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Expert Rev Neurother. Author manuscript; available in PMC 2017 January 01.
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Published in final edited form as:

Expert Rev Neurother. 2016 ; 16(1): 45–53. doi:10.1586/14737175.2016.1126181.

Family accommodation in obsessive-compulsive and anxiety

disorders: a five-year update
Eli R. Lebowitz1,*, Kaitlyn E. Panza2, and Michael H. Bloch1
1Yale Child Study Center, Yale University, New Haven, CT, USA
2Department of Psychology, Arizona State University, Tempe, AZ, USA
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Abstract
Family accommodation describes changes that individuals make to their behavior, to help their
relative who is dealing with a psychiatric and/or psychological disorder(s), avoid or alleviate
distress related to the disorder. Research on family accommodation has advanced rapidly. In this
update we aim to provide a synthesis of findings from the past five years. A search of available,
peer-reviewed, English language papers was conducted through PubMed and PsycINFO, cross
referencing psychiatric disorders with accommodation and other family-related terms. The
resulting 121 papers were individually reviewed and evaluated and the main findings were
discussed. Family accommodation is common in obsessive-compulsive disorder (OCD) and in
anxiety disorders, and manifests similarly across these disorders. Family accommodation is
associated with more severe psychopathology and poorer clinical outcomes. Treatments have
begun to focus on the reduction of family accommodation as a primary therapeutic goal and
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finally, neurobiological underpinnings of family accommodation are beginning to be investigated.

Keywords
anxiety disorders; cognitive-behavior therapy; family accommodation; family members; obsessive-
compulsive disorder; treatment outcomes

The term family accommodation describes changes that individuals (e.g., parents, partners,
siblings, and children) make to their own behavior, to help their relative who is dealing a
psychiatric and/or psychological disorder(s), avoid or alleviate distress related to the
disorder. The first systematic, empirical study of family accommodation, published in 1995,
focused on the relatives of adults suffering from obsessive-compulsive disorder (OCD) and
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found that accommodation was both prevalent and extensive. [1] Examples of family
accommodation in OCD include engaging in excessive hand washing to help reduce

*
Author for correspondence: Tel.: +1 203 785 7905, Fax: +1 203 737 6994, ; Email: eli.lebowitz@yale.edu
Financial & competing interests disclosure
E. Lebowitz has been supported by grants from the National Institute of Mental Health (NIMH Career Development Award
K23MH103555) and NARSAD (NARSAD Young Investigator Award 21470). In addition to the grant funding listed above Dr.
Lebowitz receives royalties from John Wiley and Sons, and Vandenhoeck & Ruprecht. M Bloch has been supported by a grant from
the National Institute of Mental Health (Career Development Award K23MH091240). The authors have no other relevant affiliations
or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or
materials discussed in the manuscript apart from those disclosed.
 Lebowitz et al. Page 2

contamination fears experienced by a loved one, listening to repeated confessions of a

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relative who feels the need to constantly confess, providing excessive reassurance and/or
removing knives to reduce or alleviate the distress of a relative with aggressive or suicidal
obsessions.

Following the early studies in the 1990s, [1,2] subsequent research found family
accommodation to be associated with greater severity of OCD symptoms, [3–9] more
impairment related to OCD [3,9,10] and poorer treatment outcomes. [11,12] Family
accommodation was also found to be particularly prevalent among parents of children with
OCD, who forcefully demand accommodation or react with aggression to parents’ refusal to
accommodate. [13–17]

In recent years, the construct of family accommodation has made consistent gains,
expanding the breadth and depth of research about this topic. This includes broadening the
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construct beyond OCD, to study family accommodation in the range of anxiety disorders, as
well as in other disorders, such as autism. [18] Another key area of development has been on
intervention research. Treatment protocols for anxiety disorders and OCD increasingly
emphasize the reduction of family accommodation as a key therapeutic component.
Furthermore, research has started to focus on identifying underlying mechanisms that
contribute to the maintenance of family accommodation and help to explain individual
differences in family accommodation.

The current review aims to synthesize key findings from recent family accommodation
research over the past 5 years. This 5-year update expands on and extends findings from a
previous review that synthesized earlier work in this field, focusing exclusively on OCD.
[19] This review will thus both synthesize the most current research on family
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accommodation in OCD and extend the scope of the previous review by investigating the
presence and influence of family accommodation in children and adults with other
psychopathology.

Method
PubMed and PsycINFO were searched for relevant studies (between January 2010 and
September 2015) using the following search strategy: family related terms (e.g., family
accommodation, parents, family relations) were paired with terms related to
psychopathology in general and specifically to disorders, known to the authors to have been
studied in relation to family accommodation (obsessive-compulsive disorder, separation
anxiety, specific phobia, generalized anxiety disorder, social phobia, panic disorder, and
autism), and their subheadings (i.e., OCD, GAD, ASD, etc.). Limits imposed were for
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English language and peer-reviewed journals. No additional limits were set and the resulting
121 studies were reviewed individually for relevance to the scope of this review. Of these, 92
were determined to be of relevance and reviewed in more detail. After locating relevant
abstracts, the full articles were examined for findings that contributed to the understanding
of family accommodation, and its role with regard to the specific disorders listed above, over
the past 5 years. Ultimately, 57 studies contributed to the current review. As the goal of this

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review was to provide a synthesis of the current state of the field, rather than to present every
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possible datum, references were included based on the authors’ judgment.

Results
Family accommodation in OCD
Associations with symptom severity and impairment—Results from the current
literature have continued to support the importance of this construct regarding clinical
course and treatment outcomes in OCD and have confirmed and extended earlier findings. In
line with earlier research, several studies, including one meta-analysis with reports from
caregivers of both children and adults with OCD, confirmed that family accommodation is
quite common, with evidence suggesting that almost 90% of family members accommodate
symptoms to some degree, and that family accommodation is significantly and positively
associated with OCD symptom severity and impairment. [3,4,20–27] Compared with
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previous years, family accommodation has been increasingly included as a measure of

interest in cross-sectional, longitudinal and intervention research in OCD. Not only is it
being included more regularly as a measure in these studies, but there have been significant
advances in the measurement of family accommodation. One recent advance is the
development of the Family Accommodation Scale for Obsessive Compulsive Disorder—
Patient Version, intended for use with adults with OCD to obtain ratings directly from the
patient. [28]

Also consistent with previous studies, family accommodation has been shown to be reduced
after patients received treatment, to predict poorer treatment outcomes after going through
cognitive behavior therapy (CBT), and to be associated with worse trajectories over the
naturalistic clinical course of OCD. In a randomized clinical trial of family based CBT for
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OCD in children, OCD symptom improvement was preceded by reductions in family

accommodation. [29] In another clinical trial, which compared group CBT to medication for
childhood OCD, family accommodation was reduced after both treatment modalities. [30] A
baseline-controlled examination of intensive treatment for OCD also found that family
accommodation was reduced significantly from baseline to post-treatment and from post-
treatment to follow-up. [31] Furthermore, in a study of intensive treatment for pediatric
OCD with 78 youth, family accommodation was one of three significant predictors of
treatment outcome, along with symptom severity and gender. [32] Finally, in one study
which examined the effect of family accommodation on naturalistic outcomes in 94 adults
with OCD over a 1-year period, remission was associated with significantly lower family
accommodation and level of family accommodation at baseline was found to be a significant
predictor of time to remission. [33] Overall, this these data affirm the importance of family
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accommodation in OCD and its relevance to clinical course and treatment outcomes.

Caregiver burden and quality of life—Family accommodation places tremendous

burden on caregivers and negatively impacts their quality of life. A study comparing
caregiver burden among caregivers of adult patients with OCD and depression found that
caring for a relative with OCD was more disruptive to family interactions, had greater effects
on caregiver health and was associated with greater overall burden. [5] In a study of 50

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caregivers of OCD patients (68% parents, 16% significant others, and 16% siblings or
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grandparents), level of family accommodation was positively correlated with caregiver

burden, whereas caregivers who were not engaged in substantial family accommodation
reported only minimal burden. [34] Additionally, caregivers who reported closer
relationships with their affected relative also reported engaging in higher levels of family
accommodation. Torres et al. [35] examined caregiver burden in the relatives of 47 adults
with OCD. They identified six major sources of burden (e.g., interference in the caregivers’
personal life; perception of patients’ dependence on them), and all of which correlated
significantly with family accommodation scale scores. In yet another study focused on
ratings of quality of life of children with OCD, family accommodation was not directly
related to the child’s report of quality of life, but was negatively associated with parents’
reports of quality of life. [36,37] Quality of life was also found to be negatively associated
with family accommodation levels in relatives of adults with OCD. [33]
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Family accommodation can place a particularly high burden on caregivers when it is

forcefully imposed by the relative with OCD. Coercive disruptive behaviors (i.e., forceful
and sometimes aggressive, imposition of family accommodation on relatives) have been
found to be common in childhood OCD and to be associated with the severity of the OCD
symptoms. [14–16] Common forms of coercion include verbal and physical aggression,
pestering and badgering until accommodation is provided, and emotional blackmail (e.g.,
accusing the caregivers of not loving or caring if they do not accommodate). A recent
investigation of clinical and family correlates of coercive disruptive behaviors in childhood
OCD found them to be associated with OCD severity, anxiety, oppositionality and
hyperactivity, but not depression or inattentiveness. [17] Coercive-disruptive behavior was
associated with family accommodation and related to parental distress, but not related to
dimensions of family style. Furthermore, that same study, family accommodation was found
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to mediate the link between coercive disruptive behaviors and OCD symptom severity.

Studies of temper outbursts and dysregulated emotion in youth with OCD have also
indicated that externalizing symptoms play a significant role in exacerbating accommodation
and contributing to caregiver burden. Storch et al. [13] studied rage in youth with OCD and
found that the presence of clinically significant rage was associated with higher levels of
family accommodation and that family accommodation mediated the link between rage
outbursts and severity and impairment related to the OCD symptoms. McGuire et al. [38]
examined emotional dysregulation in 144 youth with OCD and found that dysregulated
youth experienced more family accommodation and that this relation was not explained only
by increased OCD symptom severity. Using another conceptual framework, Yanagisawa et
al. [39] assessed 256 adults with OCD in Japan and found that in approximately half the
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cases patients exhibited what the researchers described as “involved behaviors.” These
“involved behaviors” included things such as forcing relatives to participate in rituals or to
assist in compulsive avoidance. Patients were more likely to be female, have more severe
symptoms and respond less well to treatment.

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Family accommodation in anxiety and other disorders

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Family accommodation in anxiety disorders

In recent years, an area of development has been the investigation of family accommodation
within other forms of psychopathology other than OCD, with the largest emphasis placed on
anxiety disorders. The first study of family accommodation in anxiety disorders was
completed by Lebowitz et al., [40] who introduced the Family Accommodation Scale
Anxiety (FASA), based on items from the Family Accommodation Scale, originally
developed for use in OCD. This study examined reports of family accommodation from 75
parents of clinically anxious children. Anxiety disorder diagnoses were based on DSM IV
TR criteria or the parent-report Screen for Child Anxiety Related Emotional Disorders and
included, generalized anxiety disorder, separation anxiety, specific phobias, social phobia
and panic disorder with or without agoraphobia. Accommodation was found to be highly
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prevalent across the anxiety disorders with the highest levels of accommodation reported by
parents of children with separation anxiety. Like in OCD, higher levels of accommodation
were found to be associated with more severe child anxiety symptoms. FASA was found to
have good psychometric properties including internal consistency, convergent and divergent
validity and a factorial structure similar to that reported in the original Family
Accommodation Scale. [40] The two-factor structure reflects parental participation in
anxiety driven behaviors and modification of family routines and schedules, aimed at
helping the child avoid or alleviate anxiety-related distress. FASA is the most widely used
instrument for assessing family accommodation in child anxiety disorders. Additional
reports confirmed the prevalence of family accommodation in anxiety disorders, and its link
to anxiety symptom severity, and increased functional impairment. [41–44]

In one study, Lebowitz et al. [44] compared family accommodation in childhood anxiety
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disorders to family accommodation in childhood OCD, as well as to a control sample of

normal children without anxiety disorders or OCD. Family accommodation was found to be
highly prevalent in anxiety disorders and OCD with overall similarities in the reports of both
groups and no significant differences in levels of participation, modification or total
accommodation levels. Both clinical groups reported significantly higher levels of family
accommodation compared to the nonclinical control group. Additionally, the clinical groups
reported greater distress associated with the need to accommodate the child than did mothers
in the control sample. This study also confirmed the positive correlation between levels of
accommodation and severity of anxiety symptoms in the child. In yet another study of
family accommodation in pediatric anxiety, Jones et al., [42] using FASA, found that family
accommodation mediated the relation between maternal anxiety and child anxiety.
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Family accommodation in anxiety disorders can manifest in various forms, often linked to
the specific areas and triggers of the affected relative’s anxiety. For example, the parents of a
child with separation anxiety disorder may sleep next to the child or refrain from leaving her
with a babysitter; relatives of a child with social anxiety disorder might avoid having guests
over at the house or may speak in place of the child in various social situations; a child with
agoraphobia may need to be accompanied everywhere; a child with generalized anxiety
disorder might seek excessive reassurance and ask endless repetitive questions; or the family

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of a child with a specific phobia might avoid any contact with, or even mention of, the object
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of the child’s specific fear.

Thompson-Hollands et al. [45] presented parents of children with anxiety disorders a

checklist of 20 examples of accommodation and asked them to rate the extent of personal
and family interference associated with each endorsed item. Almost all parents endorsed at
least one form of accommodation, with the most frequently endorsed items involving
allowing children to eat special meals and answering questions directed to the child.
Disruptions to parents’ work and leisure schedules (i.e., staying home from work or
returning early from an outing) and allowing the child to sleep in the parents’ bed were
associated with particularly high interference levels.

Benito et al. developed [46] a clinician-rated measure of family accommodation in

childhood anxiety disorders (Pediatric Accommodation Scale) and reported results similar to
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those that have been reported using parent-rated measures, such as FASA. Nearly all parents
endorsed at least some level of family accommodation with the most frequent form of
accommodation being providing reassurance to the child. [40,44] Siblings were also found
to engage in accommodation of the clinically anxious child and overall families reported
substantial distress related to the family accommodation. Johnco et al. [47], using the
Pediatric Accommodation Scale, found that the presence of rage outbursts in anxious
children were associated with a more severe clinical profile, including higher levels of
family accommodation.

Most research on family accommodation, in both OCD and anxiety, has focused on asking
the caregivers about their accommodation behaviors and has not directly queried the affected
relative about his or her perception of family accommodation. This gap was addressed in a
study by Lebowitz et al. [43] who developed a child-rated version of FASA (FASA-CR) and
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used it to compare and integrate children’s reports with those provided by their mothers.
Fifty children with primary anxiety disorders, and their mothers, participated in the study.
Overall, good agreement existed between child and mother ratings, although mothers
reported significantly higher levels of accommodation than did the children. Maternal
anxiety was found to moderate the association between child and mother ratings, such that
the correlation was stronger in more anxious mothers. In addition to mirroring the items on
the FASA, the child-rated FASA-CR also includes three items aimed at probing children’s
beliefs and attitudes relating to family accommodation. Most children indicated that they
experienced the accommodation as being helpful in reducing their anxiety in the short term,
but fewer than half believed that they would be less anxious in the longer term if the
accommodation continued. Most children did not however agree that their parents should
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accommodate less. Comparing child and parent ratings of accommodation in child anxiety
disorders is particularly important in light of the commonly reported discrepancies found
between parent and child ratings of the child’s anxiety symptoms. [48]

Only one study to date has investigated family accommodation of adults with anxiety
disorders (excluding OCD). [49] This study was conducted using an online survey, with 380
undergraduate students as the participants. Symptom accommodation was found to be
positively associated with the severity of social anxiety symptoms and degree of functional

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impairment. Anxiety sensitivity, or the belief that somatic symptoms of anxiety pose a threat
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to the individual, was also correlated with reports of family accommodation. Furthermore,
accommodation was found to mediate the relation between the social anxiety symptoms and
functional impairment. Despite methodological limitations, including the use of an online
survey and uncertain clinical characterization, this study suggests that family
accommodation in anxiety disorders is not limited to pediatric patients and should be
investigated more thoroughly in adults.

Family accommodation in other disorders

Family accommodation of anxiety symptoms has been examined among parents of children
with autism spectrum disorders. [18] Participants were 40 children, diagnosed with an
autism spectrum disorder and exhibiting clinically significant anxiety, and their parents.
Levels of family accommodation were similar to those reported among parents of anxious
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children without autism spectrum disorders and here too the most common form of
accommodation was providing reassurance. In a subset of parents who completed measures
before and after the youth received a course of CBT for anxiety, a significant reduction in
family accommodation was found after treatment. In another study, Russel et al. [50]
assessed family accommodation in a clinical trial of CBT for OCD in adolescents and adults
with autism spectrum disorders and found that higher levels of family accommodation
predicted poorer treatment outcomes. Both these studies focused specifically on the
comorbid OCD or anxiety symptoms of people with an autism spectrum disorder; however,
no studies have yet been published investigating family accommodation of the specific
symptoms of autism spectrum disorder.

Hoarding disorder is a relatively recent diagnostic entity in DSM-5, previously categorized

under OCD. Two studies reported on family accommodation by relatives of patients with
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hoarding disorder and found significant accommodation and links to functional impairment.
[51,52] Finally, another study investigated family accommodation by partners of adults with
post-traumatic stress disorder. [53] Accommodation correlated positively with partners’
ratings of patients’ symptom severity and negatively with rating of relationship satisfaction
by both partners and patients.

Interventions for reducing family accommodation

With the growing interest in family accommodation in OCD and other forms of
psychopathology, such as the anxiety disorders, there has been an increased emphasis on
reducing family accommodation as a means of enhancing or achieving therapeutic gains.
Compared to earlier treatment protocols for childhood anxiety and OCD, which
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acknowledged the importance of encouraging parents not to facilitate avoidance but only
placed a minor emphasis on the issue, recent protocols have made reducing accommodation
a more central therapeutic goal. Approaches aimed at reducing family accommodation
emphasize the behavioral and learning model of family accommodation. In this model, the
patterns of family accommodation are negatively reinforced for both the patient and the
accommodating relative. For the patient, family accommodation provides temporary relief
from distress related to the disorder, and as a consequence, behaviors that lead to family

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accommodation are reinforced. For the accommodating relative, family accommodation

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provides relief from distress related to seeing the patient suffering or to the patients’
behaviors (e.g., persistent requests for accommodation, aggressive outbursts, etc.) and thus
the accommodation is reinforced. Table 1 summarizes interventions targeting family
accommodation

The treatment protocol that has placed the strongest emphasis on reduction of family
accommodation is the Supportive Parenting for Anxious Childhood Emotions program
(SPACE). [58] SPACE is a 10- to 12-week parent-based intervention for childhood anxiety
and OCD that does not require child participation and can be delivered as a standalone
treatment or alongside child treatment. The primary focus in SPACE is on parent change
rather than on direct child change. Parents are guided to reduce unhelpful accommodation as
a way to strengthen the child’s ability to cope independently. By focusing on parent change,
the treatment can be implemented even in cases where the child is reluctant or completely
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averse to engaging in therapy directly. SPACE emphasizes systematic monitoring and

reduction of family accommodation and provides parents with tools to do so in a supportive
manner, by teaching them to acknowledge the child’s genuine struggle, while also conveying
belief in the child’s ability to tolerate distress. SPACE is unique in that the reduction of
family accommodation is hypothesized to be a central mediator of treatment outcomes. Two
open trials of SPACE have been published, one in OCD [59] and one in anxiety disorders.
[54] Both open trials supported the feasibility and acceptability of SPACE and provided
preliminary indications of its efficacy as a treatment for childhood OCD and anxiety
disorders. A larger randomized controlled trial is currently underway.

Freeman and Garcia [57] developed an intervention for early childhood OCD which stresses
the issue of family accommodation. Treatment proceeds over 14 weeks and includes both
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child-directed work and parent-directed work. Children learn tools to manage and reduce the
symptoms of OCD, while parents participate in sessions focused on improving family
functioning, including identifying instances of family accommodation. A web-based
modification of this approach was developed and piloted by Comer et al. [67] Parents and
children participated in the treatment via teleconferencing. Preliminary results from a small
series of cases showed promise regarding symptom improvement and global severity
reductions. In yet another study, Lewin et al. [56] published a pilot trial of a family based
behavioral treatment also targeting OCD in young children. The family work included an
emphasis on family accommodation, which was embedded into the treatment protocol, and
the authors attributed the effects of the intervention in part to this targeting of family
accommodation.
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Interventions targeting family accommodation in relatives of adults with OCD and anxiety
have also been increasingly studied. Thompson-Hollands et al. [55] conducted a randomized
trial of a brief adjunctive intervention aimed at reducing family accommodation in the
family members of adult OCD patients. Patients (18 in total) received cognitive behavioral
treatment with or without two adjunct sessions with family members. Family sessions
included an emphasis on the reduction of family accommodation. Patients whose family
members received the two family sessions improved more than those whose relatives did

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not. Furthermore, reduction in family accommodation accounted for a significant amount of

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variance in OCD symptoms after treatment.

Another study examined accommodation of insecure romantic partners using a modified

version of the family accommodation scale, with an emphasis on reassurance seeking (e.g.,
“How often did you reassure your partner about the status of your relationship?”) [60].
Participants were 21 couples, with one highly insecure partner in each dyad. Insecurity in the
relationship was exhibited through behaviors such as the need for excessive reassurance of
the partner’s love or suppression of personal concerns because of a fear of “rocking the
boat” and angering the partner. The researchers found that 2 weeks after a single-session
psychoeducational intervention, focused on relationship-based anxiety, there was a reduction
in reassurance seeking on the part of the anxious partner, as well as in the accommodating
behaviors of the other partner. Another pilot trial aimed at reducing accommodation within
romantic relationships explored a couple-based behavioral treatment for OCD. [61]
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Preliminary results showed reductions in OCD symptoms and improvements in relationships

functioning.

Biological mechanisms in family accommodation

Various mechanisms have been proposed as the neurobiological strata underlying family
accommodation. Norman et al. [62], in a recent review of accommodation in anxious
children, emphasized two neurobiological systems that potentially modulate family
accommodation: the cortico-limbic neural network and the oxytocinergic system. The
amygdala is consistently implicated in fear and anxiety. It thus has been hypothesized that
hyperactivation of the amygdala may be related to overly protective parental behavior.
Support for this hypothesis comes indirectly through research showing that maternal
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distress, in reaction to viewing one’s child exhibiting a distressed facial expression, is

associated with neuronal activation in the amygdala and hippocampus. [63]

The oxytocinergic system is implicated both in the regulation of stress and anxiety, and in
the modulation of close interpersonal behavior. [64] Family accommodation of anxiety
disorders represents the intersection of anxiety regulation and close interpersonal behavior
as the individual with the anxiety disorder looks to loved ones for aid in avoiding or
regulating anxiety and the relatives are propelled to step in and provide accommodation to
their distressed loved one. Peripheral oxytocin is the first biomarker to be directly examined
in the context of family accommodation. Lebowitz et al. [65] examined salivary oxytocin
levels from 50 clinically anxious youth and reported a significant negative correlation
between salivary oxytocin levels and degree of reported family accommodation. This novel
finding is the first indication of the biological basis of family accommodation and additional
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research is needed to replicate and extend these findings.

Discussion
Family accommodation is a common and important feature of OCD and anxiety disorders
and may be present in many other disorders as well. Family accommodation predicts
symptom severity and functional impairment with more accommodation being associated

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with worse clinical presentation. Engaging in excessive family accommodation, whether

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voluntarily or under duress through forceful demands from the affected relative, is
associated with lower quality of life and increased burden for caregivers. The reduction in
quality of life and relationships, the increased caregiver burden and the link between greater
family accommodation and worse treatment outcomes, all point to the importance of
reducing family accommodation as a crucial therapeutic goal.

Interventions for anxiety disorders and OCD are increasingly focused on the reduction of
family accommodation as a treatment objective and as a possible mediator of treatment
outcomes. Preliminary indications from clinical trials are promising, and point to feasibility,
acceptability and potential efficacy of these approaches. Larger efficacy trials are needed to
confirm these initial findings. Reducing family accommodation allows for work delivered
through caregivers rather than directly with patients and may open up the possibility of
treatment even in cases of patients who decline to participate in typical patient-delivered
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therapy. Two trials have been published in which caregivers (parents) attended treatment
alone and positive results were achieved. [54,59] A related question pertains to timing and
sequencing, as no studies have yet examined when, in the treatment sequence, family
accommodation should be addressed for optimal outcomes. Reducing accommodation prior
to CBT may be useful in raising motivation for treatment and setting the stage for a more
effective treatment trajectory. Conversely, working with individual CBT first may make the
process of reducing accommodation easier as patients receive psychoeducation and some
therapeutic gains are achieved. Furthermore, in addition to studies examining targeting
family accommodation as a part of the sequence of CBT, it may also be interesting to
explore how including reducing family accommodation as part of other interventions, such
as interpersonal therapy or the interpersonal and social rhythm therapy, influences outcomes.
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Future research should continue to explore the question of family accommodation in

additional areas of psychopathology. Depressed patients, for example, may rely on
caregivers for many forms of accommodation including providing basic needs, helping to
avoid unwanted social situations or engaging in unhelpful ruminative conversations. People
with bipolar disorders may also depend on caregivers for various forms of accommodation,
related to symptoms of depression, such as those mentioned above, or to symptoms of
mania. Externalizing disorders may also elicit other forms of accommodation as caregivers
work to prevent potential triggers for negative behaviors. Two studies addressed the issue of
accommodation in autism spectrum disorders. These studies focused on anxiety [50] or
OCD [18] symptoms in patients with autism, but core symptoms of autism may also elicit
family accommodation and should be further investigated. For example, caregivers may
engage in accommodation of repetitive and restrictive behaviors, or avoid making changes
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that trigger negative consequences. A key question in this regard will be differentiating
helpful accommodation that scaffolds the patient and has an overall positive impact from
unhelpful accommodation that predicts worse functioning and more severe symptoms.

An exciting and burgeoning area of development is on the biological mechanisms underlying

or maintaining family accommodation. Only one study has provided empirical evidence for
a possible biomarker of family accommodation. Salivary oxytocin levels in clinically
anxious children predicted family accommodation, with lower oxytocin levels associated

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with more family accommodation. [65] In addition to replicating this finding, future studies
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should examine whether the association holds for adult patients as well as children and
whether accommodation of other disorders shows a similar correlation with salivary
oxytocin. Caregiver peripheral oxytocin levels would also be of interest and may provide a
more complete understanding of the biology of the interpersonal dynamics of family
accommodation. An important question that rises from this finding, and other potential
biomarkers of accommodation, is whether these markers might moderate treatment
outcomes. A better understanding of these mechanisms would help to more accurately
identify those families most in need of interventions aimed at reducing family
accommodation.

Expert commentary
The past 5 years have seen an expansion of the construct of family accommodation within
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OCD and its application to areas of psychopathology other than OCD, in particular within
anxiety disorders. Current data suggest that, as in OCD, more family accommodation is
associated with more severe anxiety and greater impairment. It remains to be seen, however,
whether family accommodation is a reliable predictor or moderator of treatment outcomes in
anxiety disorders. Interventions that target family accommodation are beginning to flourish,
but more systematic randomized controlled trials are still needed.

Five-year view
Family accommodation is clearly a key construct for a range of childhood and adult
disorders. Further research in the coming years should focus on additional testing of
interventions for reducing family accommodation, as well as continuing to explore the issue
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of family accommodation in even more disorders of childhood and adulthood. Research is

only now beginning to explore biological underpinnings of family accommodation and
should continue to focus on understanding these mechanisms and identifying relevant
biomarkers.

References
Papers of special notes have been highlighted as:

• of interest

•• of considerable interest

1••. Calvocoressi L, Lewis B, Harris M, et al. Family accommodation in obsessive-compulsive

disorder. Am J Psychiatry. 1995; 152(3):441–443. This is the first study of family
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accommodation in OCD. [PubMed: 7864273]

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Key issues
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• Family accommodation is common in childhood anxiety disorders as well as

obsessive–compulsive disorder (OCD).

• Family accommodation is common in adults with OCD and is starting to be

recognized in adults with anxiety, as well.

• Family accommodation causes significant distress and interference to

consanguines of affected probands.

• Family accommodation is positively associated with symptom severity and

functional impairment.

• Family accommodation in anxious children is associated with salivary oxytocin

levels.
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• Treatment aimed at reducing family accommodation shows promise as

standalone or adjunct treatments.

• Future research of family accommodation should focus on more randomized

controlled trials to study intervention effects, better understanding of
neurobiological underpinnings and more studies into linkages with other mental
disorders such as autism.
Author Manuscript
Author Manuscript

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Table 1

Interventions for reducing family accommodation.

Emphasis on family
Intervention Target diagnosis Key points Duration accommodation Clinical trials
Lebowitz et al.

SPACE Program [54,59] Anxiety disorders; OCD Parent-based, children need not be directly 10–12 sessions Major 2 open trials, RCT in progress with
involved. CBT as comparison

Adjunctive parent-training [55] OCD Brief intervention for parents, added to E/RP 2 sessions Major 1 RCT with treatment as usual as
comparison

Psychoeducation for Relationship- Relationship-based anxiety Psychoeducation session 1 session Major 1 open trial
Based Anxiety [60]

Family-based ER/P [56] Early childhood OCD Parents and children attend together 12 sessions Partial 1 RCT comparing to treatment as
usual

Family-based CBT [57,66] Early childhood OCD Combination of E/RP for youth and behavior 12 sessions Minor 2 RCTs with relaxation as control
management for parents condition. 1 open trial

Family-based CBT [67] Early childhood OCD Similar to Freeman et al.— Delivered over 14 sessions Minor Case series (n = 5)
Internet

CBT: Cognitive behavior therapy; E/RP: Exposure and response prevention; RCT: Randomized controlled trial; SPACE: Supportive Parenting for Anxious Childhood Emotions.

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