Despite the recognized importance of family accommodation (Storch et al., 2007) and of disruptive behaviours (Langley, Lewin, Bergman, Lee, & Piacentini, 2010) for the course of paediatric obsessive compulsive disorder (OCD), little has been published about children using disruptive and coercive behaviours as a means of imposing accommodation on their surroundings (Lebowitz, Omer, & Leckman, 2011; Lebowitz, Vitulano, & Omer, 2011). In an attempt to assess the frequency with which experts encounter such behaviours, and to determine some key aspects of the phenomenon as well as beliefs about how best to formulate and treat it, we conducted a worldwide survey among OCD experts. The survey was distributed via email to 511 corresponding authors of papers on OCD and to the approximately 4500 members of the Association for Behavioral and Cognitive Therapies (ABCT) via that organization’s list-serve. Overall, 110 experts from 27 countries completed the survey. The respondents included primarily psychologists and psychiatrists (52.7% and 40.9%, respectively).
The behaviours of interest were described as follows: Coercive/Disruptive behaviours refer to situations in which a child or adolescent with OCD attempts to impose rules and prohibitions on others, particularly family members, because of his or her disorder. Coercion can include accommodation of rituals or forced participation in them, demands to perform actions instead of the child or to refrain from certain behaviours because they cause the child with OCD distress, and compulsive behaviours on the part of the child that negatively impact on others.
All but one of the responders (i.e.99%. see Figure 1(a)) reported encountering the coercive and disruptive behaviours described in at least some cases of paediatric OCD and most reported that they characterize at least one quarter of all of their paediatric OCD cases. Most responders reported that physical violence and/or the threat thereof were exhibited in some of the cases.
The primary targets of the coercive and disruptive behaviours were reported to be mothers, identified as a target by 95% of all responders (Figure 2). Fathers (57%) and siblings (49%) were also frequent targets. Most responders (58%) endorsed the view that these behaviours were most frequently restricted to the immediate home environment although in some cases the behaviours were seen in extended family settings as well as with peers.
Most responders (64%) agreed that coercive behaviours were, more often than not, associated with increased family accommodation and all report that this is true in at least some cases. Parent training was the intervention identified by most responders (86%) as being the most effective intervention strategy for reducing coercive behaviours. Cognitive behavioural therapy (CBT), (53%) and medication (17%) were also commonly endorsed as being effective treatments. Treatment modality notwithstanding, most responders felt that the majority of cases responded to treatment so that the coercive behaviours largely disappeared.
The large majority (88%) agreed with the view that these coercive/disruptive behaviours are better seen as secondary to the OCD rather than as representative of a primary disruptive behaviour disorder. In addition, the majority (69%) reported that in only a minority of cases (<25%) did the coercive/disruptive behaviours persist after the OCD showed clear signs of improvement.
The OCD symptom dimension most commonly reported by the experts to be associated with coercive behaviours was contamination/washing (67%). Other dimensions commonly identified were symmetry/ordering (42%) and harm/checking (39%). Less commonly indicated were hoarding and sexual and/or religious obsessions and related checking compulsions. Stressful life events were not reported to be a significant factor impacting the coercive behaviours.
The survey revealed few differences between psychiatrists and psychologists, apart from the finding that psychologists (64%) were more likely than psychiatrists (40%) to endorse CBT as an effective strategy for reducing the coercive behaviours (χ2(1) = 5.765, p < 0.05) whereas psychiatrists (29%) were more likely than psychologists (9%) to endorse medication treatment (χ2(1) = 7.218, p < 0.01).
Coercive/disruptive behaviours may be an important factor in devising treatment plans for cases of paediatric OCD. The responders in this survey agree that the coercive behaviours often significantly contribute to an increased level of family accommodation. In a recent study, family accommodation was the only family related variable to predict treatment outcomes, with higher levels of accommodation predicting poorer results irrespective of whether cognitive behavioural therapy or medication was the modality employed (Garcia et al., 2010).
The survey responders’ strong endorsement of parent training emphasizes the need for parent training programs that specifically target these coercive/disruptive behaviours in order to provide parents with tools for avoiding or reducing accommodation. The finding that siblings are frequent targets of the coercive behaviours also highlights the importance of addressing such behaviours as it emphasizes the potentially negative impact that one child’s OCD may have on other children in the home.
The suggestion by the responders that the disruptive behaviours disappear when OCD symptoms recede supports approaching them within the context of OCD rather than as a comorbid condition that must be treated before the OCD can be alleviated. Assessing the presence and severity of coercive behaviours with tools such as the Coercive Disruptive Behavior Scale for Pediatric OCD (CD-POC) (Lebowitz, Omer, et al., 2011) may be helpful in planning successful treatment strategies for these families.