An observational study of parent–child behaviours in paediatric OCD: Examining the origins of inflated responsibility
Introduction
Cognitive behavioural theories of Obsessive–Compulsive Disorder (OCD) are widely accepted (Pietrefesa, Schofield, Whiteside, Sochting & Coles, 2010) and provide the basis for cognitive-behavioural therapy (CBT), which is currently the most effective psychological treatment for OCD (Barrett, Farrell, Pina, Peris & Piacentini, 2008). These models propose that biological and environmental factors account for vulnerability; whereas maladaptive beliefs about the experience of intrusive thoughts (i.e., obsessions) lead to the development and maintenance of obsessions, related distress and the urge to neutralize (Rector, Cassin, Richter & Burroughs, 2009). Arguably the most widely studied cognitive theory in OCD research is Salkovskis (1985) model of inflated responsibility. This cognitive model of OCD proposes that distorted cognitive appraisals of risk and responsibility for harm are what differentiate normal intrusive thoughts from those characteristic of OCD (Rachman, 1993, Salkovskis, 1985, Salkovskis, 1989. Salkovskis, 1985, Salkovskis, 1989 proposed that the interpretation of intrusive thoughts as indicating personal responsibility for harm to self or others, leads to increased discomfort and anxiety, increased salience of the intrusive thoughts, and neutralizing behaviours (e.g., “if do not check my sleeping baby all night, she might die, and that would be my fault”). In a study of 59 OCD patients given both the Responsibility Interpretations Questionnaire (RIQ) and the Responsibility Attitudes Scale (RAS; Salkovskis et al., 2000) it was found that compared to 22 anxious controls and 69 non-clinical controls, beliefs concerning responsibility for harm were specific to OCD, regardless of whether the participant reported checking behaviours or not (Cougle, Lee & Salkovskis, 2007). These results have been replicated in other survey based studies with adult participants (e.g. Rhéaume, Freeston, Dugas, Letarte & Ladouceur, 1995; Wilson & Chambless, 1999). Experimental studies in adults have similarly illustrated that high responsibility conditions exacerbate checking behaviours, as compared to participants in reduced responsibility conditions (e.g. Arntz et al., 2007; Ladouceur et al., 1995; Ladouceur, Rhéaume & Aublet, 1997). Given that these biases appear to play central role in mainitinaing OCD symptoms, understanding the development of such biases warrants investigation. Salkovskis, Shafran, Rachman & Freeston (1999) argue that the development of these maladaptive beliefs may originate in early childhood through one or more of five developmental pathways, including: (1) a broad sense of responsibility that is deliberately or implicitly encouraged during childhood; (2) rigid or extreme codes of conduct characterised by authoritarian enforcers, blame, guilt and punishment; (3) sensitivity to responsibility, as a result of being overprotected from it; (4) an incident where one's (in)actions contributed to a serious misfortune to self or others, and; (5) an incident where one's thoughts or (in)actions appeared to cause a serious misfortune.
While cognitive theories have received strong empirical support in the adult literature (see Obsessive Compulsive Cognitions Working Group, 1997; 2001; Rhéaume et al., 1995; Wilson & Chambless, 1999; Cougle et al., 2007), initial investigations in paediatric samples suggest the origin and nature of these cognitive biases is less clear (Lawrence and Williams, 2011, Farrell et al., 2013). The degree to which responsibility develops as a result of specific parenting practices/family environment is not yet known. Several studies show support for inflated responsibility in children and youth. For example, Reeves, Reynolds, Coker & Wilson (2010), manipulated responsibility in a sample of 81 school children (aged 9–12) by asking the children to sort sweets into containers for those sweets containing nuts, those that may contain nuts and those which did not contain nuts. The sweets would then be given to a group of children, one of which had an allergy to nuts. Responsibility was induced by telling the children in the inflated responsibility group that their sorting would not be checked by the researcher, in the moderate responsibility group children were not provided with any information regarding who would be checking or who would be to blame and in the reduced responsibility group children were told the researcher would double-check their sorting and that if anything were to go wrong it would be the fault of the researcher. Children in the inflated responsibility group engaged in more checking and hesitant behaviours during a series of tasks as compared to those in the reduced responsibility group. Furthermore, in a clinical sample of children aged 11–18 years, responsibility scores on the RAS independently predicted the severity of OCD symptoms, and furthermore, children with OCD scored significantly higher than both anxious and non-clinical controls (Libby, Reynolds, Derisley & Clark, 2004). In contrast, Barrett & Healy (2003) found that inflated responsibility occurred in both children with OCD and anxious children, as compared to non-clinical controls, in a younger sample of 7–13 year olds. In another study which experimentally manipulated responsibility in children and adolescents with OCD (n=43, 7–17 years) during behavioural avoidance tasks (BATs), Barrett & Healy did not find an association between the high responsibility BAT and associated anxiety, ritualizing or avoidance behaviours. These studies provide mixed support for the process of inflated responsibility biases in paediatric samples. Consequently, adult cognitive theories, which are currently applied top-down to the treatment of paediatric OCD may not be appropriate, however, limited bottom-up research in clinical paediatric samples currently exists (Turner, 2006). Evidence for the importance of parents and families in understanding the development and maintenance of paediatric OCD symptoms, and moreover, the establishment of maladaptive belief domains, therefore represents an important area of future research. This study extends current research by examining the nature of parent–child interactions, focusing on validated constructs shown to be associated with anxious and OCD samples, during a parent–child problem solving task. Furthermore, this study examines whether parents may “enhance” responsibility for solving problems, therefore examining Salkovskis et al. (1999) proposed pathways to the development of responsibility bias, in particular pathways (1), (2) and (3) as described above. These pathways were specifically tested since they relate to rearing processes, which potentially can be reliably observed and coded during parent–child interaction tasks, as opposed to pathways (4) and (5) which specifically relate to how parents and children may have responded to a past event.
Section snippets
Parenting factors and childhood OCD
An authoritarian familial context of rigid and extreme codes of conduct might be characterised by families which are high on rejection and control (Pathways 1. 2 and 3; Salkovskis et al., 1999); dimensions which have been largely examined in the broader literature on child anxiety disorders, and to a lesser extend childhood OCD (e.g. Barrett, Shortt & Healy, 2002). Research using different methodologies (McLeod et al., 2007, Bögels and Brechman-Toussaint, 2006) has focused on parental rearing
Participants
Two groups of children aged 8–17, along with a parent, were recruited, including 24 children with a primary diagnosis of OCD (mean age=12.96, SD=2.55), and 20 children with no clinical diagnosis (mean age=13.13, SD=2.68). The mean age of the overall combined sample was 13.04 years (SD=2.58) and genders were recruited equally (50% male). Participants with a primary diagnosis of OCD and their mother (n=22) or father (n=2), were recruited through the Griffith University OCD Treatment research
Data analysis
All analyses were carried out using the Statistical Package for Social Sciences (SPSS) computer program, version 22.0. There were two parts to the analyses in order to address the two aims of the study. Prior to the analyses central to the study’s aims and hypotheses, descriptive data across the two groups were compared in order to characterise the sample on self-reported anxiety and depression (parent–child). Across self-report measures there were a few participants on each with missing data
Discussion
The current study examined the nature of parent–child behavioural characteristics during a family discussion task, in order to better understand the familial context of paediatric OCD. On the basis of past research (see McLeod et al. (2007), Farrell et al. (2013), and Barrett et al. (2002)) it was hypothesized that OCD dyads would score higher on aversiveness, withdrawal and overinvolvement, and lower on confidence, warmth and autonomy granting relative to a community control group engaged in
Overall implications and conclusion
Interactions between a parent and child with OCD tend to be characterised as critical (Alonso et al., 2004, Barrett et al., 2002, Lennertz et al., 2010). This study substantiated those findings by observing more withdrawal and aversiveness and less warmth across parents and children in OCD-dyads. Interestingly, while there was no clear support for parental or child enhancement of responsibility specific to OCD dyads, there was a trend for children with OCD enhancing their own responsibility in
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