsive disorder: Parent, child, and family characteristics

    Journal of the American Academy of Child and Adolescent Psychiatry

    (2008)
  • J. Piacentini et al.

    Controlled comparison of family cognitive behavioral therapy and psychoeducation/relaxation training for child obsessive–compulsive disorder

    Journal of the American Academy of Child and Adolescent Psychiatry

    (2011)
  • R. Rosenthal

    The file drawer problem and tolerance for null results

    Psychological Bulletin

    (1979)
  • E.A. Storch et al.

    Rage attacks in pediatric obsessive–compulsive disorder: Phenomenology and clinical correlates

    Journal of the American Academy of Child and Adolescent Psychiatry

    (2012)
  • E.A. Storch et al.

    Predictors of functional impairment in pediatric obsessive–compulsive disorder

    Journal of Anxiety Disorders

    (2010)
  • E.A. Storch et al.

    Mediators and moderators of functional impairment in adults with obsessive–compulsive disorder

    Comprehensive Psychiatry

    (2014)
  • C. Strauss et al.

    A meta-analytic review of the relationship between family accommodation and OCD symptom severity

    Journal of Anxiety Disorders

    (2015)
  • B. Van Noppen et al.

    Testing a conceptual model of patient and family predictors of obsessive compulsive disorder (OCD) symptoms

    Behaviour Research and Therapy

    (2009)
  • M.S. Wu et al.

    Phenomenological considerations of family accommodation: Related clinical characteristics and family factors in pediatric OCD

    Journal of Obsessive–Compulsive and Related Disorders

    (2014)
  • A.H. Zohar

    The epidemiology of obsessive–compulsive disorder in children and adolescents

    Child and Adolescent Psychiatric Clinics of North America

    (1999)
  • American Academy of Child and Adolescent Psychiatry

    Practice parameters for the assessment and treatment of children and adolescents with obsessive–compulsive disorder

    Journal of the American Academy of Child and Adolescent Psychiatry

    (2012)
  • American Psychiatric Association

    Diagnostic and statistical manual of mental disorders

    (2013)
  • D.W. Black et al.

    The impact of obsessive–compulsive disorder on the family: Preliminary findings

    Journal of Nervous and Mental Disease

    (1998)
  • M. Borenstein et al.

    Comprehensive meta-analysis (Version 2)

    (2005)
  • M. Borenstein et al.

    Introduction to meta-analysis

    (2009)
  • L. Calvocoressi et al.

    Family accommodation in obsessive–compulsive disorder

    The American Journal of Psychiatry

    (1995)
  • L. Calvocoressi et al.

    Family accommodation of obsessive–compulsive symptoms: Instrument development and assessment of family behavior

    Journal of Nervous and Mental Disease

    (1999)
  • N.E. Caporino et al.

    A structural equation analysis of family accommodation in pediatric obsessive–compulsive disorder

    Journal of Abnormal Child Psychology

    (2012)
  • D.J. Castle et al.

    Gender differences in obsessive compulsive disorder

    The Australian and New Zealand Journal of Psychiatry

    (1995)
  • J. Cohen

    Statistical power analysis for the behavioral sciences

    (1988)
  • R. Crino et al.

    The changing prevalence and severity of obsessive–compulsive disorder criteria from DSM-III to DSM-IV

    American Journal of Psychiatry

    (2005)
  • K. Dickersin

    The existence of publication bias and risk factors for its occurrence

    JAMA

    (1990)
  • S. Duval et al.

    Trim and fill: A simple funnel-plot-based method of testing and adjusting for publication bias in meta-analysis

    Biometrics

    (2000)
  • M. Egger et al.

    Bias in meta-analysis detected by a simple, graphical test

    BMJ

    (1997)
  • R.A. Fisher

    Statistical methods for research workers

    (1970)
  • Cited by (103)

    • Combined Emotional Socialization Training and Family Accommodation Modification: Impact on Emotional Regulation and Anxiety Symptoms in Anxious Children

      2022, Behavior Therapy
      Citation Excerpt :

      With regard to family accommodation, parents of anxious children report that when their child becomes anxious, they do not know how to respond (Calvocoressi et al., 1995; Shafran et al., 1995), so they take actions that temporarily reduce the child's anxious behavior (Storch et al., 2007). This temporary reduction in anxious behavior, through negative reinforcement, also reinforces the parents’ maladaptive behaviors (Wu et al., 2016). At the same time, these accommodations do not help reduce their child's anxiety in the long run (Lebowitz et al., 2015; Lebowitz et al., 2020); thus, a negative cycle is created in which the child's anxiety leads to the use of accommodation and the use of accommodation exacerbates the symptoms of anxiety.

    View all citing articles on Scopus
    View full text