Corresponding author’s address: Dr. Osman Sabuncuoğlu Halk Cad. Emin Ongan Sk. 11/ 7 80300 Üsküdar / Istanbul, Turkey Phone: +90(542)4253397 +90(216)3271010-514 Fax:+90(216)3250323 E-mail: sabuncuoglu2004@yahoo.com
Marmara Medical Journal 2004;17(2);73-77
ORIGINAL RESEARCH
THE CONTRIBUTION OF HOME-FAMILY DISTRESS TO THE
PRESENTATION DIFFERENCE OF CHILDHOOD
OBSESSIVE-COMPULSIVE DISORDER ACROSS HOME AND SCHOOL SETTINGS
Osman Sabuncuoğlu, Meral Berkem
Department of Child Psychiatry, School of Medicine, Marmara University, Istanbul, Turkey
ABSTRACT
Objective: Further to our recent finding of presentation difference in the symptoms of childhood obsessive-compulsive disorder
across home and school settings, and that home is where symptoms predominate, we aimed to find out whether this phenomenon is related to home-family distress.
Methods: After the application of CY-BOCS, CGI and a questionnaire consisted of items that served as a comparison of the
symptoms across home and school settings, family distress was rated on a 5-point scale (FDM) which reflected home stress factors such as unemployment, parental conflict and care of elderly.
Results: Of the 20 children enrolled in the study, 70% were boys and 30% girls who had a mean age of 12.45 ± 3.36. Both
CY-BOCS and CGI-severity (home and school) scores did not differ significantly within themselves regarding caseness criteria of +3 cutscore on the FDM. Among the data obtained by CY-BOCS and CGI, only Compulsion Subscale of CY-BOCS revealed significant correlation with FDM scores ( r = 0.510, p<0.05).
Conclusion: Preliminary data did not support any association between home-family distress and presentation difference. A larger
sample is needed to conclude on the contribution of home-family stress factors to the presentation difference in childhood obsessive-compulsive disorder.
Keywords: Obsessive-compulsive disorder, Child, Adolescent, Schools, Family
ÖZET
Amaç: Çocukluk çağı obsesif-kompulsif bozukluğunda, ev ortamında okul ortamına göre belirtilerin daha fazla dışavurulduğu
yönündeki son bulgumuzdan sonra bu sonucun ev-aile stresiyle ilişkili olup olmadığını araştırmayı amaçladık.
Yöntem: Yale-Brown Çocuklar İçin Obsesif-Kompulsif Sorulistesi (YBÇOKS), Klinik Global İzlenim Ölçeği (KGİÖ) ve
ev-okul ortamları arasında belirtileri karşılaştırmaya yarayan sorulistesinin uygulanmasından sonra işsizlik, ebeveyn çatışması ve yaşlı bakımı gibi nedenlerle yaşanan ev-aile stresi 5 bölümlük ölçek üzerinden puanlandı.
Bulgular: Çalışmaya alınan 20 çocuğun %70'i erkek, %30'u kız ve ortalama yaşı 12.45 ± 3.36 idi. Gerek YBÇOKS, gerek ev
ve okul için verilen KGİÖ-Hastalık Şiddeti puanları aile stresi için +3 olan olgusallık ölçütüne göre farklılık göstermedi. Yalnız YBÇOKS Kompulsiyon altölçeği aile stres bulgularıyla anlamlı korelasyon gösterdi (r = 0.510, p<0.05).
Sonuç: On bulgular belirti dışavurumunda farklılık ile ev-aile stresi arasında bir ilişki olmadığını gösterdi. Çocukluk çağı
obsesif-kompulsif bozukluğunda ev-aile stresinin belirti dışavurumunda farklılığı nasıl etkilediğine karar vermek için daha geniş bir örneklem incelenmelidir.
Anahtar Kelimeler: Obsesif kompulsif bozukluk, Çocuk, ergen, Okullar, Aile
INTRODUCTION
Childhood obsessive-compulsive disorder (OCD) is a chronic and underrecognized psychiatric condition affecting 1% to 4% of children and adolescents 1. The lifelong characteristic of OCD
necessitates in depth understanding of childhood OCD in terms of age at onset, diagnosis, symptom
presentation, treatment and course of the disorder. Although information on childhood OCD still accumulates, various phenomenological dimensions await to be determined. The symptom profile of children with OCD across home and school settings is one of the topics which remain unknown, unlike, for instance ADHD. Although Rapoport notes that children with OCD may have
a partial voluntarily control of symptoms in public, there is no particular reference to any study 2. On the other hand, DSM-IV criteria for
OCD merits the significant interference of symptoms with school, social activities and important relationships 3.
Recently we have described presentation difference phenomenon characterized by significant difference in the presentation of obsessive-compulsive disorder across home and school settings 4. We found that home is where
symptoms predominate. Family setting is of interest in numerous reports in relation to the problem behavior of children. Early adverse family circumstances and parenting characteristics were found to have no contribution to the prediction of later psychopathology once child characteristics were accounted for 5. Contrary to
this finding, there are studies reporting direct concurrent relations between home-family distress and the problem behavior of children 6,7. Family
context in childhood OCD has also been highlighted as a risk factor in the development and maintenance of the disorder 8.
As an implication of our previous research, we aimed to determine whether presentation difference phenomenon is related to the family distress experienced at home.
MATERIALS AND METHODS
Twenty schoolchildren, aged 6 to 17 from our OCD cohort, were enrolled in the study. Child psychiatric diagnoses were based on the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) criteria. After the application of original measures on admission, each case was assessed by the same child psychiatrist (Dr. O. S.) in a following session regarding home-family distress. Previous progress records were used when necessary. Basic informative data was gathered from the file records of the children.
Measures
Children’s Yale-Brown Obsessive Compulsive Scale (CY-BOCS): This scale is a 10-item, clinician rated, semi structured instrument designed to rate the severity of obsessive and compulsive symptoms in children, aged 6 to 17 years 9,10. Information obtained from the child and parent which reflects the average course of symptoms in the week prior to the study is rated
by the interviewer. A Turkish version was used for the present study 11.
Clinical Global Impression (CGI) – Severity Subscale 12: It is scored from 1 (no illness) to 7
(completely nonfunctional). The interviewer determines the overall severity of the illness. In the present study design, two ratings, one for the school and one for the home setting were made and compared.
Setting Specificity of OCD Symptoms In Children Questionnaire: This questionnaire was prepared by the research team and was based on the results obtained on the CY-BOCS. The children and their parents were questioned about the frequency of symptoms across home and school settings with particular reference to the CY-BOCS results. Family Distress Measure (FDM): The clinician rated the overall family distress on a 5-point scale which reflected home stress factors such as unemployment, parental conflict, illness and care of elderly. This measure was introduced with a perspective similar to CGI and +3 cutscore was accepted as the level of clinical concern. Home-family distress secondary to the child’s psychiatric disorder was not taken into account.
SPSS 10.0 for Windows was used to analyze the findings. T-test, Mann-Whitney U Test and Correlational tests were required to analyse the data.
RESULTS
Of the total number of children, 70% were boys and 30% girls with had a mean age of 12.45 ± 3.36.
The mean obsession and compulsion subscores were 10.75 ± 4.05 and 10.55 ± 3.73 respectively, both summing up a total score of 21.30 ± 6.77. Table I displays the prevalence of obsessions and compulsions experienced by the children in the present sample. Ten (50%) of the subjects were pure OCD whilst the remaining children had some comorbid diagnoses. CGI-severity scores for both home and school settings were 4.40 ± 0.88 and 2.20 ± 0.76 respectively, at a significant level of difference (t=8.41, df=38, p<0.0001 and Levene’s test revealing egual variances F= 1.59, p<0.05). Child and parent estimated distribution of the frequency of OCD symptoms according to the Setting Specifcity Questionnaire is presented in Fig. I.
Table I : Prevalences of obsessions and compulsions on the CY-BOCS. OBSESSIONS n % COMPULSIONS n % Contamination 13 65 Washing/Cleaning 13 65 Aggressive 12 60 Checking 10 50 Sexual 3 15 Repeating 12 60 Hoarding/Saving 0 0 Counting 0 0 Magical Thoughts/Superstitious 4 20 Ordering/Arranging 0 0 Somatic 3 15 Hoarding/Saving 3 15 Religious 2 10 Excessive Magical Games 1 5
Miscellaneous 0 0 Rituals Involving Others 1 5
Miscellaneous 7 35
Table II : The comparison of the CY-BOCS and CGI scores of the children with respect to low (n=14) and
high FDM (n=6) scores CY-BOCS COMP CY-BOCS OBS CY-BOCS TOTAL CGI HOME CGI SCHOOL Mann-Whitney U 21,000 40,000 30,500 39,000 35,000 Wilcoxon W 126,000 145,000 135,500 60,000 140,000 Z -1,745 -,167 -,952 -,268 -,639
Asymp. Sig (2-tailed) ,081 ,867 ,341 ,789 ,523
Exact Sig.[2*(1-tailed Sig.)] ,091a ,904a ,353a ,841a ,602a
a. Not corrected for ties
Fig. 1: Child and parent estimated distribution of the frequency obsessive compulsive symptoms across settings.
The mean family distress measure (FDM) score was found to be 2.00 ± 1.12. According to +3 cutscore of FDM, 6 cases were identified. The CY-BOCS and CGI scores of the children, each dichotomised with respect to caseness criteria on the FDM, were analysed using Mann-Whitney U
Test. In comparison, no significant difference was found between the dichotomised groups (Table II).
Among the data obtained by CY-BOCS and CGI, only Compulsion Subscale of CY-BOCS revealed significant correlation with FDM scores (r = 0.510, P<0.05).
DISCUSSION
Although distress experienced within the family might have an additive impact on the childhood OCD overall, it seems that the presentation difference is not determined by this kind of distress. Presentation difference is consistant in the vast majority of enrolled children.
The positive correlation between the FDM and CY-BOCS Compulsion Subscale is of interest. It seems that, to some extent, the level of stress experienced in the home environment is associated with children’s compulsions experienced either at home or at school. What should be kept in mind is that, although we found significant presentation difference in the entire sample, high FDM cases did not differ from the low FDM cases in the variables studied. Thus, our findings are in line with Mesman’s study 5.
Interpersonal factors that might trigger OCD symptoms within the family should be studied. Early parental preoccupation and behavior surrounding the birth of a family member implicated in the possible evolutionary origins of OCD may provide insight regarding the presentation phenomenon 13. The contribution of
secondary family distress stemming from the child’s OCD is worth investigating in further studies.
Given these results, we can also hypothesize that the distraction experienced in the school environment may relieve the intrusive obsessions and therefore lead to a better functioning at school. In addition, certain forms of compulsions might not be easily performed in the school setting for practical reasons and due to anticipated shame. If these factors predominate, any sort of home-family distress is unlikely to contribute to the presentation difference.
As this study was based on the self-reports of children with the agreement of their parents, secrecy was out of question in the studied sample. In addition, the prevalence of obsession and compulsion in our sample is similar to that of previous findings in Turkey 14.
Therapeutic implications should be derived from the presentation difference phenomenon as, outlining the factors which relieve the symptoms at school may be self-educative for a better control over the symptoms experienced at home. Interpersonal factors, such as the persistence of early parental preoccupations should also be
studied before developing proper treatment strategies.
In conclusion, preliminary data showed no association between home-family distress and presentation difference. The study should be replicated on a larger sample to conclude on the contribution of home-family stress factors to that phenomenon.
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