The link between mother and child's obsessive-compulsive symptoms: A test of simple and serial mediation models in a healthy community sample
Introduction
According to the fifth edition of the Diagnostic and Statistical Manual for Mental Disorders (DSM-5; APA), obsessive–compulsive disorder (OCD) is a typically chronic disorder characterized by the presence of intrusive and disturbing thoughts (obsessions) and repetitive behaviors an individual feels driven to perform (compulsions), which cause distress, are time-consuming, or interfere with age-appropriate functioning (American Psychiatric Association, 2013). Large community estimates over recent decades have estimated the prevalence of OCD among children to be somewhere close to 3% (James, Farrell & Zimmer-Gembeck, 2017). Pediatric OCD is a heterogeneous condition: symptoms may include obsessions regarding contamination, aggressive thoughts, hoarding, somatic, religious, superstitious and sexual beliefs, as well as compulsive washing, checking, repeating, counting, ordering, hoarding, magical thinking or rituals involving other people. Moreover, comorbidity is very high and along with suffering from other disorders, children diagnosed with OCD might be at greater risk of coercive-disruptive behaviors, social isolation and peer victimization (James, Farrell, & Zimmer-Gembeck, 2017; Lebowitz, Storch, MacLeod Leckman, 2014; Storch et al., 2006). Empirical findings also highlight a mixed prognosis for the long-term outcomes of OCD with onset in childhood and adolescence, with some youths becoming subclinical over time, whereas others have to struggle with a persistent disorder in the long term (James et al., 2017). Taken together, these findings suggest the need for practitioners to possess a deep understanding of the aetiological and maintenance factors of this disorder as well have access to evidence-based treatment protocols targeting children with OCD.
Evidence from multiple disciplines supports the idea that pediatric OCD is a multi-factorial condition, characterized by the co-occurrence of hereditary, biological, and environmental mechanisms. As such, findings fit the major assumptions of the developmental psychopathology perspective (Cicchetti & Cohen, 1995), which implies that psychopathology is the result of a complex and dynamic interplay of multiple factors acting in a developing organism (Drabick & Kendall, 2010).
Evidence supporting genetic vulnerability, as indicated by family aggregation of OCD, is quite consistent (e.g., Mataix-Cols et al., 2013; Taylor, 2013). Neurochemical mechanisms have also been suggested to play a role, such as dysfunctions in brain serotonergic systems and the glutamatergic system (Goodman, Grice, Lapidus, & Coffey, 2014), together with neuro-anatomical and neurophysiological mechanisms, recently highlighted with neuro-imaging procedures (for an extensive review see Basile, Saettoni, & Mancini, 2016).
Unfortunately, less consensus exists on the environmental factors that might serve as aetiological and/or maintenance conditions of pediatric OCD, working either in conjunction with one another or as modulators of certain genotypes (Brander, Perez-Vigil, Larsson, & Mataix-Cols, 2016; Murphy & Flessner, 2015 for reviews). Many aspects of adverse family functioning have been targeted as possible vulnerability factors for OCD (Barcaccia, Tenore, & Mancini, 2015): retrospective findings collected on adults and late adolescents, both healthy and those diagnosed with OCD, seem to suggest that perceived overprotecting, authoritarian and rejecting parental styles, as well as attachment anxiety, are associated with increased risk of OCD (Brander et al., 2016; Timpano, Keough, Mahaffey, Schmidt, & Abramowitz, 2010; Yarbro, Mahaffey, Abramowitz, & Kashdan, 2013). More recent findings show that in the context of treatment, when compared to patients with other diagnoses, OCD patients reported significantly more childhood memories characterized by parental blame/reproach and guilt inducing contents (Basile et al., 2018). Nevertheless, not all retrospective designs confirm the relationship of recollected family functioning and parental rearing styles with OC symptoms in adulthood (Mancini, D'Olimpio, Prunetti, Didonna & Del Genio, 2000; Sawyer, Williams, Chasson, Davis, & Chapman, 2015).
When it comes to concurrent designs, evidence appears to be more consistent; moreover, since it has now been accepted and recognized by the fifth edition of the Diagnostic and Statistical Manual for Mental Disorders (DSM-5; APA, 2013) that the difference between clinical and sub-clinical OC symptoms is in quantity/intensity and not in quality (Mancini, 2019), many investigations have been conducted on sub-clinical OC symptoms among large community samples, as well as on small clinical samples, leading to quite robust evidence. An early review (Waters & Barrett, 2000) concluded that family risk factors specific to pediatric OCD were still theoretical, given the very little evidence which was at that point available; 15 years later an updated review (Murphy & Flessner, 2015) indeed concluded that there was sufficient empirical evidence supporting a strong association between pediatric OCD and many aspects of family and parents functioning, such as parental mental health, family dynamics and emotional climate in the family.
Of particular interest for the present study is the fine-grained evidence of the current state of the art of literature, drawn from indirect and observational measures on children and adolescents from both healthy and clinical samples, showing that dysfunctional parenting, including overprotection and controlling, authoritarian and negative behavior might lead to an offspring's OC symptoms by sensitizing children to inflated responsibility, obsessional beliefs related to responsibility and threat estimation, as well as responsibility attitudes (Aycicegi, Harris, & Dinn, 2002; Farrell, Hourigan, & Waters, 2013; Haciomeroglu & Karanci, 2013; Hofer et al., 2018; Jacobi, Calamari, & Woodard, 2006; Murphy & Flessner, 2015).
Notwithstanding the relevance of this evidence, the correlates of such dysfunctional parenting have not yet been highlighted. We suggest that one possible candidate could be parental OC symptoms: indeed, both above mentioned reviews identify parental mental health, such as depression, anxiety and psychoticism, as a possible risk factor for an offspring's OCD. While Waters and Barrett's (2000) review does conclude that subclinical obsessive–compulsive traits are commonly observed in parents of children with OCD and parents are slightly more at risk of receiving a diagnosis of OCD, with fathers almost three times as likely as mothers, none of the studies analyzed in Murphy and Flessner's review (2015) focused on OC symptoms among the parental mental health conditions which might predispose offspring to OCD. Only one study has attempted to show that parental OC symptoms might predict the same symptoms in adolescents, through parents' obsessive beliefs related to responsibility, but it failed to support the mediation according to Baron and Kenny’s (1986) criteria.
A second issue to be explored as a possible correlate of dysfunctional parenting in the onset of a child's OC symptoms is parenting stress: like parents' OC symptoms, parenting stress has also received scant research attention in relation to an offspring's OC symptoms. Parenting stress has been conceptualized as a negative psychological response to the obligations of being a parent (Bornstein, 2002) and is universally recognized as a risk factor for the quality of caregiving and child development (Deater-Deckard & Panneton, 2017): meta-analytic findings document a significant negative association of parenting stress with sensitive caregiving (Booth, Macdonald, & Youssef, 2018) and a positive association with child behavior problems (Barroso, Mendez, Graziano, & Bagner, 2017). The evidence linking parenting stress to caregiving behaviors relevant in the maintenance of OC symptoms among children, such as negative, rejecting, punitive, controlling and authoritative symptoms, is certainly also of interest to the present study (Han & Lee, 2018; Putnik et al., 2008; for a review, see; Crnic & Ross, 2017).
Notwithstanding this evidence, parenting stress has received little research attention in the investigation of the environmental factors involved in pediatric OCD: to the best of our knowledge, only one study showed that the parents of children affected by trichotillomania, which is a OCD related disorder according to the DSM V Ed., reported higher parenting stress compared to healthy controls (Keuthen, Fama, Altenburger, Allen, & Raff, 2013), suggesting that parenting stress might be one family risk condition implicated in the disorder's onset or maintenance, or might hamper the process and outcome of treatment. Nevertheless, no study has jointly investigated the role of parenting stress and dysfunctional behaviors in increasing their offspring's risk of OC symptoms. Furthermore, the possible relation between parental OC symptoms and parental stress remains largely unexplored, with the only exception being the work of Doron, Derby, and Szepsenwol (2017): studying a community sample of parents these scholars found that parenting stress was significantly related to their OC symptoms. Nevertheless, whether parental OC symptoms and parenting stress are related to children and adolescents' OC symptoms is, thus far, an unexplored issue.
To sum up, neither parents' OC symptoms nor stress have received sufficient research attention as possible correlates of children's OC symptoms. Building on the findings reviewed above, the study firstly aims to test whether these two parental features are related to children's OC symptoms: based on the findings reviewed above suggesting that both might be parental correlates of children's OC, we expect such relations to be confirmed.
The second objective aims to contribute to the understanding of how a parent's OC symptoms might be linked to the same kinds of symptom in the child: possible mediators are both parenting stress and dysfunctional behaviors and a set of simple and serial mediation models will be tested. More specifically, we will test whether parenting stress or dysfunctional parenting alone mediate the relation between a parent's and child's OC symptoms; in such cases, it is hypothesized that parenting stress and dysfunctional parenting might be independently related to OC symptoms in children.
Alternatively, or additionally, sequential effects might also be suggested, according to which the parent's OC symptoms are related to parenting stress, which might be linked to dysfunctional parenting behaviors, resulting in OC symptoms in the child. Given the findings reviewed above, we expect both simple and sequential pathways from parents' to children's OC symptoms to be confirmed, particularly those pathways involving dysfunctional parenting dimensions that might sensitize children to experience inflated responsibility and guilt (Barcaccia et al., 2015; Basile et al., 2018; Mancini & Gangemi, 2004), which have been suggested as being vulnerability conditions for children's OC symptoms.
Section snippets
Participants
The sample used in the present study included 113 mother-child dyads: these were derived from a larger sample of 143 parent-child dyads, including 24 fathers and 119 mothers. Given the small sample size of fathers, these dyads were dropped. Since the study relied on parent reports, mothers were required to have achieved at least a high school diploma, in order to guarantee a good enough understanding of the questionnaires. For this reason, 6 dyads were dropped because the mothers reported
Mothers-reported measures
Mothers completed the Parenting Stress Index – Short Form (PSI-SF; Abidin, 1995; Guarino, Di Blasio, D'Alessio, Camisasca, & Serantoni, 2008 for the Italian version). This is a self-report screening tool which helps providers and families identify the sources and different types of stress that come with parenting. Parents report their level of agreement with 36 items on a four-point scale and scores are then averaged to obtain a Total Stress Score which is an indicator of the overall level of
Preliminary analyses
All analyses were conducted with the IMB SPSS package 24° Ed. Firstly, we tested whether the children's and mothers' ages and years of education were related to the variables of interest. A set of Pearson's correlations were run. Results are reported in Table 2 and show that sociodemographic variables (mothers' age and years of education, child's age) were associated with some of the study variables. Gender differences were investigated on both mother and child reported measures; no significant
Discussion
This empirical contribution aimed to build on the current state of the art on the parental correlates of OC symptoms among school-age children by addressing a gap related to the possible relations of parental OC symptoms, parenting stress and dysfunctional caregiving behaviors with children's OC symptoms We firstly suggested that parents' OC symptoms and parenting stress might be good candidates to investigate. Due to the lack of participation by fathers, such relations could be tested only on
Ethical approval
All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.
Informed consent
Informed consent was obtained from all individual participants included in the study.
Funding
This study received no funding.
Declaration of competing interest
The authors declare that they have no conflict of interest.
Acknowledgements
The authors express appreciation to the families and school principals for taking part in the data collection.
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