International Journal of Clinical and Health Psychology (2019) 19, 218---227

International Journal
of Clinical and Health Psychology
www.elsevier.es/ijchp

ORIGINAL ARTICLE

Family involvement and treatment for young children

with Obsessive-Compulsive Disorder: Randomized
control study
Ángel Rosa-Alcázar a , Ana I. Rosa-Alcázar b,∗ , Pablo J. Olivares-Olivares b ,
José L. Parada-Navas c , Encarnación Rosa-Alcázar b , Julio Sánchez-Meca d

a
Department of Psychology, Universidad Católica de Murcia, Spain
b
Department Personality, Assessment & Psychological Treatment, Universidad de Murcia, Spain
c
Faculty of Education, Universidad de Murcia, Spain
d
Department of Basic Psychology & Methodology, Universidad de Murcia, Spain

Received 14 March 2019; accepted 6 June 2019

Available online 15 July 2019

KEYWORDS Abstract()
Obsessive-Compulsive Background/Objective: The aim of this paper was to evaluate the diferential efficacy of cog-
Disorder; nitive behavioral family treatment in children under 8 years of age with Obsessive-Compulsive
Family involvement; Disorder (OCD) in the reduction of obsessive-compulsive responses and secondary outcomes in
Young children; three treatment conditions: (a) Treatment of parents and child, (b) Treatment of mother and
Cognitive-behavioral child, and (c) Treatment of mother.
Therapy; Method: Forty-four children with obsessive-compulsive disorder, aged 5.2-7.9 years old and
Experiment their parents, were randomized to one of three groups in a 1:1:1 ratio. Seventy-five percent
was male and 100% Caucasian (White-European). Treatment involved 12 individual sessions of
is Cognitive-Behavioral Family-Based Treatment delivered.
Results: The three conditions produced clinical improvements in post-test and follow-up in the
primary (symptom severity OCD) and secondary outcomes. The results showed no intergroup
differences in variables related to OCD symptom severity, although statistically significant dif-
ferences were found in groups in Internalizing and Externalizing problem, mother and fathers
accomodation.
Conclusions: The most efficient condition was that including a greater number of family mem-
bers even when there was high family accommodation. The direct involvement of the child in
the psychological treatment was important in achieving better results.
© 2019 Asociación Española de Psicologı́a Conductual. Published by Elsevier España, S.L.U. This
is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/
by-nc-nd/4.0/).

∗ Corresponding author. Department Personality, Assessment & Psychological Treatment, Faculty of Psychology, Espinardo Campus, Murcia,

30100, Spain
E-mail address: airosa@um.es (A.I. Rosa-Alcázar).
https://doi.org/10.1016/j.ijchp.2019.06.001
1697-2600/© 2019 Asociación Española de Psicologı́a Conductual. Published by Elsevier España, S.L.U. This is an open access article under
the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
Amily involvement in pediatric OCD 219

PALABRAS CLAVE Implicacion familiar y tratamiento de niños pequeños con Tastorno

Trastorno Obsesivo-Compulsivo: un estudio aleatorizado
Obsesivo-Compulsivo;
Resumen
Acomodación
Antecedentes/Objetivo: El objetivo fue analizar la eficacia diferencial de un tratamiento
familiar;
cognitivo-conductual para la reducción de obsesiones y compulsions y otras medidas secundarias
Niños pequeños;
en niños menores de 8 años con Trastorno Obsesivo-Compulsivo (TOC). Las tres condiciones de
Terapia
tratamiento fueron: (a) Tratamiento a los padres y al niño, (b) Tratamiento a la madre y al niño,
cognitivo-conductual;
(3) Tratamiento a la madre.
Experimento
Método: Cuarenta y cuatro niños, con edades comprendidas entre 5,2---7,9 años, y sus padres
fueron asignados al azar a uno de los tres grupos, ratio de 1:1:1. El 75% eran varones y el 100%
españoles. El tratamiento consistió en 12 sesiones individuales de Terapia familiar cognitivo-
conductual.
Resultados: Las tres condiciones de tratamiento produjeron mejorías clínicas en el postest y
seguimiento en las medidas primarias (severidad TOC) y secundarias. Los resultados mostraron
que no existían diferencias entre los grupos en las variables relacionadas con síntomas de severi-
dad, mientras que sí se hallaron en problemas internalizantes y externalizantes, y acomodación
de la madre y del padre.
Conclusiones: La condición más eficiente fue la que incluía mayor número de miembros famil-
iares, sobre todo cuando había una mayor acomodación familiar. La participación directa del
niño en el tratamiento psicológico fue importante para lograr mejores resultados.
© 2019 Asociación Española de Psicologı́a Conductual. Publicado por Elsevier España, S.L.U.
Este es un artı́culo Open Access bajo la licencia CC BY-NC-ND (http://creativecommons.org/
licenses/by-nc-nd/4.0/).

Several studies report early onset Obsessive-Compulsive and maintaining achievements (Fernández-Sogorb, Inglés,
Disorder (OCD) indicating that children are often under diag- Sanmartín, Gonzálvez, & Vicent, 2018; Kreuze, Pijnenborg,
nosed for various reasons. Among these are that parents de Jonge, & Nauta, 2018; Stewart et al., 2017).
consider symptoms of this behavior as simply transitory. In The first study exclusively with young children with OCD
addition, some children might hide these symptoms from (4-8 years olds) was carried out by Freeman et al. (2008).
their parents. Both children and parents are unable to assess Freeman et al. (2014) conducted a study with 127 children
the frequency of the rituals and intensity of the distress. (4-8 years), reported on the efficacy of CBFT in a multicen-
It has also been shown that a high percentage of adults ter RCT, where CBFT was superior to family-based relaxation
suffering OCD have reported that their symptoms began in training in reducing obsessive-compulsive symptoms. Lewin
childhood or adolescence (Geller & March, 2012). et al. (2014) used the CBFT with children 3-8 years, more
Treatment options for children with OCD include Cog- focused on EPR, compared to treatment in Muscle Relax-
nitive Behavioral Therapy (CBT), pharmacotherapy or both ation and Education in positive emotions. The effect size in
(Geller & March, 2012; Selles et al., 2018). The American reducing obsessive-compulsive symptoms was high (d = 1.8).
Academy of Child and Adolescent Psychiatry Committee on Clinical response percentage was 58.8% (mean CY-BOCS ≤
Quality Issues (2012) considers that the standard of care 12) in CBFT. In addition, improvements were obtained in
in very young children with OCD is Cognitive-Behavioral other secondary measures. Other researchers have reported
Family-Based Treatment (CBFT), which includes the same a series of single case studies, obtaining positive results in
core components of CBT with significant family involve- very young children (Comer et al., 2017) even when treat-
ment. Parent involvement in treatment for young children ment was performed on the Internet (Aspvall el al., 2018).
with OCD is of particular importance for several reasons. Rosa-Alcázar et al. (2017) presented the results of the com-
First, the absence or little introspection of minors regarding parison of two intervention (mother and child and only
obsessions and compulsions hinders their involvement in mothers) of a program developed and adapted to young chil-
treatment and motivation for change (Bornas, Torre-Luque, dren (Rosa-Alcázar, 2012a). Some limitations of this study
Fiol-Veny, & Balle, 2017; Chou, DeSerisy, Garcia, Freeman, were its reduced sample size (n = 10), the need to increase
& Comer, 2017). Second, high levels of distress, anxiety and exposure sessions and the failure to include measures to
conflict have been observed in relatives of children with evaluate the accommodation of both parents.
OCD (Ho, Dai, Mak, & Liu, 2018; Peris et al., 2012). Third, The main aims of the study was: (1) to test differen-
behavioral family accommodation can have important tial efficacy of a modified family intervention program
implications in the course and maintenance of a child’s (Rosa-Alcázar, 2012a, 2012b, 2012c) for children with OCD
OCD (Lebowitz, 2016; Wu & Storch, 2016). Finally, the fact between 5-8 years old in the primary outcome (CY-BOCS)
that the parents participate as co-therapists and carry out through three treatment conditions (a) Treatment of
the exposure tasks at home allows us to come closer to parents and child, (b) Treatment of mother and child, and
ideal treatment as this contributes both to generalizing (c) Treatment of mother. (2) To analyze the percentage
220 Á. Rosa-Alcázar et al.

of participants in post-test and in follow-up who met the fashion prior to initiating the study. Considering their years
clinical remission criteria, defining it as a reduction in the of experience, we can assume that the both clinicians
Total CY-BOCS. (3) To examine the differential outcome exhibited similar competence. Half of the patients in the
on secondary measures (Global assessment, Child problem group were treated by each of the two therapists. Forty
behavior, Family Accomodation). four families whose children met inclusion criteria were
offered a discount (−30%) off the treatment price if they
Method participated in the study.

Participants Instruments

Participants were 44 children (75% males) between 5.20- Anxiety Disorders Interview Schedule for DSM-IV-Child and
7.90 years old (M = 6.66, SD = 0.72) recruited from eight Parents (ADIS-IV-C/P; Silverman, Albano, & Barlow, 1996).
public and private clinics in Murcia (n = 3), Castilla-La Man- This interview was administered to the children and parents.
cha (n = 2) and Valencia Regions (n = 3) of Spain from 2012 It has been widely used, demonstrating validity and inter-
to Dicember 2018. Five clinics ---psychological consultations- rater in samples with very young children.
were private and three public (Mental Health Units for Chil- Children’s Yale Brown Obsessive Compulsive Scale (CY-
dren and Youth). All were caucasian (white-european) and BOCS; Scahill et al., 1997). This interview was jointly
urban. The inclusion criteria were: (a) primary diagnosis administered to children and parents to assess overall OCD
of OCD according to DSM-IV-TR, DSM-5 criteria (American symptom severity. The CY-BOCS yields an Obsessions Sever-
Psychiatric Association, 2000, 2014); (b) a clinical severity ity score, Compulsion Severity and Total score. This scale
rating of ≥16 in Childreńs Yale-Brown Obsessive-Compulsive has shown excellent psychometric properties in very young
Scale (CY-BOCS; Scahill et al., 1997); and (c) the parents children. A Total score greater or equal to 16 is considered
having available to actively participate in the therapeu- clinically significant. In this study Cronbach́s alpha was .87
tic process. Upon study entry, all parents of participating Childreńs Global Assessment Scale (CGAS; Shaffer et al.,
children were married and cohabitating. Exclusion criteria 1983). The CGAS assesses global functioning (psychological,
included: (a) comorbid autism spectrum disorder, attention social and occupational) across a 0---100 scale with higher
deficit hyperactivity disorder, psychotic symptoms, devel- scores representing better functioning.
opmental disorder that would affect the child’s ability Child Behavior Checklist (CBCL; Achenbach, 1991). The
to participate in treatment, or intellectual disability; (b) CBCL includes 118-items to assess behavioral and emotional
concurrent psychological therapy; and (c) medications not problems in children (externalizing and internalizing prob-
stable for > 8 weeks. Sample characteristics are presented lems) during the prior 6 months. This measure has shown
in Table 1. adequate internal consistency, convergent validity, and sen-
sitivity and specificity. In this study, Cronbach́s alpha for
internalizing and externalizing problems was high (␣ = .89;
Procedure
␣ = .90, respectively).
Family Accomodation Scale (FAS; Calvocoressi et al.,
The study met ethical standards according to the Declaration
1999). Items are rated according to a 5-point Likert scale
of Helsinki and has been approved by the Ethics Commit-
from 0 (Never) to 4 (Extreme). This instrument has shown
tee of the University of Murcia (Spain). All families provided
strong internal consistency and convergent validity. It is
written informed consent. The recruitment flow is shown
considered the gold standard in measuring family accom-
in Figure 1. The procedure was as follows: (1) Informa-
modation (Francazio et al., 2016). In this study, Cronbach́s
tion from eight clinics about study performance (from 2012
alpha was .90.
to 2018); (2) the first and the second authors carried out
Satisfaction Scale (Rosa-Alcázar, Iniesta-Sepúlveda,
an unstructured clinical interview (DSM-IV-TR and DSM-5).
Parada-Navas, & Rosa-Alcázar, 2012). This self-report
Two specialized child-psychologists administered the Ini-
measure was developed by the research team to assess
tial Assessment Interviews Involved (ADIS-P/C; Silverman,
satisfaction with the treatment program. It includes 4-items
Albano, & Sandín, 2003) and the CY-BOCS (Scahill et al.,
rated in a 4-point Likert scale from 1 (very unsatisfied)
1997) a parents. (3) The children with CY-BOCS≥ 16 met
to 4 (very satisfied) regarding the following issues: (1)
inclusion criteria and formed part of the program.
Satisfaction about treatment, (2) Satisfaction with number
Assessments were done in three time points (pre-
and duration of sessions, (3) Satisfaction with therapist,
treatment, post-treatment and 3-month follow-up period)
and (4) Satisfaction with program outcome.
by two clinicians specialized in childhood anxiety disorders
Adherence treatment: weekly homework accomplish-
blinded to group assignment. Sessions were attended by
ment and attendance at treatment sessions.
both parents and children. After obtaining written informed
consent from the parents, families were randomized to
treatment conditions at a 1:1:1 ratio using pre-prepared, Treatment
sealed envelopes. The randomization sequence was gener-
ated by a research assistant using a computer and blocking The treatment protocol was based on other programs on best
assignments as a function of the child age and sex and age of practice guidelines and research evidence. This included
the parents. Treatment was implemented by two clinicians workbooks for parents and children (Rosa-Alcázar, 2012a,
specialized in OCD (over 15 years of experience). Clinicians 2012b, 2012c). Treatment is CBFT involving 12 weekly ses-
were trained to administer CBT protocol in the uniform sions each running for 1 hr. and 1 booster session (3 months
Amily involvement in pediatric OCD 221

Table 1 Demographic and diagnostic information by group.

Characteristics Group 1(n = 14) Group 2(n = 15) Group 3(n = 15)
Age (mean ± SD) 6.73 ± 0.76 6.69 ± 0.75 6.57 ± 0.68
Gender n (%)
Males 11 (78.6) 11 (73.3) 11 (73.3)
Females 3 (21.4) 4 (26.7) 4 (26.7)
Duration of disorder(mean ± SD) 0.62 ± 0.17 0.66 ± 0.12 0.66 ± 0.20
Comorbid diagnosis n (%)
Separation anxiety 2 (14.3) 3 (20) 3 (20)
Dark phobic 3 (21.4) 4 (26.7) 4 (26.7)
Animals phobic 1 (7.1) 3 (20) 1 (6.7)
Mood 1 (7.1) 0 (0) 1 (6.7)
Comorbid diagnosis n (%)
One 5 (83.3) 6 (75) 4 (66.7)
Two 1 (16.7) 2 (25) 2 (33.3)
Age mother (mean ± SD) 36.28 ± 3.54 36.80 ± 3.28 36.40 ± 3.14
Age father (mean ± SD) 36.78 ± 3.78 38.53 ± 2.85 37.93 ± 4.13
Mother education n (%)
Elementary 0 (0) 1 (6.7) 0 (0)
High school 5 (37.5) 6(40) 4 (26.7)
College/university 9 (74.3) 8 (53.3) 11 (73.3)
Father education n (%)
Elementary 0 (0) 1 (6.7) 0 (0)
High school 4 (28.6) 6 (40) 4 (26.7)
College/university 10 (71.4) 8 (53.3) 11 (73.3)
Primary obsessions
Hoarding/saving 2 (14.3) 2 (13.3) 2 (13.3)
Magical/superstitions 2 (14.3) 2 (13.3) 3 (20)
Agressive 7 (50) 9 (60.0) 7 (46.7)
Contamination 8 (57.1) 8 (53.3) 9 (60)
Miscellaneous 8 (57.1) 5 (33.3) 6 (40)
Primary compulsions
Cheking/reassurance 7 (50) 9 (60) 8 (53.3)
Repeating 11 (78.6) 11 (73.3) 11 (73.3)
Washing/cleaning 8 (57.1) 8 (53.3) 9 (60)
Involving other person 11 (78.6) 10 (66.7) 11 (73.3)
Hoarding/saving 2 (14.3) 2 (13.3) 1 (6.6)
Note. Group 1: Parents and child; Group 2: Mother and child; Group 3: Mother; SD: Standard Deviation.

post-treatment). The workbook for children contained child- and supervised by the mother. In this condition, the father
friendly examples, and the concept of OCD was presented was required to read the workbooks with the aim of being
metaphorically (i.e., an annoying ball that the child tries able to collaborate in the reduction of responses in Family
to throw away, but which repeatedly comes back). Ten ERP Accommodation, the control of problems at home and the
sessions were applied. A summary of the protocol can be reinforcement of exposure to fear stimulus or in the worst
requested from the corresponding author. Treatment condi- case not to obstruct the performance of the mother.
tions were: Group 3: Treatment mother. All the participants were
Group 1: Treatment parents and child. Parents and child mothers. These attended the 12 weekly sessions with the
carried out the sessions. Exposure tasks at home had to psychologist. Treatment was the same but the time invested
be guided and supervised by parents. These reinforced the in the child focussed on instructing and training the mother
achievements of the child. All applied techniques in the (Role-playing) on what to be done at home with the child
intervention were described in manuals provided to par- (as in consultation). As in the condition 2, the father was
ents. required to read the workbooks to collaborate with the
Group 2: Treatment mother and child. In this condi- mother in reducing responses to Family Accomodation as in
tion, all the participants were mothers. The mother and the problematic conduct of the child and reinforcing expo-
child carried out the sessions. ERP at home were guided sure tasks.
222 Á. Rosa-Alcázar et al.

Assessed for eligibility

(N= 346) recruited from 8 public and private clinics

Declined to participate (n = 7
Reasons:
-Not interesed in research study (n =7) )

Excluded (n= 302):

- Not meeting OCD
diagnostic principal
(n=261)
- Age > 8.5 (n=3) Randomized
- Diagnosis of ADHD y ASD (n=44)
(n=21)
- Medication not stable
(n=10)

Intervention Intervention Intervention

Parents and Child Mother and Child* Mother*(n=15)
(n=14) (n= 15)

Analysed (n = 14) Analysed (n = 15) Analysed (n = 15)

Pretest (n= 14) Pretest (n= 15) Pretest (n= 15)
Postest (n= 14) Postest (n= 15) Postest (n= 15)
Follow-up (n= 14) Follow-up (n= 15) Follow-up (n= 15)

Figure 1 CONSORT Flow diagram of study development.

Note: OCD: Obsessive-compulsive disorder; ADHD: Attention deficit hyperactivity disorder; ASD: Autism spectrum disorder.
*All couples decided the mother and not the father would participate in the training with the therapist.

Data analysis produced. SPSS Statistic 22.00 was used for statistical anal-
ysis.
Chi-square and one-factor ANOVA were used to exam-
ine potential group differences in clinical and demo-
graphic (age/gender) variables at pretreatment. Two-factor Results
repeated-measures ANOVA was conducted to test the effect
of the treatments as a function of time (pre-treatment, post- Analysis of group differences at pre-treatment
treatment, and 3-month follow-up) and group (treatment
parents-child; treatment mother-child; treatment mother). The three groups were equivalent with regard to all demo-
Results of Greenhouse-Geisser correction were reported graphic variables. In particular, no statistically significant
Mauchly’s test of sphericity was significant. Statistically sig- differences were found in childreńs age (p = .820), motheŕs
nificant time by condition interactions were followed up age (p = .910), fatheŕs age (p = .430), childreńs gender in
by Sidak’s post-hoc comparisons. Cohen’s ds (standardized group (p = .930), duration of disorder (p = .755), fatheŕs
mean differences) were calculated to estimate the magni- education (p = .560), and motheŕs education (p = .590). In
tude of the between-groups differences. To interpret the addition, the baseline scores for the outcome variables
magnitude of Cohen’s ds, they were compared with the did not differ significantly between the groups: CY-BOCS
meta-analyses on the effectiveness of clinical psychology total score (p = .954), CY-BOCS obsessions (p = .213), CY-BOCS
treatments (Rubio-Aparicio, Marín-Martínez, Sánchez-Meca, compulsions (p = .671), CBCL-Externalizing (p = .870), CBCL-
& López-López, 2017). Internalizing (p = .062), FAS-mothers (p = .608), FAS-fathers
To allow comparisons with previous studies (Piacentini (p = .266), and CGAS (p = .832). Similarly, no differences
et al., 2011), the clinical remission was defined as a reduc- were found between groups regarding presence of comorbid
tion in Total CY-BOCS in four levels: Remitted (CY-BOCS disorders: Dark phobia (p = .93), Separation anxiety disorder
< 11), Subclinical (11-15), Moderate (16-24) and Severe (> (p = .901), Animal phobia (p = .430) and Mood (p = .581). See
24). Group comparisons of remission status were performed Table 1.
using ␹2 or likelihood ratio tests. Clinically significant change The most common obsessions were contamination
was based on Jacobson and Truax (1991). All participants (56.8%) and aggressive obsessions (52.3%). The compulsions
were included in the analyses, not missing cases being most frequent were involving any person (79.5%), repeating
Amily involvement in pediatric OCD 223

Table 2 Means and standard deviations CY-BOCS and secondary outcomes.

Measure Assessment point Group 1 n = 14 Mean ± SD Group 2 n = 15 Mean ± SD Group 3 n = 15 Mean ± SD
CY-BOCS Total Pre-treatment 22.86 ± 3.05 22.47 ± 4.37 22.87 ± 4.24
Post-treatment 10.14 ± 1.41 10.67 ± 2.02 11.80 ± 1.78
Follow-up 8.79 ± 0.89 8.80 ± 1.21 10.27 ± 1.03
CY-BOCS Obsessions Pre-treatment 9.64 ± 1.39 10.80 ± 2.11 10.13 ± 1.64
Post-treatment 4.71 ± 0.61 4.73 ± 0.88 5.67 ± 0.90
Follow-up 4.21 ± 0.58 4.27 ± 0.59 4.87 ± .52
CY-BOCS Compulsions Pre-treatment 13.00 ± 2.48 12.20 ± 2.21 12.60 ± 2.50
Post-treatment 5.43 ± 0.94 5.73 ± 1.16 6.13 ± 0.99
Follow-up 4.57 ± 0.51 4.80 ± 0.94 5.40 ± 0.63
CGAS Pre-treatment 50.71 ± 6.75 49.33 ± 4.95 49.67 ± 7.18
Post-Treatment 69.64 ± 6.64 70.33 ± 3.51 65.00 ± 4.63
Follow-up 75.71 ± 4.75 74.67 ± 5.50 70.67 ± 1.76
CBCL-Internalizing Pre-treatment 22.29 ± 2.61 20.47 ± 2.26 20.60 ± 1.72
Post-Treatment 10.07 ± 1.94 13.47 ± 3.52 16.60 ± 2.85
Follow-up 8.93 ± 1.27 12.27 ± 2.86 14.80 ± 2.24
CBCL-Externalizing Pre-treatment 21.14 ± 2.63 21.00 ± 3.08 21.53 ± 2.83
Post-Treatment 10.64 ± 1.45 12.27 ± 3.41 17.27 ± 2.52
Follow-up 9.36 ± 1.39 10.47 ± 1.68 15.07 ± 2.69
FAS Mother Pre-treatment 22.36 ± 2.13 23.33 ± 3.02 23.00 ± 2.70
Post-treatment 11.93 ± 1.44 14.07 ± 2.55 17.73 ± 3.01
Follow-up 9.79 ± 0.80 11.87 ± 2.10 15.07 ± 2.81
FAS Father Pre-treatment 18.00 ± 2.26 19.40 ± 2.03 19.53 ± 3.23
Post-Treatment 9.36 ± 1.95 14.60 ± 2.67 17.00 ± 3.21
Follow-up 8.29 ± 1.68 11.80 ± 1.93 15.20 ± 2.78
Note. Group 1: Parents and child; Group 2: Mother and child; Group 3: Mother; CY-BOCS: Childreńs Yale-Brown Obsessive-Compulsive
Scale. CGAS: Children’s Global Assessment Scale. CBCL: Child Behavior Checklist, FAS: Family Accommodation Scale.

(75%), cleaning/washing (56.8%), and checking/reassurance conditions in CBCL-Internalizing (p < .001), CBCL-
(54.5%). Externalizing (p < .001), FAS-mother (p < .001),
and FAS-father (p < .001), being marginally sig-
nificant in CGAS (p = .058). Within-group analyses
Primary outcome analysis
revealed significant decreases in the three treat-
ment conditions in all outcomes, with the largest
Table 2 presents the means and standard deviations for
effect sizes when comparing pre-treatment with
the three treatment conditions through the three assess-
follow-up.
ment points on the CY-BOCS. The results of the mixed
Post-hoc comparisons showed significant differences
ANOVAs shows a statistically significant time effect for the
between Group 1 vs. Group 3 in post-treatment and follow-
CY-BOCS total, Obsessions, and Compulsions scores, with
up in all secondary outcome measures (Table 3). Significant
a significant improvement in obsessive-compulsive symp-
differences were also found between Group 2 vs. Group 3
toms across assessment points, with a large percentage
in post-treatment and follow-up in all outcome measures,
of variance accounted for (2 ≥ .93). There were also
except for FAS-father post-treatment (p = .54). The com-
significant group differences in interaction in CY-BOCS
parison between Group 1 vs. Group 2 reached significant
Obsessions (p = .021).
differences for CBCL Internalizing in the post-treatment
Table 3 shows significant differences between Group 1 vs.
(p = .008) and follow-up (p = .001), for FAS-mother in the
Group 3 in post-treatment and follow-up in CY-BOCS Obses-
follow-up (p = .033) and for FAS-father in the post-treatment
sions. In this variable a better result was found from Group
and follow-up (p < .001). All effect sizes were of large mag-
1 vs. Group 3 in post-treatment (d = 1.24).
nitude (Rubio-Aparicio et al., 2017).

Secondary outcome analysis

Remission
Table 2 presents the means and standard deviations for
the three treatment conditions and assessment points The CY-BOCS was chosen as the primary outcome variable as
on secondary outcomes. Mixed ANOVAs showed a signif- it is a more objective, reliable, and valid instrument com-
icant time effect improvement in all outcomes across pared to others. Clinically significant change at an individual
assessment points, with a large proportion of variance level was defined as two standard deviations below the
accounted (2 ≥ .887). In addition, statistically significant mean at posttreatment (criteria based on Jacobson & Truax,
differences were found among the three treatment 1991). Based on these criteria 100% of the sample evidenced
224 Á. Rosa-Alcázar et al.

Table 3 Sidak post-hoc comparisons and effect size.

Measure Assessment point Group D* p 95% CI (Ll , Lu ) Cohen’s d
CY-BOCS Obsessions Post-treatment 1-2 0.02 .999 -0.73, 0.77 0.03
1-3 0.95 .009 0.20, 1.71 1.24
2-3 0.93 .009 .019, 1.67 1.06
Follow-up 1-2 0.05 .992 -0.47, 0.57 0.10
1-3 0.65 .010 0.13, 1.17 1.20
2-3 0.60 .017 0.09, 1.11 1.09
CBCL-Internalizing Post-treatment 1-2 3.40 .008 .75, 6.04 1.18
1-3 6.53 < .001 3.88, 9.18 2.66
2-3 3.13 .014 .53, 5.74 1.02
Follow-up 1-2 3.34 .001 1.26, 5.41 1.49
1-3 5.87 < .001 3.80, 7.95 3.19
2-3 2.53 .011 .50, 4.57 0.98
CBCL-Externalizing Post-treatment 1-2 1.62 .275 -.79, 4.04 0.61
1-3 6.62 < .001 4.21, 9.04 3.19
2-3 5.00 < .001 2.63, 7.37 1.67
Follow-up 1-2 1.11 .376 -.75, 2.97 0.73
1-3 5.71 < .001 3.85, 757 2.67
2-3 4.60 < .001 2.77, 6.43 2.05
FAS mothers Post-treatment 1-2 2.14 .069 -.12, 4.40 1.02
1-3 5.81 < .001 3.54, 8.07 2.43
2-3 3.67 .001 1.45, 5.89 1.31
Follow-up 1-2 2.08 .033 .14, 4.03 1.29
1-3 5.28 < .001 3.34, 7.23 2.52
2-3 3.20 < .001 1.29, 5.11 1.31
FAS fathers Post-treatment 1-2 5.24 < .001 2.77, 7.72 2.29
1-3 7.64 < .001 5.17, 10.15 2.85
2-3 2.40 .054 .03, 4.83 0.81
Follow-up 1-2 3.51 < .001 1.48, 5.54 1.94
1-3 6.91 < .001 4.88, 8.95 2.98
2-3 3.40 < .001 1.40, 5.40 1.42
Note. Group 1: Parents and Child; Group 2: Mother and Child; Group 3: Mother; CY-BOCS: Childreńs Yale-Brown Obsessive-Compulsive
Scale. CGAS: Children’s Global Assessment Scale, CBCL: Child Behavior Checklist, FAS: Family Accommodation Scale. D = Mean difference
between the two conditions. * Positive Ds indicated that the group compared in first place reached greater improvements than the group
appearing in second place. Ll and Lu : lower and upper confidence limits of 95% confidence intervals around the mean difference.

clinically significant change from pre to posttreatment on Treatment adherence and satisfaction
the CY-BOCS.
Nonstatistically significant differences among the three Treatment adherence was evaluated in terms of weekly
conditions in the pre-treatment were found, 2 (2) = 3.73, homework accomplishment and attendance at treatment
p = .155. Statistically significant differences were found sessions. The percentage of homework completion was very
between the three treatment conditions on severity cat- high (Group 1 = 95.6%; Group 2 = 93.8% y Group 3 = 93.7%), no
egories in the post-treatment, ␹2 (2) = 7.90, p = .019, and differences being found among them. Regarding attendance
follow-up LR(2) = 13.65, p = .001, indicating that all partici- at treatment sessions, two mothers (one from Group 2 and
pants moved from moderate and severe to in remission or one from Group 3), and one father (Group 1) missed one
subclinical categories. Group 1 showed the highest remis- session for personal reasons.
sion rates (71.4%) compared to 40% and 20% of Groups 2 As for results on Satisfaction Scale, statistically sig-
and 3, respectively. In follow-up, the remission rates were nificant differences were found regarding the treatment
as follows: Group 1 (100%), Group 2 (93.3%) and Group 3 format, F(2, 43) = 23.25, p < .001, and frecuency and dura-
(53.3%). Post hoc comparisons performed in post-treatment tion of sessions, F(2, 43) = 35.08, p < .001. There were no
and follow-up showed Group 1 exhibiting larger remission differences in satisfaction with the therapist and program
rates than Group 3 in post-treatment (51.4%, ␹2 (2) = 7.74, outcomes (p > .05). Post-hoc comparisons on ‘‘Satisfaction
p = .015) and follow-up (46.7%; ␹2 (2) = 11.33, p = .003). In with the format’’ showed significant diferences between
follow-up, Group 2 showed a significantly greater remission Group 1 vs. Group 3 (p < .001) and Group 2 vs. Group 3
rate than Group 3 (40%, ␹2 (2) = 6.72, p = .030). (p = .001). Post-hoc comparisons on frequency and duration
Amily involvement in pediatric OCD 225

of sessions were higher in Group 1 vs. Group 3 (p < .001) and Regarding clinical significance, the percentages of par-
higher in Group 2 vs. Group 3 (p < .001). ticipants in remission was high across groups, outstanding
being the Parents and child Group, in post-treatment
Discussion and conclusions (71.4%), similar to others such as Freeman et al. (2014) and
superior to those obtained by Lewin et al. (2014), in follow-
The main objective was to evaluate the differential efficacy up at three months. Therefore, our findings lead us to affirm
of cognitive behavioral family treatment for children ages 4 that the psychologist’s direct work with the child is essential
to 8 with OCD (Rosa-Alcázar, 2012a, 2012b, 2012c). The pro- in the treatment of OCD.
tocol used was effective in reducing obsessive-compulsive Analysis of results of the secondary variable ‘‘CBCL-
symptoms and secondary outcomes in post-treatment and Internalizing’’ revealed that the Parents and child Group
follow-up. The three ways of implementation produced clin- obtained the best results, followed by the Mother and
ical improvements and were well-accepted by parents and child Group; In the ‘‘CBCL-Externalizing’’ the same ten-
children, being the first study to carry out these three dency could be observed, but no differences were found
types of implementation. These results are similar to those between the first groups. These results lead us to con-
observed in previous studies highlighting the importance of sider that in cases where children present internalizing or
ERP and family involvement in these interventions (Comer externalizing problems, their inclusion in direct treatment
et al., 2017; Freeman et al., 2014; Lebowitz, 2016; Lewin with the therapist could help to reduce these behaviors.
et al., 2014). This may be because observation of the psychologist’s per-
The active inclusion of parents in treatment, acting formance could enhance the security of the parents, by
as co-therapists, has not only allowed the reduction of exposing themselves to ‘‘Mastery Modeling‘‘, in addition to
‘‘Family accommodation’’, but also to maintain and gen- the fact that the parents could thus better apply ERP (Amer-
eralize achievements (between contexts: from the clinical ican Academy of Child and Adolescent Psychiatry Committee
context to the home, among people: non-attending parents; on Quality Issues, 2012; Cancilliere et al., 2018; Lebowitz,
and over time: increasing improvements in follow-up mea- 2016; Wu & Storch, 2016).
sures). This study provides follow-up measures only found at Results in Family accommodation indicated that all
these ages in the study by Lewin et al. (2014), maintaining groups improved in the reduction of the’’FAS-fathers and
the same improvement trend in both investigations. This is mothers‘‘, therefore, the different formats are effec-
in line with what is recommended, not only for OCD, but also tive. These results coincide with others provided on CBFT
for other psychological disorders (Taboas, McKay, Whiteside, (Freeman et al., 2014; Lebowitz, 2016; Lewin et al., 2014),
& Storch, 2015). These results agree with those provided by although these studies did not separately analyze the mea-
different meta-analytic studies focused on children and ado- sures of’’Accommodation of the father and the mother‘‘,
lescents (Choate-Summers et al., 2008, Farrell, Schlup, & therefore, as already indicated, analysis carried out in the
Boschen, 2010; Lebowitz, 2016). In particular, Rosa-Alcázar present study is novel. In FAS-mother, the Parents and child
et al. (2015) found that 34% of children improved more when Group and Mother and child Group achieved best results
parents were trained as assistants in managing their chil- both in posttest and follow-up. Regarding the behaviors of
dren’s dysfunctional behaviors and performing ERP at home. father accommodation, best results were obtained in the
Results on the differential efficacy of the three interven- Parents and child group compared to other groups, confirm-
tion formats lead us to conclude that although there were ing the need that, in order to increase improvement, the
no intergroup differences in the variables related to the involvement of both parents in the application of treatment
severity of OCD (CY-BOCS), there were some in the following is necessary. These data suggest that, despite improving the
secondary variables: ‘‘CBCL-Internalizing/Externalizing’’ both parentś accommodation (even if neither the father nor
and ‘‘Family-Accommodation father and mother’’. Never- the child attended treatment), the best condition seems to
theless, to understand the scope of the changes among be that where all attend.
the groups as regards time, the values ??of the interac- Likewise, from the perspective of clinical implications,
tion were analyzed, verifying that in ‘‘CY-BOCS Obsessions’’ we can conclude that the implementation of interventions
there was a significant difference between the Parents and focused on parents of young children with OCD is needed
child Group, and Mother and child Group compared to the not only to overcome their problem but also to reduce fam-
Mother Group. These data indicated that groups including ily accommodation, whose existence would constitute an
children in direct interventions with the therapist were more almost insurmountable barrier for effective application of
effective than those that did not. psychological treatment. The direct involvement of the child
These findings are complemented by those found in the in the treatment is relevant, both in increasing their motiva-
study of clinical significance showing that all participants, tion and to encourage and intensify the security of parents in
moved from moderate and severe to remission or subclinical the handling of problematic behaviors that may arise during
categories of OCD severity, although outstanding was the treatment in non-clinical contexts (Pascual-Vera & Belloch,
highest percentage reached in the Parents and child Group 2018)
compared to Mother Group in post-treatment, maintaining There are several study limitations. First, the small
this improvement in follow-up. All in line with what was and homogenous characteristics of participants in terms of
pointed out by Freeman et al. (2014) and Rosa-Alcázar et al. their sociodemographic and clinical profile limit the gener-
(2015) on the importance of the involvement of parents in alizability of our results. Second, follow-up outcomes are
intervention with children and adolescents, therefore it is insufficient, i.e., they have a provisional nature and follow-
expected that high parental involvement will be followed by up is required at 6, 12 and 24 months to more rigorously
better results, with a high probability. assess the scope of achievement stability.
226 Á. Rosa-Alcázar et al.

As future perspectives, we believe it is required to DeSerisy, M., Chou, T., Sánchez, A., Khanna, M., Franklin, M.,
continue increasing the number of subjects with this treat- García, A., & Freeman, J. (2017). Internet-delivered, family-
ment in its different formats. Likewise, the study of more based treatment for early-onset OCD: A pilot randomized
predictors should be included, increasing sample size; trial. Journal of Consulting and Clinical Psychology, 85, 178.
studying relationships between the role of’’Parent Accom- http://dx.doi.org/10.1037/ccp0000155
Farrell, L. J., Schlup, B., & Boschen, M. J. (2010).
modation’’ and different educational styles, couple relation
Cognitive---behavioral treatment of childhood
shit problems and other clinical variables such as depression obsessive---compulsive disorder in community-based clini-
and parental anxiety. cal practice: Clinical significance and benchmarking against
efficacy. Behavior Research and Therapy, 48, 409---417.
Fernández-Sogorb, A., Inglés, C. J., Sanmartín, R., Gonzálvez, C.,
Funding & Vicent, M. (2018). Validation of the Visual Analogue Scale for
Anxiety-Revised and school refusal across anxiety profiles. Inter-
This article was supported by the Ministerio de Economía national Journal of Clinical and Health Psychology, 18, 264---272.
and Competitividad of the Spanish Government (Projects http://dx.doi.org/10.1016/j.ijchp.2018.07.002
No.PSI2016-78185-P). Francazio, S. K., Flessner, C. A., Boisseau, C. L., Sibrava, N.
J., Mancebo, M. C., Eisen, J. L., & Rasmussen, S. A. (2016).
Parental accommodation predicts symptom severity at long-
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