The link between mother and child's obsessive-compulsive symptoms: A test of simple and serial mediation models in a healthy community sample

Highlights

• Parental correlates of pediatric obsessive-compulsive disorder are still unclear.

• Mother's OC symptoms are indirectly linked to child's ones, through parenting stress.

• Effects from parenting stress on hostility/aggression are linked to child's OC symptoms.

• Effects from parenting stress on indifference/neglect are linked to child's OC symptoms.

• Treatment of pediatric OCD should target not only children, but also the mothers.

Abstract

This study intends to build on current literature regarding the parental correlates of obsessive-compulsive (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 the child's OC symptoms. The cross – sectional design involved 113 children (61 female; M age = 11.04 years, SD = 1.00) and their mothers (M age = 41.58 years, SD = 4.60), recruited through schools located in urban areas. Child-reported measures included OC symptoms and perceived mothers' caregiving behavior, while mother-reported measures included OC symptoms and parenting stress.

Simple and serial mediation models tested using the SPSS macro PROCESS (Hayes, 2013), supported the relation of the mother's OC symptoms with those of the child, through the simple indirect effect of parenting stress, rather than dysfunctional caregiving. Sequential effects from parenting stress on hostility/aggression and on indifference/neglect, linking indirectly the mother and child's OC symptoms, were also supported.

These findings add new information to our understanding of the parental correlates of OC symptoms in the child and have important clinical implications for the treatment of pediatric OCD, suggesting the potential to target not only children, but also their mothers.

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.