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REVIEW ARTICLE  
Year : 2019  |  Volume : 61  |  Issue : 7  |  Page : 93-103
Family accommodation in psychopathology: A synthesized review


1 Yale University Child Study Center, New Haven, CT, USA
2 Department of Psychiatric Social Work, Obsessive-Compulsive Disorder Clinic, National Institute of Mental Health and Neuro Sciences, Bengaluru, Karnataka, India

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Date of Web Publication9-Jan-2019
 

   Abstract 


Family accommodation describes changes that family members make to their own behavior, to help their relative who is dealing with psychopathology, and to avoid or alleviate distress related to the disorder. Research on family accommodation has expanded greatly in the past few years. The aim of this study was to provide a synthesized review of recent findings on family accommodation in psychopathology. Electronic databases were searched for available, peer-reviewed, English language papers, published between September 2015 and March 2018, cross-referencing psychiatric disorders with accommodation and other family-related terms. Ninety-one papers were identified and reviewed, of which 69 were included. In obsessive-compulsive disorder and anxiety disorders family accommodation has been linked to symptom severity, functional impairment, caregiver burden, and poorer treatment outcomes. Several randomized controlled trials explored the efficacy of treatments aimed at reducing family accommodation. A growing number of studies have reported family accommodation in eating disorders where it is associated with greater symptom severity and caregiver burden. Family accommodation has also been studied in other disorders, including autism spectrum disorders, tic disorders, and posttraumatic stress disorder. Research on family accommodation in psychopathology is advancing steadily, expanding across disorders. The study highlights the importance of addressing family accommodation in the assessment and treatment of various disorders.

Keywords: Accommodation, anxiety disorders, burden, family, obsessive-compulsive disorder, psychopathology

How to cite this article:
Shimshoni Y, Shrinivasa B, Cherian AV, Lebowitz ER. Family accommodation in psychopathology: A synthesized review. Indian J Psychiatry 2019;61, Suppl S1:93-103

How to cite this URL:
Shimshoni Y, Shrinivasa B, Cherian AV, Lebowitz ER. Family accommodation in psychopathology: A synthesized review. Indian J Psychiatry [serial online] 2019 [cited 2019 Jun 16];61, Suppl S1:93-103. Available from: http://www.indianjpsychiatry.org/text.asp?2019/61/7/93/249695





   Introduction Top


Family accommodation describes changes that family members (i.e., parents, siblings, children, and partners) make to their own behavior, to help their relative who is dealing with psychopathology, and avoid or alleviate distress related to the disorder. These behavioral changes generally involve relatives of the patient modifying family routines, actively participating in symptoms of the disorder, or facilitating avoidance related to the disorder. Family accommodation can be identified in countless behaviors and in various disorders. Some examples include, engaging in excessive handwashing to help reduce obsessional stress in obsessive-compulsive disorder (OCD), reassuring a patient with checking compulsions that they have checked the locks “correctly,” never leaving a child with separation anxiety disorder (SAD) in the care of other adults, talking on behalf of a child with social phobia, or adhering to rigid meal-times or meal-preparation rituals in anorexia nervosa.

The desire to reduce the patient's distress is a major motivating factor driving family accommodation. The reduction in distress, however, fuels a cycle of negative reinforcement that leads to further increasing levels of accommodation and more severe symptoms, as the patient continues to rely heavily on their accommodating relative and does not develop more independent coping abilities.[1],[2],[3] By reinforcing avoidance and hindering cognitive-behavioral processes which are key to recovery, family accommodation can also impede treatment efforts.[1],[4],[5] For example, family accommodation restricts opportunities to develop tolerance to distress,[6] to collect evidence that challenge maladaptive beliefs,[7] and to experience habituation to feared objects or situations.[8]

Empirical data has generally supported these theoretical conceptualizations. Family accommodation has been most extensively studied in OCD and has been consistently found to be associated with symptom severity,[4],[9],[10],[11],[12],[13],[14] impairment related to the disorder,[7],[10],[15] and poor treatment outcomes.[16],[17] In addition to maintaining patient symptoms and hindering treatment, family accommodation also takes a tremendous toll on the accommodators and other family members, as evidenced by associations between accommodation and measures of caregiver burden and quality of life and disruption to family functioning.[18],[19],[20]

Following initial empirical studies in OCD, research on family accommodation has rapidly expanded to include a growing number of disorders and areas, such as anxiety disorders, eating disorders, autism spectrum disorder, tic disorders, and posttraumatic stress disorder (PTSD). Recent studies have also aimed to increase the understanding of individual differences in family accommodation and mechanisms that maintain it, by exploring predictors and moderators of family accommodation. Recognition of the central role of family accommodation in multiple disorders has also spurred the development of treatment protocols in which reduction of family accommodation is a main treatment goal, and generated interventional studies, including randomized control trials, that focus on accommodation as a predictor of treatment outcome.[18],[21],[22],[23],[24],[25]

In light of the rapid expansion in family accommodation research beyond the initial focus on OCD, the field is ripe for a new review to synthesize these findings. While previous meta-analyses and reviews of family accommodation have focused either exclusively or primarily on OCD,[4],[13],[26],[27] this review summarizes research on accommodation in other areas of psychopathology as well.


   Materials and Methods Top


The electronic databases PubMed and PsycINFO were systematically searched for relevant studies published between September 2015 and March 2018. Keywords related to family (family accommodation, family relations, parents, caregiver) were searched in combination with keywords related to specific disorders (OCD, anxiety disorders, generalized anxiety disorder, social anxiety disorder, specific phobia, selective mutism, panic disorder, agoraphobia, SAD, eating disorders, anorexia nervosa, bulimia nervosa, binge-eating disorder, autism spectrum disorder, tic disorder, Tourette syndrome, PTSD, depression, mood disorders, failure to launch, dependent adults, emerging adults). Reference lists of the relevant studies in the search list were also scanned to identify additional relevant publications. To ensure reliability, two researchers performed the searches independently, after which a comparison and discussion of relevance of each study was carried out. Only publications in English language and peer-reviewed journals were considered. 91 studies were identified in the search; after review and discussion, 69 were chosen based on their relevance and contribution to the understanding of family accommodation. As the aim of this review was to provide a synthesis of the main developments and findings in the area of family accommodation in psychopathology, rather than an exhaustive review of all available research on family accommodation, the authors' judgments were employed in selecting papers for inclusion.


   Results Top


Family accommodation in obsessive-compulsive disorder

Description and prevalence

Family accommodation was first empirically studied in relatives of adults with OCD,[28] In this initial study, family accommodation was found prevalent and extensive, reported by family members of 88% of the OCD patients. These accommodating behaviors included facilitation of avoidance of OCD triggers, modification of family routines and participation in patient's compulsions. Similar findings have consistently been reported since, with up to 90% of adults and children with OCD being accommodated to some extent by family members.[7],[10],[12],[14],[29],[30],[31] The most commonly endorsed accommodating behaviors include providing reassurance and awaiting ritual completion, and of the OCD dimensions, the contamination/washing dimension has been most frequently associated with family accommodation.[10],[12],[15],[32]

Correlates of family accommodation

Symptom severity and impairment – empirical research continues to support the theoretical models of family accommodation in OCD, demonstrating links between higher levels of family accommodation and increased symptom severity and impairment.[7],[11],[30],[33],[34],[35] Family accommodation has also shown to mediate the association between child symptom severity and parent-rated functional impairment.[7],[9] A recent meta-analysis including 41 studies found a moderate effect size (r = 0.42) for the association between family accommodation and symptom severity.[13] In this meta-analysis, none of the sample-dependent variables (age, gender, or comorbid anxiety or mood disorders) moderated this association. The only variable found to moderate the association between family accommodation and symptom severity was the number of items extracted from the different versions of the Family Accommodation Scale (FAS).[28] Specifically, associations between family accommodation levels and symptom severity were stronger in studies using the 9-item version of the FAS[28] (9 core items of the FAS assessing accommodating behaviors in the past month) than in studies using the 12-item version (assessing accommodating behaviors in the past week).[30] The authors attribute these findings to both the number of items extracted from the measures as well as to the time frame of the assessed accommodating behaviors (month/week) and stress the importance of agreeing on a standardized measure of family accommodation in OCD for better comparability of results (for a detailed description of the available accommodation measures in OCD see Wu et al.[36] Aside from symptom severity and impairment, family accommodation has also been linked to anxiety sensitivity (i.e., fear of anxiety-related sensations due to beliefs that these sensations have harmful physical, psychological, or social consequences[37]) in adults with OCD.[38] In this study, family accommodation mediated the relationship between the fear of losing mental control (an aspect of anxiety sensitivity) and functional impairment.

Caregiver burden, quality of life, and family functioning – caring for a person with OCD negatively impacts the lives of caregivers as well as the entire family unit.[11],[20],[27] Studies show factors such as caregiver burden, quality of life, and impairment of family functioning, to be associated with family accommodation. For example, in a study of 50 caregivers of adult OCD patients, the level of family accommodation was positively correlated with caregiver burden, whereas caregivers who showed low levels of family accommodation reported only minimal burden.[39] Torres et al.[40] identified six dimensions of caregiver burden in OCD (interference in the caregiver's personal life, perception of patient's dependence, feelings of irritation or intolerance, guilt, insecurity, and embarrassment), all of which positively correlated with family accommodation levels.

Quality of life refers to caregivers' perceptions of their physical, psychological, and social well-being and has been negatively associated with family accommodation in adults and children with OCD.[19],[41],[42] Recently, Wu et al.[43] examined caregiver burden and quality of life in 72 children and caregiver dyads receiving intensive treatment in outpatient and partial hospitalization programs for OCD. Higher levels of family accommodation were associated with poorer caregiver psychological well-being and with several aspects of caregiver burden, including burden on caregivers' time, development, and social relationships.

Stewart et al.[18] focused on family functioning, identifying aspects of family functioning that are negatively impacted by the OCD, as well as the correlates and predictors of impaired family functioning. Integrating and comparing reports from 118 trios of children with OCD and their parents, this multisite study showed family accommodation to be a key predictor of family impairment based on reports of both parents, though it was not a predictor of child-reported family impairment. The study further identified areas of family disruption, such as morning and bedtime routines, that may increase vulnerability to family accommodation. The multi-informant approach applied in this study highlights the value of attaining information from children as well as from their parents when assessing OCD related impairment.

Adding to caregiver burden and negatively impacting family functioning is the presence of coercive-disruptive behaviors reported in a majority of children with OCD.[35],[44],[45] These forceful impositions of family members to accommodate symptoms often include behaviors such as demands that others abide by rules of cleanliness or participate in rituals, prohibitions against opening windows, or forceful demands for repeated reassurance. When met with resistance to these demands, physical aggression or verbal abuse is common. Coercive-disruptive behavior has been linked to increased family accommodation,[34],[35],[44] and in Lebowitz et al.,[34] family accommodation mediated the association between coercive-disruptive behavior and OCD symptom severity.

Family accommodation in anxiety disorders

Description and prevalence

Research on family accommodation in anxiety disorders has focused on pediatric anxiety. The first study to investigate family accommodation in anxiety disorders was conducted by Lebowitz et al.[3] Nearly, all parents of anxious children (97.3%) reported at least some level of family accommodation and most parents (76%) endorsed both participation in symptoms and modification of the family's routines. Subsequent studies have also consistently shown family accommodation to be highly prevalent in anxiety disorders, with 95%–100% of parents of anxious children reporting at least few accommodating behaviors.[46],[47],[48],[49],[50],[51] Providing reassurance, facilitating avoidance and changing family routines due to the child's anxiety have been reported as the most frequent accommodations,[3],[46],[48],[49] while allowing the child to take a “mental health day” or sleep in the parent's bed, and answering frequent texts or phone calls from the child have been reported as most interfering for parents.[51]

There is some evidence to suggest that parents of children with SAD are particularly prone to accommodating.[3],[46],[50],[51] One explanation is that the nature of SAD, with its intense focus on parental proximity makes accommodation almost inevitable. Another explanation is that the kind of accommodation sought by children with SAD (i.e., being close to a parent) elicits positive feelings in the parent, predisposing them to consent to the accommodation.[50],[52] Biological factors may also contribute to the link between SAD and accommodation. Lebowitz et al.[53] found lower levels of salivary oxytocin in children with SAD compared to anxious children without SAD; child oxytocin levels were negatively associated with family accommodation. Further supporting the possible role of oxytocin in promoting family accommodation in SAD, a subsequent study found that oxytocin levels rose significantly following an interaction between separation-anxious children and their mothers.[54]

Correlates of family accommodation

Accumulating evidence continues to support consistent associations between family accommodation and anxiety symptoms and impairment.[46],[47],[48],[50],[55] Research has also linked family accommodation to other child and family variables. Benito et al.[48] found that family accommodation was positively correlated with parent depression symptoms. This study was also the first to report on sibling accommodation. In approximately 60% of families with more than one child, parents reported that siblings engage in some form of accommodation. Associations of family accommodation with internalizing, externalizing, and depressive symptoms in the child have also been reported.[46],[55] A relatively new area of research in pediatric anxiety is that of sleep-related problems.[56],[57],[58] Peterman et al.[59] found a significant association between family accommodation and sleep-related problems in anxious children.

Mixed findings have been reported regarding associations between family accommodation and child age and sex. Some studies reported a negative association between child age and family accommodation, with parents of younger children accommodating more,[46],[50],[51] while others did not find age and accommodation to be related.[3] One study found that parents of girls accommodate more,[3] but this has not been replicated in subsequent studies.[46],[50],[51]

Some studies have focused on interactions between anxiety, accommodation, and third variables. Family accommodation was found to mediate the link between maternal anxiety and child anxiety.[60] Lebowitz et al.[49] found that maternal anxiety moderated the association between mother and child reports of family accommodation, such that the association was stronger in the more anxious mothers. In Settipani and Kendall,[61] mothers were queried about their responses to vignettes describing imaginary situations involving their child. Mothers with high levels of anxiety and empathy were more likely to select an accommodating response when the child was described as experiencing a high level of distress. Schleider et al.[62] examined child's anxiety sensitivity as a moderator of the association between family accommodation and symptom severity. The association between family accommodation and anxiety symptom severity was significant when anxiety sensitivity was low, but not when anxiety sensitivity was high.

Studies on accommodation in pediatric anxiety have relied primarily on parent ratings of accommodation. One notable exception is a study by Lebowitz et al.[49] who introduced a child-rated version of the FAS anxiety and compared accommodation ratings of 50 clinically anxious children and their mothers. Overall, mother and child reports showed good concordance, with mothers reporting higher levels of accommodation than children.

Interventions for reducing family accommodation in obsessive-compulsive disorder and anxiety disorders

Reducing family accommodation is increasingly recognized as an important treatment goal in OCD and anxiety. The Supportive Parenting for Anxious Childhood Emotions (SPACE) program[22] stands out in this context, for placing accommodation reduction at the core of its theoretical foundation and treatment objectives. SPACE is a parent-based intervention that does not require child participation and can be delivered as a standalone treatment or alongside child treatment. Parents in SPACE are guided to reduce their own accommodating behaviors, rather than trying to actively control or change the child's behavior. Two open trials, in anxiety[22] and in OCD,[21] found SPACE to be feasible and acceptable and provided preliminary evidence in support of its efficacy. A randomized control trial has recently been completed (clinicaltrials.gov, NCT 02310152).

Other interventions have incorporated accommodation reduction into individual cognitive behavioral therapy (CBT), group CBT, or family-based CBT with varying levels of emphasis. [Table 1] summarizes interventions addressing family accommodation.
Table 1: Interventions for reducing family accommodation in obsessive-compulsive disorder and anxiety disorders

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Family accommodation and treatment outcomes in obsessive-compulsive disorder and anxiety disorders

Family accommodation in OCD and anxiety disorders has been repeatedly found to predict poor treatment outcomes. A recent systemic review of moderators and predictors of CBT for pediatric OCD concluded that family accommodation, along with older age, symptom and impairment severity, and comorbidity, were consistent predictors of poorer outcome of CBT.[17] In a randomized clinical trial of family-based CBT for pediatric OCD, reductions in family accommodation predicted improvement in OCD symptom severity.[74] A study investigating treatment response to a group-based CBT program for pediatric OCD found that greater family accommodation levels at baseline were associated with greater OCD symptom severity at 12-months follow-up.[25] In a study of intensive treatment for pediatric OCD, family accommodation was one of three significant predictors of treatment outcome, along with symptom severity and gender.[75] In Kagan et al.,[76] higher baseline levels of family accommodation predicted poorer response to CBT for pediatric anxiety, and reduction in family accommodation was significantly associated with parent-rated anxiety severity posttreatment, even when controlling for baseline anxiety levels. In a randomized control trial of computer-based CBT for pediatric anxiety, Salloum et al.[77] found that the impact of family accommodation on child predicted remission, while the accommodation level itself did not. Contrary to this body of research, in the Nordic long-term OCD Treatment Study, including 269 children and adolescents,[78] higher levels of family accommodation were not associated with poorer treatment outcomes after 14 weeks of CBT.

Several studies show significant reductions in family accommodation following treatment for OCD and anxiety disorders.[22],[50],[52],[59],[76],[79] For example, La Buissonnière-Ariza et al.[50] examined family accommodation of anxiety symptoms in children undergoing CBT for OCD or anxiety disorders, in either intensive outpatient, partial hospitalization, or residential treatment settings. Significant reductions in family accommodation were noted following treatment. Furthermore, posttreatment reduction in family accommodation was associated with improvements in symptom severity and functional impairment. Finally, in a study examining the effect of family accommodation on naturalistic outcomes in adult OCD over a 1-year period, remission was associated with lower accommodation, and accommodation levels of baseline significantly predicted time to remission.[19]

Family accommodation in other disorders

Eating disorders

Family accommodation has been identified as a maintaining factor in eating disorders, with most empirical research concentrating on mixed samples of adolescents and adults.[80],[81] According to the cognitive-interpersonal maintenance model of anorexia nervosa, developed by Schmidt and Treasure,[82] caregivers' dysfunctional responses to the disorder, in the form of family accommodation, high expressed emotion (i.e., criticism or emotional over-involvement), and anxious or depressed emotional reactions, act as interpersonal maintaining factors. By tolerating or permitting the symptoms of the eating disorder, family accommodation reinforces and contributes to the maintenance of the symptoms. Specifically, patients become increasingly entrapped within the rule-bound eating, and the weight and shape control behaviors that characterize the disorder.[81] As in OCD and anxiety disorders, family accommodation in eating disorders can take many forms. Examples include, avoiding the purchase of certain foods because of the patient's distress in having these foods in the house, providing constant reassurance about the patient's weight or looks, adhering to a very rigid schedule of meal times or to meal-preparation rituals, and allowing the patient to control the nature and duration of activities of other family members in the kitchen.

Clinical correlates

A qualitative study of 8 caregivers of patients with anorexia nervosa concluded that when met with patient's resistance to treatment, caregivers felt powerless over the disorder, and over time, were left with compromised emotional reserve. Consequently, they increased their accommodating behaviors, despite recognizing this as counterproductive to recovery.[80] Others have reported that accommodating the symptoms of eating disorders is often followed by feelings of shame, self-blame, anger, and disgust as well as high levels of anxiety and frustration regarding the acceptance of these problematic behaviors and their impact on family functioning.[83],[84] Taken together, these data indicate that family accommodation can both lead to and increase caregiver burden in eating disorders.

Quantitative data also support associations between family accommodation and factors that increase caregiver burden.[85],[86],[87] Family accommodation is higher in caregivers of patients with a longer duration of the disorder, patients with anorexia nervosa (compared to bulimia nervosa), when the caregiver spends more time with the patient, has a personal history of an eating disorder, and when the caregiver or the patient have high levels of anxiety.[86],[88],[89] Family accommodation also mediated the relation between objective indicators of burden (i.e., time spent across caregiving tasks) and subjective perception of burden (caregivers' distress) in mothers of patients with anorexia nervosa.[90]

Data on associations between family accommodation and symptom severity of eating disorders are scarce and inconsistent. Salerno et al.[91] followed 54 triads (mother, father, and adolescent) monthly for a year. Results showed a person-/dose-dependent relation between family accommodation and patients' symptom severity over time: When both mothers and fathers were highly accommodating, symptom severity was highest; when only one parent was highly accommodating, symptom severity was intermediate; and when both parents were low on accommodation, symptom severity was lowest. In contrast, Goddard et al.[92] examined 152 dyads of caregivers and patients (adults and adolescents) with a primary diagnosis of an eating disorder and did not find associations between family accommodation and symptom severity.

Interventions addressing family accommodation

Interventions aimed at caregivers of patients with eating disorders generally aim to enhance caregivers' understanding of the disorder, help them cope with the burden and distress of caring for an eating disordered patient, and guide them in providing support for their relative with the eating disorder. These caregiver interventions are not meant as standalone treatments for eating disorders, and most do not emphasize family accommodation as a central feature.[89],[93] An exception is the New Maudsley Collaborative Care.[89],[94] This intervention was originally delivered as a six-session workshop and has recently also been delivered in the form of self-management materials (with guidance). Components include a manual, a set of five instructional digital video disc (DVD), and a series of telephone coaching sessions. Caregivers are guided in several skills, including gradually reducing accommodating behaviors. The New Maudsley Collaborative Care intervention was found to be feasible, acceptable, and effective for reducing distress and burden in caregivers, with some evidence to support the efficacy of this intervention in reducing family accommodation.[95] Reductions in family accommodation were also reported in a randomized control trial by Goddard et al.[96] comparing self-help and guided self-help versions of an intervention aimed at supporting caregivers of patients with eating disorders (Expert Carers Helping Others).[97] Both interventions reduced caregivers' accommodating behaviors, and reduction in family accommodation was one of the variables that mediated improvements in caregivers' distress and their perceived level of patient functioning. In sum, family accommodation is perceived as an important maintaining factor in eating disorders, but most current caregiver interventions do not focus on accommodation reduction.

Autism spectrum disorder

A small number of studies have examined the role of family accommodation in autism spectrum disorders. These have focused on individuals with autism spectrum disorders and comorbid anxiety or OCD. In a sample of 40 children with autism spectrum disorders and comorbid anxiety disorders, family accommodation was reported by 97.5% of parents, with providing reassurance being the most commonly reported accommodation. In a subset of these 40 children who completed a course of CBT for anxiety, parent report of family accommodation was reduced significantly after treatment.[52] In a randomized control trial of CBT for adults and adolescents with comorbid high functioning autism spectrum disorder and OCD, higher levels of pretreatment family accommodation predicted poorer treatment outcomes.[98] More recently, Griffiths et al.[99] examined autism spectrum disorder traits in a sample of 80 children with a diagnosis of OCD. Results showed that autism spectrum disorder traits were associated with greater functional impairment beyond OCD severity, and that family accommodation mediated the relationship between autism spectrum disorder traits and functional impairment.

Tic disorders

Using the Tic FAS, Storch et al.[100] examined the nature and correlates of family accommodation in a sample of 75 parents of children with tic disorders (Tourette's or chronic motor/vocal tics). Family accommodation was reported by 68% of parents and modifications to parents' environment was the most commonly endorsed accommodation. Family accommodation was not associated with tic severity. Family accommodation did, however, predict tic-related functional impairment beyond the effects of tic symptom severity, anxiety, depressive symptoms, and externalizing symptoms.

Hoarding disorder

Two studies have explored family accommodation by relatives of patients with hoarding disorder and found significant accommodation and links to functional impairment.[101],[102] Drury et al.[101] compared patients meeting Diagnostic and Statistical Manual of Mental Disorders (DSM-V) criteria of hoarding disorder to others, self-identified as collectors. Substantial functional impairment was found in both hoarding disorder individuals and their relatives. Hoarding disorder relatives reported significantly greater caregiver burden and accommodation of hoarding behaviors than relatives of collectors. A single case study has described treatment for hoarding aimed at reducing family accommodation of the hoarding symptoms.[103]

Somatoform disorder

A single case study that described family accommodation by a spouse of a patient with somatoform disorder has demonstrated improvement in symptoms after guiding the spouse to reduce the accommodating behaviors.[104]

Externalizing problems

Family accommodation has been linked to externalizing behaviors in OCD and anxious populations.[52],[105] This suggests that accommodation may also be prevalent in families of children diagnosed with externalizing disorders such as attention-deficit/hyperactivity disorder (ADHD), oppositional defiant disorder (ODD), disruptive mood dysregulation disorder, and conduct disorder. To date, no systematic investigations of family accommodation of these disorders have been published.

Posttraumatic stress disorder

A small number of studies have reported on partner accommodation in adults with PTSD. In one study, partner accommodation was associated with more severe symptoms and lower ratings of relationship satisfaction by both partners and patients.[106] In a randomized control trial of cognitive-behavioral conjoint therapy for PTSD, Fredman et al.[107] reported that partner accommodation levels did not change over treatment. Interestingly, partner accommodation had a positive prognostic value; higher levels of partner accommodation were associated with greater improvements in posttraumatic symptoms, depressive symptoms, and relationship satisfaction among patients. Campbell et al.[108] explored the bidirectional relations between accommodation and symptom severity using 2-week daily diaries of military servicemen with PTSD and their partners. Results showed that PTSD symptoms predicted next-day levels of accommodation in partners, but partners' accommodation predicted only next-day behavioral avoidance, and no other PTSD symptoms.

Failure to launch

Another intriguing area, in which family accommodation plays a critical role is that of adult children living at home who are highly dependent on parents, a phenomenon also known as “failure to launch.”[109] This chronic condition involves a pattern of reliance on parents to provide age inappropriate accommodations. These accommodations help the young adults in avoiding situations they find distressing, such as higher education and employment. Lebowitz et al.[110] examined changes in family accommodation and functional impairment in 27 young adults after parent training in nonviolent resistance.[111] Results showed reductions in parents' accommodating behaviors and improvements in patient's functioning in terms of independent residence and employment.


   Discussion Top


Research on family accommodation is growing rapidly and expanding to include an increasing number of psychiatric problems. Evidence continues to support the centrality of family accommodation in OCD and anxiety disorders, and new advances establish the relevance of family accommodation in a growing number of disorders. Across disorders, family accommodation is highly prevalent and has been associated with unfavorable clinical presentations, including more severe symptoms, greater functional impairment, poorer treatment outcomes, increased caregiver burden, and disruption to family functioning. Research has also begun to reveal more complex relations between variables associated with family accommodation, such as maternal anxiety, maternal empathy, and child's anxiety sensitivity.

The increased severity of clinical presentation associated with family accommodation has led to the development of interventions that include accommodation reduction as an explicit treatment goal, and to treatment studies, that focus on accommodation reduction as a primary treatment outcome. Some of these interventions were found feasible, acceptable, and effective in reducing family accommodation.

These empirical findings inform the development of a conceptual model of family accommodation. According to this model, distress related to the disorder leads to family accommodation. The accommodations alleviate the distress in the short-term but promote long-term avoidance and ongoing reliance on the accommodation for regulation and coping. These contribute to the maintenance and exacerbation of the symptoms, in turn causing more distress, and ultimately leading to further increases in family accommodation. [Figure 1] illustrates this conceptual model of family accommodation.
Figure 1: Conceptual model of family accommodation

Click here to view


Future research should continue to build on and expand current trends, including the exploration of family accommodation in additional psychopathologies. For example, research in eating disorders has focused on anorexia and bulimia, though accommodation is likely to appear in other eating disorders as well, such as in the newly defined DSM-V diagnosis of avoidant restrictive food intake disorder (ARFID). ARFID shares some clinical characteristics with anxiety disorders, as children with ARFID often experience anxiety related to possible outcomes of eating certain foods.[112] This anxiety leads to avoidance and restriction of food intake and may lead parents to accommodate. For example, a child with fear of choking on solid foods may be accommodated by parents provide food in liquid form. Treatment protocols have not yet been published for ARFID and incorporating accommodation reduction may be a promising direction. Family accommodation has been associated with depressive symptoms, externalizing problems, and irritability in OCD and in anxious children, but has not been explored directly in children or adults with depression, ODD, or ADHD without anxiety or OCD. Family accommodation has also been studied in comorbid anxiety and autism, but not in autism alone. These disorders are characterized by symptoms that may elicit accommodation by parents. For example, parents fearing an outburst may accommodate an irritable child by avoiding situations that tend to be associated with temper outbursts, and parents of a depressed child may provide all of the child's needs, enabling avoidance of basic functional tasks.

Research has established the role of parents as accommodating figures, and only a small number of studies have explored accommodation by other figures, such as siblings in anxiety disorders[48] and partners of adults with PTSD.[107],[108] Future research should follow these initial explorations and study accommodation by others including teachers and coaches. Although the school setting is central in children's lives, systematic research on accommodation in this setting is lacking.


   Conclusion Top


Research on family accommodation has steadily expanded in recent years, highlighting the centrality of this construct in the current understanding of psychopathology. Family accommodation has been studied in a growing number of disorders and shown to negatively impact the clinical presentation of these disorders. Findings underscore the importance of assessing family accommodation and addressing it during treatment. Future research should continue to explore the nature of family accommodation in psychopathology and to develop interventions aimed at its reduction.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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Correspondence Address:
Dr. Yaara Shimshoni
Yale Child Study Center, 230 S. Frontage Rd., New Haven, CT 06520
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DOI: 10.4103/psychiatry.IndianJPsychiatry_530_18

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