by Noah Chase Berman, PhD
RESEARCH MADE POSSIBLE BY THE IOCDF RESEARCH GRANT FUND
A child, age eight, is playing in his backyard on a summer afternoon. A few garden tools are leaning up against a painted shed nearby. As the boy plays, his eye catches the sun’s reflection off his mother’s pruning shears. Suddenly a thought crosses his mind: “Those look sharp. I might stab my sister with them.” Although the boy has had strange thoughts before, this thought really scares him and he can’t get it out of his head. He loves his baby sister and doesn’t want to hurt her. In tears, he runs to find his mother. Our research focuses on what happens next.
The research in this article was made possible by a $30,000 grant awarded to Dr. Berman by the IOCDF and funded entirely by donors to our Research Grant Fund. To learn more about how you can contribute to the next discovery, please visit iocdf.org/research.
Past studies have closely examined how obsessive-compulsive symptoms in children can be influenced by family behaviors (e.g., Berman, Jacoby, Sullivan, Hoeppner, Micco, & Wilhelm, 2018). Accommodating a child’s obsessive-compulsive symptoms (e.g., buying extra soap for a child who compulsively washes her hands), or attempting to control a child’s intrusive thoughts, have been shown to be ineffective and potentially harmful. However, very little research has focused on the internal experiences and thought processes of parents when they are confronted with a child’s intrusive thoughts.
Let’s consider the case example described on the cover. The young boy has run inside and found his mother. Crying, he explains his fears about harming his sister. The boy’s mother will interpret his intrusive thoughts in some way (e.g., this thought is harmless; this thought is dangerous) and may recommend some course of action to help him feel better. We know that interpreting one’s own thoughts as dangerous or overly significant amplifies distress, often leads to compulsive behaviors (i.e., cognitive model of OCD; Rachman 1997; 1998), and can even make obsessive-compulsive symptoms (OCS) worse (e.g., Abramowitz, Khandker, Nelson, Deacon, & Rygwall, 2006). But does this pattern hold true for the parent’s interpretation of their child’s thought? Can parents’ interpretations of their children’s intrusive thoughts help explain why certain children experience persistent and worsening OCS, or develop OCS in the first place? What makes these questions so important is that they all pertain to changeable elements of the family environment, an area where further research is both critically needed (National Research Council and Institute of Medicine, 2009; Society for Prevention Research, 2004), and has the potential to make a dramatic impact on the lives of children who struggle with interfering OCS or full-blown OCD.
AN OVERVIEW OF THE STUDY
We anticipated that parents who appraise a child’s normally occurring intrusive thoughts (e.g., son’s unwanted image of stabbing his sister) as threatening (e.g., because my son had this thought, he must want to do it) will experience an increase in uncomfortable emotions (e.g., anxiety, shame). As a result, we predicted that parents will offer directives to the child to neutralize the obsessional content (e.g., demand her son go hug his sister and/or pray). This sequence of events would unintentionally model an unhelpful, or maladaptive, interpretation of, and reaction to, a harmless passing thought. We believe this process may set the foundation for the child’s development of “OC features,” which include: (a) obsessional beliefs that are present in a range of contexts extending far beyond the original intrusive thought; (b) obsessive-compulsive-related interpretation biases (e.g., interpreting one’s intrusion as dangerous); and (c) OCS. If our predictions are supported, and parents’ threatening interpretations of intrusive thoughts are associated with children’s OC features, then clinicians can directly target this process in parents and potentially prevent children from developing a harmful relationship with naturally occurring intrusive thoughts.
Hypothesis 1: Based upon past research and clinical observations, we hypothesized that parents who interpreted their child’s intrusive thoughts as more threatening would offer more maladaptive strategies for managing the unwanted thought (e.g., require the child to ritualize or suppress the passing intrusion).
Hypothesis 2: We also predicted that children’s OC features would be more severe if their parents interpreted their intrusive thoughts as threatening.
To test our hypotheses, we recruited nearly 30 families in which the OCS of both the child (between ages 8-18) and their primary caregiver fell across a spectrum of severity from mild to severe. We did so because research demonstrates that OCS occurs across a continuum in the population (e.g., Abramowitz, Fabricant, Taylor, Deacon, McKay, & Storch, 2014; Voltas, Hernández-Martínez, Arija, Aparicio, & Canals, 2014), and because including participants with a range of symptoms — even those that are not severe enough to receive a diagnosis — is recommended when studying how to prevent the onset or worsening of psychological illnesses (e.g., Ginsburg, Drake, Tein, Teetsel, & Riddle, 2015; Rishel, 2007).
Participants were first administered diagnostic interviews and several self-report questionnaires. Next, eligible families were invited to attend a testing session and complete behavioral tasks. More specifically, after orienting the child and parent to the study procedure and receiving their written consent, two research assistants guided the child and parent into separate rooms. The child was then asked to think about a personalized intrusive thought — “I will physically hurt [insert the child’s beloved relative] even though I don’t want to” — using a laboratory paradigm for studying obsessions that has been shown to be safe (Berman, Abramowitz, Wheaton, Pardue, & Fabricant, 2011; Berman, Calkins, & Abramowitz, 2013). To enhance the intensity of the child’s intrusive thought, the research assistant asked the child to (a) record the intrusion on a notecard in black ink, (b) “think about the event happening” for 30 seconds, and (c) read the personalized thought aloud. Although all children were given permission to skip this task and it was made clear that there would be no consequences for doing so, no participants opted out of this component of the study. Next, we assessed how children interpreted the thought by asking them to rate the likelihood of the feared event (e.g., hurting the relative) happening simply because they had thought about it.
Once children completed their ratings, the notecard with the intrusive thought was delivered to the parent and they were asked to complete two self-report questionnaires in response to the child’s intrusion. The first questionnaire assessed the degree to which they interpreted their child’s thought as threatening. The second questionnaire listed common strategies for managing intrusive thoughts (e.g., pray; suppress; accept it) and parents were asked to endorse the strategies they would recommend their child use to manage this intrusion.
WHAT DID THE STUDY FIND?
To test Hypothesis 1 (that parents who interpret a child’s intrusion as more threatening would recommend more maladaptive strategies to manage the intrusive thought) we first labeled the strategies as either adaptive (i.e., helps the child recognize that intrusive thoughts are normal and acceptable) or maladaptive (i.e., leads the child to perceive their intrusive thoughts as dangerous or overly significant) using the feedback of approximately a dozen OCD experts. Notably, the experts agreed that (a) identifying the thought as an intrusion, (b) accepting that these thoughts sometimes occur, and (c) reminding children that intrusive thoughts are normal, were all adaptive responses. On the flip side, recommending (a) increasing attention towards the thought, (b) inflicting physical pain (e.g., snap a rubber band on wrist when an intrusive thought occurs), (c) punishment, (d) thought stopping, (e) suppressing the thought, or engaging in (f) mental or (g) behavioral compulsions were reliably considered maladaptive responses. Supporting our prediction, we found that parents who interpreted their child’s thought as more threatening recommended more maladaptive, but not adaptive, strategies for managing intrusions.
To test Hypothesis 2 (that a more threatening interpretation of their child’s thought would be associated with more severe OC features in the child) we conducted another set of statistical tests. We looked at the children’s obsessive beliefs (using the Obsessional Beliefs Questionnaire-Child Version; Coles, Wolters, Sochting, de Haan, Pietrefesa, & Whiteside, 2010), interpretation biases (using the ratings of likelihood immediately after the intrusion induction), and OCS severity (using the Obsessive Compulsive Inventory – Child Version; Foa, Coles, Huppert, Pasupuleti, Franklin, & March, 2010). In line with our prediction, we observed that the more parents interpreted their child’s thought as threatening, the greater the child’s beliefs regarding exaggerated responsibility, perceived likelihood of the feared event occurring, and OCS severity.
TAKE-HOME MESSAGES FROM THIS RESEARCH
Results suggest that parents who misinterpret their children’s unwanted intrusive thoughts as significantly threatening recommended more maladaptive strategies, like suppression or neutralizing behaviors. This is in line with our predictions, and supports the idea that a parent’s threatening appraisal of their child’s intrusive thought may lead them to suggest ritualistic behaviors that unintentionally teach the child that these thoughts are dangerous and need to be controlled or managed. In addition, the degree to which the parent appraised their child’s thoughts as threatening was associated with greater obsessive beliefs, interpretation biases, and OCS severity in the children (Berman, Wilver, & Wilhelm, 2018). Given that we did not follow the children over time, we cannot conclude that the parents’ misinterpretation led to the increase in children’s OC features; however, our results can still inform future research that examines this unique (and changeable) risk factor for the onset, persistence, and worsening of childhood OCS.
IMPLICATIONS FOR PREVENTION AND TREATMENT
Prevention efforts for childhood anxiety disorders indicate that modifying parents’ maladaptive cognitive or behavioral processes can lead to adaptive functioning in their children (e.g., Kennedy, Rapee, & Edwards, 2009; Rapee, Kennedy, Ingram, Edwards, & Sweeney, 2005). Given our findings, researchers could examine whether teaching parents (in their own therapy sessions) to alter their threatening interpretations of their children’s intrusive thoughts would improve children’s outcomes. Moreover, given our recent research demonstrating the difficulty associated with regulating emotions in children with OCS (Berman, Shaw, Curley, & Wilhelm, 2018), it may benefit future researchers to complement parents’ cognitive training with instructions for how to better regulate their emotional responses when their children have intrusive thoughts. By doing so, parents could model effective emotion regulation strategies for their children. In the example of the young boy who fears he will harm his sister with a garden tool, a therapist may work with his mother to help her develop more adaptive cognitive responses to the child’s intrusive thoughts (e.g., “even though the thought about harming his sister terrifies me, a thought is just a thought”), as well as model more helpful emotional responses (e.g., accept the uncomfortable emotions rather than try to manage them by directing the child to ritualize). Of course, more research is needed to confirm whether this type of intervention would be effective; our findings strongly suggest that this area should be explored further.
It is also important to interpret our findings in the context of our study’s limitations. Most importantly, our group of participants was small and they had symptoms across a range of severity, meaning that we cannot say that our findings apply to every family and child. Future researchers should recruit a larger sample of parents who report more severe OCS and continually assess children’s OC features over time to determine the connection between the way parents think about and respond to their child’s OCS, and the risk that it poses for their children.
In closing, we are excited to share our results with the IOCDF community and hope that our findings will be of interest to clinicians, researchers, and families alike.
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*Berman, N. C., Jacoby, R., Sullivan, A., Hoeppner, S., Micco, J., & Wilhelm, S. (2018). Parent-level risk factors for children’s obsessive beliefs, interpretation biases, and obsessive-compulsive symptoms: A cross-sectional examination. Journal of Obsessive-Compulsive and Related Disorders, 18, 8–17.
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*Berman, N. C., Wilver, N., & Wilhelm, S. (2018). My child’s thoughts frighten me: Maladaptive effects associated with parents’ interpretation and management of children’s intrusive thoughts. Journal of Behavior Therapy and Experimental Psychiatry, 61, 87-96.
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* Indicates publications from this study to date