A cross-sectional study of insight and family accommodation in pediatric obsessive-compulsive disorder

Abstract

Background: Factors predicting treatment outcome in pediatric patients with obsessive-compulsive disorder (OCD) include disease severity, functional impairment, comorbid disorders, insight, and family accommodation (FA). Treatment of pediatric OCD is often only partly successful as some of these predictors are not targeted with conventional therapy. Among these, insight and FA were identified to be modifiable predictors of special relevance to pediatric OCD. Despite their clinical relevance, insight and FA remain understudied in youth with OCD. This study examined the clinical correlates of insight and FA and determined whether FA mediates the relationship between symptom severity and functional impairment in pediatric OCD.

Methods: This was a cross-sectional, outpatient study. Thirty-five treatment-naive children and adolescentswith DSM-IV diagnosis of OCD (mean age: 13.11 ± 3.16; 54.3% males) were included. Standard questionnaires were administered for assessing the study variables. Insight and comorbidities were assessed based on clinician's interview. Subjects were categorized as belonging to a high insight or a low insight group, and the differences between these two groups were analyzed using ANOVA. Pearson's correlation coefficients were calculated for the remaining variables of interest. Mediation analysis was carried out using structural equation modeling.

Results: Relative to those in the high insight group, subjects in the low insight group were younger, had more severe disease and symptoms, and were accommodated to a greater extent by their families. In addition, comorbid depression was more frequent in subjects belonging to the low insight group. Family accommodation was positively related to disease severity, symptom severity, and functional impairment. Family accommodation totally mediated the relationship between symptom severity and functional impairment.

Conclusions: Results support the differences in the diagnostic criteria between adult and pediatric patients with OCD with respect to the requirement of insight. Subjects with low insight displayed clinical characteristics of increased severity compared with their high insight counterparts, suggesting that subjects with low insight may require multimodal approach to treatment. Family accommodation was found to mediate the relationship between symptom severity and functional impairment; the use of family-based approaches to cognitive behavioral therapy, with one of the aims of reducing/mitigating FA, may provide better treatment outcomes in pediatric OCD.

Figure 1

Insight across the age groups.

Figure 2

Path diagram for the mediation model (n = 35). Standardized and unstandardized path coefficients are reported. *CY-BOCS = Children’s Yale-Brown Obsessive-Compulsive Scale; †COIS-RP = Child Obsessive-compulsive Impact Scale, Revised-Parent report;‡FAS-PR = Family Accommodation Scale-Parent Report *Standardized coefficient for the total effect. §Correlation is significant at the 0.001 level (2-tailed).