An experimental manipulation of responsibility in children: A test of the inflated responsibility model of obsessive-compulsive disorder

Abstract

The objective of this study was to investigate whether Salkovskis (1985) inflated responsibility model of obsessive-compulsive disorder (OCD) applied to children. In an experimental design, 81 children aged 9–12 years were randomly allocated to three conditions: an inflated responsibility group, a moderate responsibility group, and a reduced responsibility group. In all groups children were asked to sort sweets according to whether or not they contained nuts. At baseline the groups did not differ on children's self reported anxiety, depression, obsessive-compulsive symptoms or on inflated responsibility beliefs. The experimental manipulation successfully changed children's perceptions of responsibility. During the sorting task time taken to complete the task, checking behaviours, hesitations, and anxiety were recorded. There was a significant effect of responsibility level on the behavioural variables of time taken, hesitations and check; as perceived responsibility increased children took longer to complete the task and checked and hesitated more often. There was no between-group difference in children's self reported state anxiety. The results offer preliminary support for the link between inflated responsibility and increased checking behaviours in children and add to the small but growing literature suggesting that cognitive models of OCD may apply to children.

Introduction

OCD in children and young people is similar in presentation to OCD in adults (March & Leonard, 1996) and is associated with severe impairment in children's academic, social, and family functioning (Piacentini, Bergman, Keller, & McCracken, 2003). Between 50 and 80% of adults with OCD identify their onset of symptoms before the age of 18 years (Pauls, Alsobrook, Goodman, Rasmussen, & Leckman, 1995).

Behaviour therapy involving exposure and response prevention (ERP) is the dominant psychological treatment for children and adolescents with OCD (March, 1995). There is evidence that ERP is effective for childhood OCD (e.g. Knox, Albano, & Barlow, 1996) and it is recommended in the UK by The National Institute of Health and Clinical Excellence (NICE, 2005) for moderate to severe OCD that has not responded to self-help. However, ERP can be experienced as demanding and aversive and is associated with a high drop-out rate (Allsopp & Verduyn, 1990).

Cognitive theory offers an account of the development and maintenance of OCD, with the emphasis on the way in which intrusive thoughts are interpreted and responded to. Salkovskis, 1985, Salkovskis, 1989 proposed that inflated responsibility is central to OCD and an obsessional pattern occurs if intrusive thoughts are interpreted as meaning that the person is responsible for subsequent harm to themselves or others, unless they take action for it to be prevented. This leads to distress and Salkovskis proposed that the individual tries to neutralise their intrusive thoughts by completing compulsive behaviours. There is evidence for the inflated responsibility model of OCD in adults from questionnaires studies indicating that OCD symptoms are associated with responsibility beliefs (for example Rhéaume et al., 1995, Wilson and Chambless, 1999). Additionally, experimental studies have demonstrated that participants in high responsibility conditions checked more than participants in reduced responsibility conditions (for example Arntz et al., 2007, Ladouceur et al., 1995, Ladouceur et al., 1997). Arntz et al. (2007) found that responsibility induction did not arouse OCD behaviours in non-patients which contrasts to the findings of Ladouceur et al., as their results indicated that OCD-like phenomena could be induced in non-patients. One hypothesis is that high levels of experienced personal responsibility for negative consequences probably elicits OCD behaviours in everybody, whereas low levels of responsibility only trigger such behaviours in vulnerable people (Bouchard, Rhéaume, & Ladouceur, 1999).

More recently, cognitive models of OCD include the role of guilt as well as responsibility in the development of OCD in adults. These views purport that OCD may be characterized by a fear of guilt resulting from behaving irresponsibly. Support for this comes from empirical evidence showing that the induction of responsibility and guilt leads to increased OCD-like behaviours compared to control conditions (Arntz et al., 2007, Mancini et al., 2004, Mancini and Gangemi, 2004).

Research into the role of cognitive factors in OCD amongst children and adolescents is sparse. By extension from the adult literature, cognitive therapy is a possible development for treating children with OCD. There is some evidence to suggest that cognitive therapy is at least or more effective than ERP for adults with OCD. For example, Van Oppen et al. (1995) found that a higher percentage of cognitively treated patients achieved “recovered” status compared to those who were treated with ERP. It has been suggested that cognitive techniques may be helpful in engaging patients in ERP and as an alternative where ERP is not acceptable (Salkovskis, 1999). Amongst young people, there is evidence from case reports that cognitive therapy is appropriate and is associated with symptom change (Williams, Salkovskis, Forrester, & Allsopp, 2002).

More recently a systematic review examined if cognitive models of OCD apply to children and younger people (Reynolds & Reeves, 2008). Overall, the evidence suggested that cognitive models of OCD apply to children and adolescents. However, the existing literature is based largely on observational studies meaning that a causal relationship between cognitive processes and obsessive-compulsive symptoms cannot be assumed. The aim of the present study therefore was to test the inflated responsibility model of OCD in non-clinical children aged 9–12 years, using an experimental task based on Ladouceur et al., 1997, Ladouceur et al., 1995 study. In order to test the effect of different levels of perceived responsibility on obsessive-compulsive behaviours, responsibility was induced in three different groups: an inflated responsibility group, a moderate responsibility group and a reduced responsibility group. By experimentally manipulating levels of responsibility it can be determined whether inflated responsibility is causally associated with OCD type behaviours. It was hypothesised that participants in the high responsibility group would take longer to complete the sorting task and would check and hesitate more than participants with less responsibility.