DEPRESSION AND ANXIETY 311018–1025 (2014)Research Article.docx
1. DEPRESSION AND ANXIETY 31:1018–1025 (2014)
Research Article
COMPARING FAMILY ACCOMMODATION IN PEDIATRIC
OBSESSIVE-COMPULSIVE DISORDER, ANXIETY
DISORDERS, AND NONANXIOUS CHILDREN
Eli R. Lebowitz, Ph.D.,1∗ Lindsay A. Scharfstein, Ph.D.,1 and
Johnna Jones, Ph.D.2
Background: Family accommodation describes ways in which
parents modify
their behavior to help a child avoid or alleviate distress caused
by emotional
disorders. Accommodation is associated with increased
symptom severity, lower
functioning, and poorer treatment outcomes. Accommodation is
prevalent in
childhood obsessive-compulsive disorder (OCD) and anxiety
disorders (ADs) but
no studies have compared accommodation in these groups or
compared them to
healthy controls to ascertain if accommodation is prevalent in
the general popu-
lation. This study addresses these gaps by comparing patterns of
accommodation,
factors that maintain accommodation, and its relation to
symptom severity in
OCD and AD, relative to healthy controls. Method: We directly
compared reports
of accommodation to childhood OCD (N = 26) and AD (N = 31),
4. accommodation.[13–16]
Family accommodation describes the ways in which
parents modify their behavior to help a child avoid or
alleviate states of distress and negative affect caused by
emotional disorders. Though well intentioned, family
accommodation is linked to greater symptom severity,
lower functioning, and poorer treatment outcomes.
Childhood OCD and AD are both characterized by
high degrees of family accommodation.[13, 15–17] No
studies have compared family accommodation in OCD
and AD to investigate whether the accommodation,
its relation to symptom severity, or the factors that
maintain it are similar or different in these clinical
groups. Additionally, studies of accommodation in
OCD and AD have generally not included comparisons
to healthy control subjects, making it difficult to
discern how specific these behaviors are to the clinical
populations. This study aims to address these gaps.
We first briefly review the literature regarding family
accommodation in pediatric OCD and AD, and then
present the first direct comparison between parental
reports of accommodation in children with OCD or
AD, relative to a nonanxious (NA) control group.
ACCOMMODATION IN OCD
Studies of pediatric OCD have reported high frequen-
cies of accommodating behaviors. These include active
participation in the child’s symptoms (e.g., parents wash-
ing their hands excessively) and modifications to routines
and schedules (e.g., returning home early from work).
More than 90% of parents report at least some accom-
modation, and most report accommodating daily.[13, 16]
The most common forms of accommodation in OCD
include providing reassurance and awaiting completion
5. of rituals.[17, 18]
Greater family accommodation is associated with
more severe symptoms in the child and poorer function-
ing for child and family.[17, 19–21] Accommodation also
predicts poorer outcomes for behavioral and pharma-
cological therapy.[16, 22] Greater accommodation before
treatment predicts less therapeutic gains and more re-
fractoriness, whereas successful treatment is associated
with reduced accommodation.[13, 21, 23]
Various factors maintain ongoing family accommo-
dation. Parents commonly report temporary exacerba-
tion of the child’s symptoms and/or displays of dis-
tress when they do not accommodate, suggesting that
accommodation is powerfully reinforced.[13, 24, 25] Many
1The term “child” is used throughout this article to describe
individuals
aged 18 and younger, and includes adolescents.
parents report their child becoming angry or abusive
when symptoms are not accommodated.[13, 17] Accom-
modation may be imposed through rage,[26] physical ag-
gression, or emotional blackmail from the child (e.g.,
“you hate me”).[27–29] Some children feel unable to com-
plete daily tasks when not accommodated, placing more
pressure on the parents to accommodate. Parental psy-
chopathology, particularly symptoms of OCD and other
internalizing disorders, has been associated with greater
accommodation, a link that may be explained by greater
difficulty tolerating the child’s distress or stronger iden-
tification with the child’s experience.[19, 30]
ACCOMMODATION IN AD
Studies have highlighted the impact of childhood AD
6. on family functioning, but generally do not focus specif-
ically on accommodation.[31–33] One study systemati-
cally examined accommodation among children with
AD.[15] Accommodation was found to be highly preva-
lent and associated with child symptom severity. Sepa-
ration anxiety had the highest levels of accommodation,
and specific phobia had the lowest. School-related anx-
iety and worried preoccupation were the most powerful
dimensional predictors of accommodation. As in OCD,
providing reassurance was the most frequent form of
accommodation in AD. Most parents reported experi-
encing distress resulting from accommodation and neg-
ative consequences of not accommodating the child’s
symptoms. Among the negative consequences, exacer-
bation of the child’s distress was most common and the
child becoming angry/abusive was frequently noted.
To summarize, high levels of family accommodation
have been consistently reported in childhood OCD and
more recently in AD. To date, there have been no com-
parisons of family accommodation between these clinical
groups. Derisley et al.[33] compared general family func-
tioning in children with OCD and AD and a nonclinical
group. They reported both clinical groups had poorer
family functioning than normal controls but did not find
differences between family functioning in OCD and AD.
Comparing family accommodation in childhood
OCD and AD can increase our understanding of the role
that family factors play in the development and mainte-
nance of childhood psychopathology. This knowledge
could help clinicians shape appropriate treatments. In-
terventions targeting family accommodation have al-
ready shown promising results in treating OCD or AD
in children who decline treatment, children too young
7. for cognitive behavior therapy, and children who fail to
respond to it.[34–37]
We directly compared maternal reports of accommo-
dation across OCD and AD and a comparison NA group.
Mothers also reported on their child’s OCD and anxi-
ety symptom severity. We hypothesized that parents of
children with OCD and AD would endorse more ac-
commodation, greater distress related to accommoda-
tion, and more severe behavioral consequences of not
accommodating than parents of NA children. Further,
Depression and Anxiety
1020 Lebowitz et al.
TABLE 1. Demographic characteristics of children (N = 87)
AD (n = 31) OCD (n = 26) NA (n = 30) F/χ 2/t value Partial
η2/η2
Age (M/SD) 11.13 (2.2) 12.07 (3.0) 12.13 (2.8) 1.347 .031
Sex (n/%) 0.828 .098
Females 15 (48.4) 14 (53.8) 18 (60.0)
Males 16 (51.6) 12 (46.2) 12 (40.0)
AD, anxiety disorders; OCD, obsessive-compulsive disorder;
NA, nonanxious.
we hypothesized a significant positive relationship be-
tween accommodation and anxiety symptom severity in
all three groups.
MATERIALS AND METHOD
8. PARTICIPANTS
Participants were mothers of children, aged 7–17, who met
DSM-
IV-TR criteria for a primary diagnosis of either OCD (n = 26)
or AD
(n = 31), and mothers of NA children (n = 30). The three groups
did
not differ significantly on age (F[2,84] = 1.347, P = 0.26, η2 =
.031)
or sex of the child (χ 2[2] = 0.828, P = 0.66, η2 = .098) . All
moth-
ers completed an in-person evaluation, during which all
measures for
the present study were collected. The Institutional Review
Board ap-
proved the study and participants provided written informed
consent.
Demographic characteristics are summarized in Table 1.
PROCEDURE AND MEASURES
Children in the OCD group presented at an OCD Specialty
Clinic
at a major medical center in the United States and diagnosis was
confirmed with the Children’s Yale-Brown Obsessive
Compulsive Scale
(CYBOCS).[ 38 ] CY-BOCS is a semistructured, clinician-
administered
inventory of pediatric OCD symptoms and severity and yields a
total
score, from 0 to 40, and subscale scores. A total score of 16 or
higher
was required for inclusion in the study. Experienced clinicians
trained
by one of the authors of the measure administered the CY-
9. BOCS.
The CY-BOCS is widely used and yields reliable and valid
scores for
OC symptom severity.[ 39 ] Scores for this sample fell within
the severe
OCD symptom range (M = 27.50, SD = 3.8).
Children in the AD group presented at Programs for Anxiety
Dis-
orders in two major medical centers and diagnoses were
confirmed
with the Anxiety Disorders Interview Schedule for Children:
Parent Ver-
sion (ADIS-P).[ 40 ] Children did not meet criteria for OCD.
ADIS-P
is a semistructured interview designed to assess DSM-IV AD
and other
psychiatric disorders. A clinical psychologist or postgraduate
clini-
cal psychology student administered the interviews. ADIS-P has
high
inter-rater reliability[ 41 ] and is the gold standard for
establishing AD
diagnoses. In the AD group, 40% of children met criteria for a
single
AD diagnosis, 47% fit two diagnoses, and 13% fit three
diagnoses.
The most common AD was generalized anxiety (41%), followed
by
separation anxiety (31%), specific phobias (16%), and social
phobia
(12%).
The NA group comprised nontreatment-seeking individuals
recruited from the community with no history of OCD, AD, or
other
10. psychiatric diagnosis. The Screen for Childhood Anxiety
Related
Emotional Disorders–Parent Report (SCARED-PR)[ 42 ] was
used
to screen for anxiety concerns. Subjects whose total SCARED
score
exceeded 12, well below cutoff for clinical anxiety, were
excluded
from the NA group.
FAMILY ACCOMMODATION
Mothers in the OCD group completed the 13 items from the
Fam-
ily Accommodation Scale (FAS) by Calvocoressi et al.[ 14 ]
These items
have frequently been used in self-report form and have
demonstrated
excellent psychometric qualities.[ 17, 18, 43 ] Items were rated
on a 5-
point Likert-type scale ranging from 0 (never) to 4 (daily). An
overall
Accommodation score was calculated based on the first nine
items
including Participation (five items) and modification (four
items). Ad-
ditional items assess Distress related to accommodation (one
item) and
negative Consequences of not accommodating (three items).
Internal
consistency for the FAS accommodation items was high (α =
.861).
Mothers in the AD group completed the Family Accommodation
Scale–Anxiety (FASA).[ 15 ] FASA closely mirrors the FAS
items but
11. was adapted to measure accommodation to anxiety rather than
OCD
symptoms. The FASA yields the same overall Accommodation
score
and subscale scores of Participation, Modification, Distress, and
Con-
sequences as the FAS. The FASA has good internal consistency
and
convergent and divergent validity and is sensitive to detecting
fam-
ily accommodation among various childhood ADs.[ 15 ]
Mothers in the
NA group also completed FASA. Although the children did not
have
clinically significant anxiety, FASA items are better suited to
the gen-
eral population of children (who presumably experience anxiety
some
of the time) than the FAS items, which are OCD specific. The
FASA
Accommodation items displayed adequate internal consistency
for the
AD (α = .870) and NA (α = .725) groups.
ANXIETY SYMPTOM SEVERITY
All mothers completed the SCARED-PR[ 42 ] to obtain a
measure of
the child’s anxiety symptoms. Forty-one items were rated on a
three-
point scale. A SCARED-PR total score and the four subscale
scores of
Panic/Somatic, Generalized Anxiety, Separation Anxiety, Social
Anx-
iety, and School Anxiety were calculated. The SCARED-PR
differen-
12. tiates between clinically anxious and NA children.[ 44 ] Internal
consis-
tency of the SCARED-PR total score was adequate for the OCD,
AD,
and NA groups (α = .923, .941, .739, respectively).
RESULTS
FAMILY ACCOMMODATION
Accommodation was highly prevalent in both clinical
groups. Most mothers of AD (61%) and OCD (69%)
children reported daily participation in symptoms, com-
pared to 23% of NA mothers. Daily modification of
routines and schedules was reported by mothers of AD
(19%) and OCD (27%) children, whereas no mothers of
NA children reported daily modifications. Sixteen per-
cent of AD mothers and 23% of OCD mothers reported
both daily participation and modifications. Two mothers
(one OCD and one NA) reported no accommodating be-
haviors at all. Item-by-item comparisons of the AD and
Depression and Anxiety
Research Article: Accommodation in Childhood OCD and
Anxiety 1021
TABLE 2. Accommodation and anxiety levels in the three study
groups (N = 87)
AD M(SD) n = 31 OCD M(SD) n = 26 NA M(SD) n = 30 F-
Value Partial η2
FASA/FAS
Accommodation 15.39 (8.9)a 18.77 (9.0)a 5.57 (3.9)b 23.411*
.358
14. School Anxiety 3.35 (2.7)a 2.65 (2.1)a 0.17 (0.5)b 21.522* .339
FAS, Family Accommodation Scale; FASA, Family
Accommodation Scale-Anxiety; SCARED-PR, Screen for
Childhood Anxiety Related Emotional
Disorders—Parent Report; AD, anxiety disorders; OCD,
obsessive compulsive disorder; NA, nonanxious.
a,b,cMeans sharing superscripts are not significantly different.
*P-value < .001.
OCD groups on all the FAS/FASA questions revealed no
differences in the distribution of answers to any of the
accommodation items (P > .17 for all χ 2 tests). The high-
est rated accommodating behavior across all groups was
providing reassurance (MOCD = 3.1, MAD = 3.1, MNA =
2). The lowest rated items in the AD and OCD groups
were avoiding things/places and doing things instead of the
child, respectively, and in the NA group modifying leisure
activities.
A series of analyses of variance (ANOVAs) examined
the effect of group on maternal reports of overall Accom-
modation, and the subscales of Participation, Modifica-
tion, Distress, and Consequences. Significant F scores
were followed by least significant difference (LSD) tests
to determine where differences occurred. A Bonferroni
correction was applied to avoid inflation of the type I
error rate. Means and standard deviations are reported
in Table 2. A priori power analysis indicated the number
of participants necessary to achieve power of 0.8 to de-
tect an overall group difference with an effect size of f =
0.35 is 84, whereas the necessary sample size to achieve
power of 0.8 to detect a difference between the two clin-
ical groups with an effect size of d = 0.8 is 52; hence the
study was adequately powered.
15. There was a significant main effect for group on Ac-
commodation (F[2,84] = 23.411, P < .001, partial η2 =
.358) and the subscales of Participation (F[2,84] =
18.676, P < .001, partial η2 = .308), Modification
(F[2,84] = 17.174, P < .001, partial η2 = .290), Distress
(F[2,84] = 24.050, P < .001, partial η2 = .364), and Con-
sequences (F[2,84] = 18.967, P < .001, partial η2 = .311).
Post hoc LSD tests did not reveal any significant
differences between the two clinical groups for overall
accommodation, participation, or modification. These
groups did not differ significantly with regard to distress
from accommodation or negative consequences of not
accommodating.
Mothers of AD and OCD children had significantly
higher scores than the NA group across all accommoda-
tion measures including overall accommodation and the
subscales of participation and modification (P < .001).
Finally, mothers of children with OCD or AD reported
significantly greater distress resulting from accommoda-
tion (P < .001) and more negative consequences of not
accommodating, compared to mothers of NA children
(P < .001).
ANXIETY SYMPTOM SEVERITY
A series of ANOVAs examined the effect of group on
mothers’ reports of their child’s anxiety symptoms based
on the SCARED-PR total, Panic/Somatic, Generalized
Anxiety, Separation Anxiety, Social Anxiety, and School
Anxiety scores. Significant F scores were followed by
Depression and Anxiety
16. 1022 Lebowitz et al.
LSD tests to determine where differences occurred. A
Bonferroni correction was applied to avoid inflation of
the type I error rate. The means and standard deviations
are reported in Table 2.
A significant main effect existed for group on total
score (F[2,84] = 45.848, P < .001, partial η2 = .522),
and the Panic/Somatic (F[2,84] = 16.759, P < .001, par-
tial η2 = .285), Generalized Anxiety (F[2,84] = 47.518,
P < .001, partial η2 = .531), Separation Anxiety
(F[2,84] = 14.096, P < .001, partial η2 = .251), Social
Anxiety (F[2,84] = 43.123, P < .001, partial η2 = .507),
and School Anxiety (F[2,84] = 21.522, P < 0001, partial
η2 = .339) subscales.
Post hoc LSD tests revealed that children with AD
were rated higher on panic/somatic symptoms and sep-
aration anxiety than children with OCD (Ps < .05). The
AD and OCD groups were not significantly different on
overall anxiety, generalized anxiety, social anxiety, and
school anxiety (Ps > .05).
Children with AD and OCD were rated as experienc-
ing more overall anxiety (both Ps < .001), panic/somatic
symptoms (P < .001 and .020, respectively), generalized
anxiety (Ps < .001), separation anxiety (P < .001 and
.040, respectively), social anxiety (Ps < .001), and school
anxiety (both Ps < .001) than NA children.
RELATION BETWEEN ACCOMMODATION AND
ANXIETY SEVERITY
17. A series of correlations explored the relation between
overall accommodation on the FAS/FASA and dimen-
sions of child anxiety on the SCARED-PR scores. There
was a significant positive correlation between overall Ac-
commodation and overall anxiety (r = .426, P = .017)
and school anxiety (r = .431, P = .016) for the AD group.
For the OCD group, total Accommodation was signifi-
cantly correlated with overall anxiety (r = .465, P = .017)
and general anxiety (r = .654, P < .001). There were no
significant correlations between overall Accommodation
and dimensions of child anxiety for the NA group (all
Ps > .1).
DISCUSSION
This study directly compared maternal reports of fam-
ily accommodation among children with OCD, AD, and
a comparison group of NA children. The study aimed to
investigate whether patterns of accommodation, factors
that maintain it and its relation to symptoms of child anx-
iety are similar or different among these groups. Over-
all findings highlight family accommodation as a phe-
nomenon that applies broadly and in a similar manner
in childhood AD and OCD.
PATTERNS OF ACCOMMODATION
Accommodation was highly prevalent among moth-
ers of children with OCD and AD. Examinations of the
subdomains of accommodation indicated that mothers
of children with OCD and AD frequently participate in
their children’s symptoms. Participation includes verbal
reassurance, facilitating avoidance, providing items, and
parental avoidance. Mothers of children with OCD and
AD also reported modifying their routines because of the
18. child’s symptoms (e.g., changing family/work schedules,
altering leisure activities, and completing the child’s re-
sponsibilities). These data suggest that family accommo-
dation, a construct well studied in OCD, is also impor-
tant to consider among children with AD, among whom
it has been less extensively studied.
There were no significant differences between OCD
and AD in parent participation, modification, and over-
all accommodation. These results are in line with an ear-
lier comparison of family functioning in pediatric OCD,
AD, and NA children.[33] Parents of OCD and AD chil-
dren reported greater use of avoidance strategies than
parents of NA children, with no significant differences
between the clinical groups. However, not all studies
found similar patterns in families of OCD and AD chil-
dren. Parents of OCD children were observed to provide
less praise for autonomy and display less confidence in
their child’s ability relative to parents of AD, externaliz-
ing, or NA children.[45] Other studies have highlighted
less autonomy granting as a feature of parental behavior
in AD.[46] Clearly, more research is necessary to deepen
the understanding of the similarities and differences in
parental behavior in OCD and AD. The current study
highlights the similarities, at least with regard to family
accommodation.
Comparisons of accommodation between clinical
children and NA children supported the study hypothe-
ses. Mothers of AD or OCD children reported more
overall accommodation, participation, and modification
than mothers of NA children, for whom infrequent ac-
commodation was reported. An obvious interpretation
is that lower rates of accommodation of NA children
simply reflect NA children being less anxious. But the
results of this study also highlight another interesting
19. possibility. A strong and significant correlation existed
between child anxiety severity and overall accommoda-
tion in both clinical groups. No such correlation was
found in the NA group. Perhaps parents of NA chil-
dren are less responsive to their child’s anxiety, even
when it manifests. Given the strong data supporting
the link between accommodation and impairment, it is
plausible that when parents are not overly responsive,
the child is less likely to develop clinically significant
anxiety. Although tantalizing in its implications for pre-
ventive efforts, confidence in this interpretation is tem-
pered by the truncated range of anxiety scores in the
NA group and by the lack of longitudinal data on these
families. Further research should investigate the possi-
bility that less-accommodating parenting may serve as
a protective factor in lowering risk for developing a full
blown AD.
The findings suggest that accommodation is an im-
portant element to consider in assessing families of
children with AD or OCD. The practice parameters
for treatment of childhood OCD call for evaluating
Depression and Anxiety
Research Article: Accommodation in Childhood OCD and
Anxiety 1023
family accommodation as part of standard assessments
and a similar recommendation may be appropriate for
AD.[47] The findings also indicate that FASA adequately
captures the phenomenon, and effectively distinguishes
between clinical and nonclinical patterns of accommo-
dation.
20. FACTORS THAT MAINTAIN ACCOMMODATION
Mothers in the OCD and AD groups reported similar
consequences of not accommodating their child’s symp-
toms. Both groups reported the child frequently becom-
ing angry or abusive and described a short-term wors-
ening of the child’s symptoms. Accommodation may be
fueled or reinforced by short-term relief from the aver-
sive experience of parenting a child under emotional
duress. The results might reflect the circuitous relation-
ship between anxiety and accommodation, regardless of
the particular stimuli that trigger the emotional distress.
Clinically, understanding the cycle of anxiety and ac-
commodation may be important for aiding families in
overcoming AD or OCD. Parents appear to respond to
children’s distress with greater accommodation, despite
the accommodation causing them significant personal
distress. The accommodation provides children with
short-term relief, negatively reinforcing the displays of
distress. The continued reliance on parent accommo-
dation may further undermine the children’s ability or
willingness for self-regulation and coping with the symp-
toms, further perpetuating the cycle. Parents may benefit
from work that would better prepare them for dealing
with the child’s distress or from cognitive restructuring
of the thoughts they have when the child is distressed;
children may benefit from treatments that replace the re-
liance on parent accommodation with self-efficacy; and
reducing accommodation may show both parents and
child that the cycle can in fact be mitigated.
RELATION BETWEEN ACCOMMODATION AND
ANXIETY SYMPTOM SEVERITY
21. Consistent with previous research, accommodation
was associated with increased overall anxiety symptom
severity, but only for the clinical groups. As mentioned
earlier, the relation between overall anxiety severity and
family accommodation did not hold in the NA group.
In the AD group only, the school anxiety SCARED-PR
subscale was also associated with degree of accommo-
dation and in the OCD group, the generalized anxiety
subscale correlated positively with family accommoda-
tion.
LIMITATIONS
Some limitations of this study should be noted.
First, we examined family accommodation based on
maternal report only. Earlier studies in both OCD
and AD have indicated that mothers are the primary
“accommodators”[29] and parents tend to agree on over-
all family functioning,[48] but paternal perspective could
enhance the report. Second, FAS/FASA include rel-
atively broad statements describing forms of accom-
modation, not detailed qualitative descriptions. This is
strength in allowing for the direct comparison this study
undertook but also limits the subtlety of the information
received. It is plausible, for example, that although both
OCD and NA mothers “provide items” to accommo-
date their children, the kinds of items may be different.
Indeed, there are likely differences within the different
ADs as well. This relates to another limitation. Although
the sample size permitted between-group comparisons,
it was not sufficient to investigate accommodation within
the various AD, particularly given the typically high co-
morbidity in these disorders. An additional limitation is
the absence of clinical and psychosocial data relating to
mothers in this study and of broader clinical data on the
22. children, apart from anxiety symptoms. Such informa-
tion would greatly enrich the clinical picture and our
understanding of the potentially causal role of family
accommodation (FA) for the course of AD. These lim-
itations may be addressed in future research, some of
which is already underway.
IMPLICATIONS FOR TREATMENT
The results of the current study highlight the impor-
tance of assessing the presence and extent of family ac-
commodation in youth with OCD or AD. Parents should
be educated on the potentially negative implications of
FA. In particular, providing reassurance is very common
across both AD and OCD, and parents will need alter-
native strategies for coping effectively with their chil-
dren’s distress. Prospective longitudinal studies will in-
vestigate the causal role of FA in the development of AD
but the current data already point to the need for inter-
ventions that effectively reduce accommodation. Further
studies are needed to assess the efficacy of the SPACE
program,[36] which focuses on this aim.
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Depression and Anxiety
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Mobile Therapy: Use of Text-Messaging in the Treatment
of Bulimia Nervosa
Jennifer R. Shapiro, PhD1*
Stephanie Bauer, PhD2
Ellen Andrews, BA1
Emily Pisetsky, BA1
Brendan Bulik-Sullivan1
Robert M. Hamer, PhD1,3
Cynthia M. Bulik, PhD1,4
ABSTRACT
Objective: To examine a text-messaging
program for self-monitoring symptoms of
bulimia nervosa (BN) within the context
32. of cognitive-behavioral therapy (CBT).
Method: Thirty-one women partici-
pated in 12 weekly group CBT sessions
and a 12 week follow-up. Participants
submitted a text message nightly indicat-
ing the number of binge eating and
purging episodes and rating their urges
to binge and purge. Automatic feedback
messages were tailored to their self-
reported symptoms.
Results: Fully 87% of participants
adhered to self-monitoring and reported
good acceptability. The number of binge
eating and purging episodes as well as
symptoms of depression (BDI), eating
disorder (EDI), and night eating (NES)
decreased significantly from baseline to
both post-treatment and follow-up.
33. Discussion: Given the frequent use of
mobile phones and text-messaging glob-
ally, this proof-of-principle study sug-
gests their use may enhance self-moni-
toring and treatment for BN leading
to improved attendance, adherence,
engagement in treatment, and remis-
sion from the disorder. VVC 2009 by Wiley
Periodicals, Inc.
Keywords: bulimia nervosa; treatment;
technology; text messaging
(Int J Eat Disord 2010; 43:513–519)
Introduction
Bulimia nervosa (BN) is characterized by recurrent
binge-eating followed by inappropriate compensa-
tory behaviors such as self-induced vomiting or
misuse of laxatives. Individuals with BN place
undue emphasis on weight and shape. BN com-
monly occurs in women of normal body weight,
has a typical onset in adolescence or early adult-
hood, and afflicts 1–3% of young adult women.1
CBT is a multimodal intervention that includes
34. techniques such as psychoeducation, recognizing,
and modifying responses to antecedent cues, chal-
lenging automatic thoughts, thought restructuring,
problem solving, exposure with response preven-
tion, and relapse prevention.
2
Self-monitoring of
food intake, binges, and purges is a central element
of therapy. Treatment is most commonly adminis-
tered in individual or group therapy over 16–20 ses-
sions, although substantial clinical change can
occur in as few as eight sessions.3,4 Group therapy
represents a more parsimonious use of therapist
time, is an effective treatment, and ultimately is
more cost-effective,
5
although the time course to
recovery may be somewhat slower and abstinence
rates lower.6
Although CBT is effective for �40–67% of
patients,7–10 efforts are required to augment and
improve treatment to better serve individuals who
drop out (0–33%),11,12 fail to engage (14%),12 or
relapse (33%).8 The highest risk period for relapse
is in the 6 months after treatment,13 with risk
declining at 4-year follow-up.8 After 10 years, 11%
of individuals originally diagnosed with BN contin-
ued to meet full diagnostic criteria for BN and
18.5% met criteria for eating disorder not otherwise
specified.7,8 Due to these substantial concerns, a
35. recent systematic review of the treatment of eating
disorders has highlighted the importance of explor-
ing adaptations of technology to further enhance
CBT or fluoxetine treatment.14
Various means of information technology (e.g.,
web-based treatment, text messaging, personal
Accepted 28 June 2009
1 Department of Psychiatry, University of North Carolina at
Chapel Hill, Chapel Hill, North Carolina
2 Center for Psychotherapy Research, University of Heidelberg,
Heidelberg, Germany
3 Department of Biostatistics, University of North Carolina at
Chapel Hill, Chapel Hill, North Carolina
4 Department of Nutrition, University of North Carolina at
Chapel Hill, Chapel Hill, North Carolina
*Correspondence to: J.R. Shapiro, University of North Carolina
at
Chapel Hill, Department of Psychiatry, CB 7160, Chapel Hill,
North
Carolina 27599. E-mail: [email protected]
Supported by Mental Health Initiative (A Foundation for Mental
Health and an Alexander von Humboldt Stiftung German-
Ameri-
can Trans-Coop grant).
36. Published online 28 August 2009 in Wiley Online Library
(wileyonlinelibrary.com). DOI: 10.1002/eat.20744
VVC 2009 Wiley Periodicals, Inc.
International Journal of Eating Disorders 43:6 513–519 2010
513
REGULAR ARTICLE
digital assistants [PDAs]) are currently being used
for self-monitoring and treatment delivery. This
may increase the frequency of patient-provider
contact, reach individuals who may not have
access to specialty care, and result in better
treatment acceptability in today’s technological
society thus leading to increased treatment
engagement and decreased attrition. Although
self-monitoring is one of the hallmark features of
CBT for BN, patients often do not adhere to self-
monitoring.
15,16
Grounded in behavioral theory of practice and
reinforcement, text messaging may enhance self-
monitoring given that behaviors change most when
goals are set, and when cueing, support, and posi-
tive reinforcement are provided.17 In contrast to
traditional paper diaries, text messaging can be
used discretely and quickly and provides time/day
stamps so behaviors are recorded immediately and
37. accurately and can be set up to provide individuals
with immediate support and feedback to their
monitoring behavior. This approach to self-moni-
toring is in marked contrast to the potential shame,
stigmatization, and drudgery associated with carry-
ing around paper self-monitoring diaries, the fre-
quent practice of back-fill, and having to wait until
your next appointment (if at all) to get feedback on
your behaviors. Text messaging has been shown to
be acceptable for providing support, effecting
behavior change, and/or maintaining treatment
gains in diabetes,18,19 asthma,20 smoking cessa-
tion,21,22 and monitoring targeted behaviors associ-
ated with obesity in children.
23
Bauer and col-
leagues developed a text-messaging program to
support individuals on a weekly basis after they
completed CBT for BN. Results showed that
patients found the intervention to be highly con-
venient, flexible, and well tolerated. The vast ma-
jority rated the program as good or very good,
noted that they would recommend the program to
others and indicated that they would participate
again if they needed additional assistance.
Although most were satisfied with weekly check-
ins, 39% felt that more frequent interaction would
have been valuable.24,25 In contrast, Robinson
et al.26 found a low use of text messaging for after-
care in BN and high attrition and suggested that
text messaging required further adaptation to make
it a more useful tool. The current proof-of-principle
study was designed to expand on these previous
investigations to examine the feasibility and
38. acceptability of using a text-messaging program for
daily self-monitoring of BN symptoms during CBT.
Method
Participants
Women over the age of 18 with BN were recruited
through physician referral, referral from the University
of North Carolina Eating Disorders Program, and adver-
tisements in the community. Exclusion criteria include
diagnosis of anorexia nervosa, developmental learning
disorders that could interfere with comprehension of
the intervention, current severe depression [score � 29
on the Beck Depression Inventory; BDI;27] or active sui-
cidal intent, and inability to speak English fluently.
Individuals taking psychoactive medication were
included if their BN symptoms remained stable (i.e.,
were neither improving not deteriorating) while on
medication. A total of 54 women called and left a mes-
sage of interest about the study. Of these 54, 11 never
responded to a follow-up phone call and 43 underwent
39. the telephone screening. Of these 43, 12 did not
advance to a personal meeting due to not living in
North Carolina during the treatment (n 5 4), time of
group was inconvenient (n 5 4), did not show to inter-
view (n 5 2), did not meet diagnostic criteria for BN on
the phone (n 5 2). Thus, a total of 31 women pre-
sented for the personal interview and completed base-
line data. Of these, 29 (93.6%) were Caucasian, 1 (3.2%)
was African American, and 1 (3.2%) was Asian. The
mean age of participants was 26.3 6 8.6 years (range:
17–49 years; note: one person was almost 18 and per-
mitted through IRB and parental consent to partici-
pate). Nineteen (61.3%) have been previously treated
for BN.
Procedure
Participants first underwent a telephone screening (n
5 43). Those who met preliminary criteria were invited
to a personal interview, which included an initial brief
40. semistructured assessment to rule out any exclusion
criteria, establish BN diagnosis, and to provide consent
to participate. Assessments occurred at baseline, week
12 (post-treatment), and week 24 (follow-up). The study
was approved by the Biomedical Institutional Review
Board at the University of North Carolina at Chapel
Hill.
Measures
Height and Weight. Height and weight were assessed in
a hospital gown and without shoes using a stadiometer
and digital physician’s scale, respectively, calibrated regu-
larly according to protocol. BMI (kg/m2) was calculated.
Structured Clinical Interview (SCID) for DSM-IV, Eating
Disorders Modules.28 The eating disorders portion of
the SCID was administered to determine BN
diagnosis and rule out other eating disorders
diagnoses.
SHAPIRO ET AL.
514 International Journal of Eating Disorders 43:6 513–519
41. 2010
Eating Disorders Inventory-II (EDI).29 This self-report
instrument contains 91 items used to assess sever-
ity of symptomatology on dimensions clinically rel-
evant to eating disorders.
Binge-Purge Questionnaire. We created a measure to
investigate number of binge eating and purging episodes
based on recall. At post-treatment and follow-up, partici-
pants responded to two questions ‘‘In the past week, how
many binges (and purges) did you have?’’ These numbers
were compared with the numbers of weekly binge eating
and purge episodes that the participant provided during
the interview at baseline.
Night Eating Questionnaire.30 The NEQ is a brief, 14-
item questionnaire which evaluates the behavioral
and psychological symptoms of NES, including
morning hunger, craving, and control of food
42. intake after the evening meal and upon waking
at night, evening hyperphagia, nocturnal inges-
tions of food, and sleep and mood disturbance.30
The measure has an acceptable alpha (0.70);
convergent and discriminant validity have been
established.30
Beck Depression Inventory-II (BDI).27 The BDI is one
of the most widely used self-report measures of
depression. The BDI-II contains 21 items and
measures depression on four levels of severity. A
score of � 29 is defined as severe depression.
Self-Monitoring. Consistent with standard CBT, all par-
ticipants were instructed to record their daily food intake
(type and amount of food); thoughts, feelings, and situa-
tions associated with the eating episode; and binges/
purges each day via paper diaries. At the end of the day,
participants were instructed to complete daily responses
to the following three items: (1) How many binges did
you have today? (2) How many times did you purge today
43. (vomit, restrict, laxative use, excessive exercise)? (3) How
strong was your peak urge to binge today (0 5 no urge, 8
5 extreme urge)? and (4) How strong was your peak urge
to purge today (0 5 no urge, 8 5 extreme urge)? Given
that some engage in binge/purge behavior without feel-
ing an urge, whereas others feel an urge but do not
engage in the behavior, we opted to measure both urges
and actual behavior. Participants were encouraged to
keep paper and pencil diaries since despite low adher-
ence, they remain the ‘‘gold standard’’ of self-monitoring.
The text-messaging program was designed to record the
four targeted symptoms described above (i.e., not used
as an entire program to monitor meal plans, thoughts,
feelings, and cues).
Treatment Acceptability. At post-treatment participants
completed treatment acceptability Likert scales to
address the following questions: (1) How much did the
intervention meet your expectations? (2) How likely
44. would you be to recommend the intervention to a friend?
(3) How likely would you be to participate in the inter-
vention again if necessary? (4) How much did you enjoy
the self-monitoring forms? (5) How much did you enjoy
using the text-messaging program? A description of the
scale was provided such that 0 5 never or not at all
or extremely negative and 10 5 extremely positive.
Although this is not a previously validated measure,
similar measures have been used in previous studies.23
Text Messaging
Each night participants submitted a text message to
the program indicating their numbers of: (1) binge eating
episodes, (2) purging episodes, (3) peak urge to engage in
binge, and (4) peak urge to engage in a purge (Likert scale
0–8; 0 5 no urge, 8 5 extreme urge) and received an im-
mediate feedback message. Hundreds of feedback mes-
sages were developed to avoid duplicate messages and
included specific feedback on data as well as suggestions
45. of skills to use; algorithms were based on (1) how many
goals were met (the goal was abstinence from binge eat-
ing and purging) and (2) enhancement or deterioration
from the previous day. An example feedback message
consisted of: ‘‘Good job with resisting your strong urge to
purge today. Try harder not to give into the binge eating
tomorrow. Call a friend instead.’’ If at 9 am the following
morning, there has been no input, participants received a
text-message prompt to input their data. Participants
began monitoring on treatment day 1 and continued
monitoring their symptoms during the 12 week treat-
ment phase and an additional 12 weeks for a total of 24
weeks. They then returned to the clinic for a follow-up
evaluation. All participants used their own phones and
were reimbursed for text-messaging charges during the
course of the study.
Treatment
Participants met in groups of 5–8 participants for 1.5 h
46. for 12 consecutive weeks. All groups were facilitated by a
clinical psychologist. Treatment provided skills and
techniques typical of CBT treatment for BN as described
earlier.
Statistical Analyses
This study was designed to be a proof-of-principle
study to explore the feasibility of using text messaging as
a self-monitoring tool in the treatment of BN. The pri-
mary outcome measure in this study was adherence to
self-monitoring; secondary outcome measures included
treatment acceptability, and change in symptoms of BN
over time after participating in CBT. Primary analyses
used descriptive statistics, change scores from baseline
to post-treatment and baseline to follow-up, with signifi-
cance testing performed using single-group t-tests on the
change scores. p values should be interpreted with
MOBILE PHONE TEXT MESSAGING FOR BULIMIA
NERVOSA
47. International Journal of Eating Disorders 43:6 513–519 2010
515
caution due to the exploratory nature of this study. Anal-
yses were conducted with SAS, version 9.1.3.
31
Results
Attrition
Dropouts were defined as those who stopped
coming to treatment sessions and stopped moni-
toring. The dropout date is whichever was later
(date of last treatment visit or last monitoring
date). Of the 31 who interviewed, all met inclusion
criteria but only 25 actually showed upto the first
group session. A total of 15 completed the treat-
ment and post-treatment questionnaires (48.4% of
the total sample and 60% of those who began treat-
ment). The average number of sessions attended
was 7/12 (range: 0–12) for the full 31 sample and 8/
12 (range: 1–12) for the 25 who began treatment.
Self-Monitoring Adherence
Frequency of monitoring was calculated by
counting the number of days self-monitoring was
done divided by the number of days between the
participant’s first scheduled monitoring day and
last scheduled monitoring day or drop out date.
Due to slight variations in the exact number of days
that different waves of the study were expected to
48. monitor, a more accurate comparison is percentage
of total monitoring days rather than actual number
of days monitored. Self-monitoring binge eating
and purging behavior was calculated on 18 partici-
pants who had monitoring behavior over at least a
2-week period, the first week and a nonoverlapping
last week, even if a participant dropped out before
the post-treatment evaluation.
Participants demonstrated 87% adherence to
self-monitoring. Furthermore, two of the partici-
pants asked if they could continue to use the pro-
gram even after the study ended as it helped them
with their recovery.
Treatment Acceptability
The treatment acceptability measure asked par-
ticipants to rate various aspects about the program
on a 0–10 Likert scale with 0 indicating the most
negative response and 10 indicating an extremely
positive response. The questions and the ratings
are as follows (mean 6 SD): (1) How much did the
intervention meet your expectations? (7.1 6 2.0),
(2) How likely would you be to recommend this
intervention to a friend? (7.9 6 1.6), (3) How likely
would you be to participate in this intervention
again if necessary? (7.7 6 2.8), (4) How much did
you enjoy the self-monitoring forms? (5.0 6 2.4),
and (5) How much did you enjoy using the text-
messaging program? (6.3 6 2.4). Thus, participants
rated all aspects of the program including text mes-
saging as above average other than self-monitoring
forms which were rated as average.
49. Preliminary Effectiveness
Table 1 presents baseline, post-treatment, and
follow-up scores on the various measures as well as
text-messaging data. Preliminary effectiveness was
assessed in completers only. As can be seen in the
table, participants significantly improved in their
self-reported binge and purge episodes obtained
via paper measures. Notably, participants reported
an average of six binge episodes in the past week at
baseline and 2.5 at post-treatment (p 0.01); they
reported an average of 14.5 purges in the past week
at baseline and 4.3 at post-treatment (p 0.05). In
addition, participants’ scores on all other outcome
measures (BDI, EDI, NEQ) significantly improved
from baseline to post-treatment and follow-up.
We also calculated the number of binges, num-
ber of purges, peak urge to binge, and peak urge to
purge reported during the first week of self-moni-
toring and during the last week of self-monitoring.
To do this, we had to follow an algorithm. First, a
participant had to have self-monitored for at least 2
weeks, or the first and last week would overlap,
which would make defining change problematic.
We then counted number of binges, purges, urges
to binge, urges to purge in the first week and in the
last week of self-monitoring. Thus, we were able to
calculate self-monitoring statistics on only a subset
of participants. text-messaging results showed that
only the mean number of purges significantly
reduced from the first week of monitoring to the
last week of monitoring.
Discussion
50. This study was the first study to investigate whether
a novel technology of text messaging could be used
as a self-monitoring tool within the context of out-
patient group CBT. Results showed that partici-
pants generally accepted the text-messaging pro-
gram and adhered to self-monitoring 87% of the
time, which is higher than many published self-
monitoring adherence rates.32 These results are
consistent with Stone et al. who found a 94% ad-
herence to the PDA and only an 11% adherence to
SHAPIRO ET AL.
516 International Journal of Eating Disorders 43:6 513–519
2010
paper diaries.15 Because self-monitoring is associ-
ated with increased adherence to goals, increasing
the frequency of self-monitoring could be expected
to lead to higher remission rates. In addition, par-
ticipants improved on paper and pencil self-
reported measures of binge eating and purging epi-
sodes from baseline to post-treatment as well as
improvements in depression, and both eating dis-
order and night eating symptoms. Interestingly,
when looking at the text-messaging data, only the
number of purging episodes was significantly
reduced from baseline to post-treatment. Specifi-
cally, at both baseline and post-treatment, the
number of binge episodes over the past week
reported via the binge-purge questionnaire was
similar to those reported via text messaging (i.e.,
results were similar across measurement method).
The number of purges over the past week reported
51. at baseline was also consistent across measure-
ment methods. However, at post-treatment, the
number of purges reported via text messaging was
greater (7 per week) than that reported via the
binge-purge questionnaire (4 per week). Thus, it is
unclear which data collection method is more
accurate. If the daily time stamped text-messaging
technique is more accurate than retrospective
weekly recall, then it is plausible that participants
are significantly underreporting (either accidentally
or purposefully) their symptoms when asked to
report retrospectively. This inaccuracy is important
for research and clinical purposes; errors may be
made when individuals are asked to recall the
number of binge/purge episodes on a weekly basis
but also if they back-fill their self-monitoring forms
(i.e., complete weekly forms retrospectively before
meeting with the provider).
Although this study was designed as a proof-of-
principle study, we nonetheless must discuss limi-
tations. Appreciation of these limitations will assist
with designing subsequent trials that incorporate
text-messaging components for self-monitoring.
First, the initial sample size was small. Second,
attrition was high but notably not much higher
than the reported 33% drop out rate reported in
previous studies.11,12 A large portion of participants
in most studies of BN fail to engage in treatment
and/or drop out. Thus, it is important to enhance
treatment in such ways that are likely to increase
acceptance, usability, and completion. As society
becomes more technologically savvy, researchers
and clinicians must utilize such modes of commu-
nication as they are increasingly being shown to
increase treatment acceptability. This pilot study
52. was the first to show that participants accepted and
adhered to a text messaging self-monitoring pro-
gram within the context of outpatient CBT for BN.
Future studies should continue to enhance treat-
ments to reduce attrition; however, we found that
text messaging may be one vehicle to enhance self-
monitoring for those individuals who remain in an
intervention program. Third, this was a within
group design and we did not compare results to a
traditional paper diary group. Thus, we are unable
to determine if text messaging would significantly
improve treatment acceptability, adherence, effec-
tiveness, and completion relative to a control
group. However, our results are promising in that
87% of participants adhered to self-monitoring,
which is much higher than adherence rates to tra-
ditional paper and pencil based self-monitoring.15
Fourth, when comparing the number of binge eat-
ing and purging episodes, the baseline data were
TABLE 1. Scores on baseline and post-treatment outcome
measures
Baseline: Entire Sample Baseline: Completers Only Post-
Treatment (Week 12) Follow-Up (Week 24)
Height (inches) Mean 6 SD (n) 65.2 6 3.1 (31) N/A N/A N/A
Weight (pounds) Mean 6 SD (n) 137.0 6 30.0 (31) 131.2 6 14.1
(13) 133.5 6 14.1 (13) 133.9 6 15.3 (13)
BDI Mean 6 SD (n) 24.6 6 11.0 (31) 23.1 6 10.7 (15) 11.4 6 9.6
(15)**** 8.8 6 9.4 (14)***
EDI (total score) Mean 6 SD (n) 108.9 6 41.4 (31) 102.9 6 35.4
(15) 58.7 6 34.5 (15)*** 52.6 6 18.8 (14)**
NEQ Mean 6 SD (n) 20.1 6 6.6 (31) 21.1 6 6.9 (15) 16.9 6 6.9
(15)** 14.2 6 7.6 (14)***
53. # Binges in past week: Mean 6 SD (n) 5 (30) 5.8 6 4.8 (15) 2.5
6 1.9 (15)** 2.9 (14)*
# Purges in past week Mean 6 SD (n) 7 (30) 14.5 6 19.4 (15) 4.3
6 5.4 (15)* 4.4 6 5.7 (14)*
Text-messaging dataa
Mean per day per week 6 SD (n)
# Binges N/A 0.8 6 0.9 (18) 0.7 6 0.6 (18) N/A
# Purges N/A 1.9 6 2.4 (18) 1.0 6 1.2 (18)* N/A
Urge to Binge N/A 4.7 6 2.3 (18) 4.2 6 2.6 (18) N/A
Urge to Purge N/A 5.0 6 2.4 (18) 4.0 6 2.5 (18) N/A
BDI, Beck depression inventory; EDI, eating disorders
inventory; NEQ, night eating questionnaire.
Results are compared with baseline completers only:
* 5 p0.05; ** 5 p0.01; *** p 0.001; **** 5 p0.0001.
a All data on table is based on self-report measures during data
collection periods except for text-messaging data, which is a
summary of the first and
last week of text-messaging data.
MOBILE PHONE TEXT MESSAGING FOR BULIMIA
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International Journal of Eating Disorders 43:6 513–519 2010
517
extrapolated from the SCID, whereas the post-
treatment data were taken from the binge-purge
questionnaire. Thus, although the questions
queried the same behaviors, it was asked verbally
at baseline and asked via questionnaires at post-
treatment and follow-up. However, results showed
54. that participants reported a much higher rate of
binge eating and purging episodes at baseline via a
clinical interview and fewer episodes at post-treat-
ment via a questionnaire. Despite the slight differ-
ences in methods of inquiry, we are confident that
they yielded similar results; if social desirability
was in effect, one would suspect that the results
would have been reverse (i.e., report lower frequen-
cies on a verbal interview).
Bearing the limitations in mind, these initial
promising results as well as previous studies that
have demonstrated a higher adherence rate in elec-
tronic diaries versus paper diaries,15,23 support the
further exploration of incorporate text-messaging-
based self-monitoring in larger randomized clinical
trials comparing traditional therapy with a more
enhanced technological version. Although the
results of this pilot study do not demonstrate
reduced attrition, the text messaging demonstrated
a high self-monitoring adherence rate for those
who remained in the study.
Independent of the limitations inherent in our
study, there are inherent challenges with text mes-
saging that may limit generalization and wide-
spread use. Providers must have access to a secure
server to host the text-messaging program. The
server at times may malfunction and not accept
incoming or outgoing text messages until it is
rebooted. Although the cost of text-messaging
plans is relatively inexpensive, it may be inaccessi-
ble for individuals without mobile phones and indi-
viduals who live in rural areas may have no mobile
phone coverage. However, these limitations were
infrequent and the benefits strongly outweighed
55. the challenges we encountered.
In sum, the specific advantages of text messaging
include its wide dissemination, low cost, availabil-
ity, flexibility, convenience, and interactivity. Men-
tal health professionals are currently limited in the
services available to patients. In terms of behavioral
treatment, patients often do not receive any clinical
input beyond the 50 min per week that they meet
with their therapist. In addition, after terminating
treatment, relapse is common.8 Text messaging
could be used as part of a stepped care approach to
maintain more frequent contact with patients after
they are discharged from inpatient or partial hospi-
talization treatment to maintain contact and help
prevent relapse. Finally, the cost-effectiveness of
such programs should be examined in greater
detail; text messaging may prove to be a cost-effec-
tive method for increasing adherence and effecting
behavior change, which could ultimately enhance
CBT for those who do not have regular access to
treatment providers, need more frequent contact,
drop out of treatment, or for treatment nonres-
ponders. If effective, this methodology could read-
ily be exported to other populations and settings
for improving digestive diseases, nutritional disor-
ders, and other eating disorders as well as dissemi-
nation to remote settings in which access to
health-care is limited.
The authors greatly appreciate Lauren Reba-Harrelson,
MA for facilitating some of the intervention groups.
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![and a compar-
ison group of nonanxious (NA) children (N = 30). Mothers
completed measures
of accommodation (Family Accommodation Scale (FAS)/Family
Accommodation
Scale–Anxiety (FASA)), anxiety (Screen for Childhood Anxiety
Related Emo-
tional Disorders–Parent Report (SCARED-PR)), and OCD
(Children’s Yale-
Brown Obsessive Compulsive Scale (CYBOCS)). Results:
Family accommoda-
tion is prevalent among mothers of children with OCD and AD.
Few differences
were found between the two clinical groups who reported more
accommodation
(F[2,84] = 23.411, P < .001, partial η2 = .358), greater distress
(F[2,84] =
24.050, P < .001, partial η2 = .364), and more consequences of
not accommo-
dating (F[2,84] = 18.967, P < .001, partial η2 = .311), than the
NA group.
Accommodation was associated with severity of anxiety in AD
(r = .426, P =
.017) and OCD (r = .465, P = .017), but not in the NA group.
Conclusions:
Findings highlight family accommodation as a phenomenon that
applies broadly
and in a similar manner to children with AD and OCD.
Evaluating accommo-
dation provides useful information for clinical care and is an
important part of
the assessment of children with AD and OCD. Depression and
Anxiety 31:1018–
1025, 2014. C© 2014 Wiley Periodicals, Inc.
Key words: family accommodation; child/adolescent; anxiety](data:image/gif;base64,R0lGODlhAQABAIAAAAAAAP///yH5BAEAAAAALAAAAAABAAEAAAIBRAA7)