Children and parents suffer from anxiety at high rates, but little is known regarding the role of family accommodation in the relationship between parent anxiety and child anxiety. Family accommodation is the process by which families accommodate patient symptoms by providing reassurance or by modifying family routines to avoid anxiety producing situations, which is in direct opposition to clinical therapeutics, like Cognitive Behavioral Therapy (CBT), which focus on confronting rather than accommodating symptoms. It is important to identify family variables that are relevant to understanding the role of the parent in their child's anxiety, and family accommodation is promising because it has been implicated in impairment, symptom severity, and poor treatment outcomes in children and adults with obsessive-compulsive disorder. However, less is known about family accommodation and anxiety. Therefore, the purpose of the present study was to explore the possibility that family accommodation might mediate the relationship between parent anxiety and child anxiety by using survey methodology to acquire data from 85 parents via community and clinical sampling. Measures included "The Family Accommodation Scale Anxiety," "The State Trait Anxiety Inventory for Adults," and "The Screen for Child Anxiety Related Emotional Disorders." Multiple regression analyses revealed that family accommodation fully mediated the relationship between parent anxiety and child anxiety, as evidenced by a statistically significant Sobel test of mediation and by a reduction in the parent anxiety child anxiety relationship from significant to non-significant. This study fills an important gap in the literature by providing empirical evidence that family accommodation plays an important role in mediating the relationship between parent anxiety and child anxiety. Implications include the potential for development of effective interventions for child anxiety by including focused treatment components designed to reduce and eliminate family accommodation. / text

Parental accommodation refers to the ways in which a parent modifies his/her behavior to avoid or reduce the distress their child experiences. Parental accommodation of youth anxiety is common, and reduction in accommodation is associated with reduced anxiety after treatment. The current study evaluated the efficacy of an adapted cognitive-behavioral therapy program (CBT) designed to address parental accommodation (Accommodation Reduction Intervention; ARI). Sixty children and adolescents (age 7-17) and their parents were evaluated for youth anxiety and parental accommodation before and after 16 weeks of treatment. Thirty youth received ARI and 30 received Coping Cat (CC). Both youth anxiety and parental accommodation were significantly reduced from pre to posttreatment in youth who received ARI as well as those who received CC. No significant difference was found between the two treatment conditions on any measure of anxiety or accommodation. Findings indicate that an adapted CBT that focuses on parent accommodation (ARI) produced favorable outcomes comparable to Coping Cat. Clinical implications and future directions are discussed. / Psychology

<p>In this thesis four empirical studies dealt with children with profound multiple disabilities and their parents with regard to: (a) how parents perceived interaction with their children (b) how observed child/parent interaction was linked to behavior style of the children as perceived by the parents (c) how parents of children with profound multiple disabilities perceived child/parent interaction and behavior style of their children in comparison to parents to children without disabilities matched for communicative ability and age respectively, and, (d) how social networks and family accommodations were linked to child/parent interaction and child behavior style over time for these families according to parental appraisals. The results in study I showed that child/parent interaction occurred through out the day and constituted of mutual experience and joy. There were two processes in interaction: monitoring interaction and successful interaction. Study II found hypo- and hyper dominated behaviour style of the children to influence interaction differently. The parents were found to be experts on their children in monitoring interaction to achieve more frequent periods of successful interaction. Study III found few differences in wishes about ideal interaction between parents of children with profound multiple disabilities and parents of typically developing children. Study IV showed that the children were communicative dependent on their parents; there were few complete overlaps between the children’s and the family’s social networks; and although family accommodations were child-driven, sustainability of family life evolved around other factors. There was a “contradiction” in results for the whole thesis: child/parent interaction occurred through out ordinary everyday life and constituted of mutual experience and joy versus the children’s communicative dependency and the distance found between social networks of families and children and child/parent interaction.</p>

In this thesis four empirical studies dealt with children with profound multiple disabilities and their parents with regard to: (a) how parents perceived interaction with their children (b) how observed child/parent interaction was linked to behavior style of the children as perceived by the parents (c) how parents of children with profound multiple disabilities perceived child/parent interaction and behavior style of their children in comparison to parents to children without disabilities matched for communicative ability and age respectively, and, (d) how social networks and family accommodations were linked to child/parent interaction and child behavior style over time for these families according to parental appraisals. The results in study I showed that child/parent interaction occurred through out the day and constituted of mutual experience and joy. There were two processes in interaction: monitoring interaction and successful interaction. Study II found hypo- and hyper dominated behaviour style of the children to influence interaction differently. The parents were found to be experts on their children in monitoring interaction to achieve more frequent periods of successful interaction. Study III found few differences in wishes about ideal interaction between parents of children with profound multiple disabilities and parents of typically developing children. Study IV showed that the children were communicative dependent on their parents; there were few complete overlaps between the children’s and the family’s social networks; and although family accommodations were child-driven, sustainability of family life evolved around other factors. There was a “contradiction” in results for the whole thesis: child/parent interaction occurred through out ordinary everyday life and constituted of mutual experience and joy versus the children’s communicative dependency and the distance found between social networks of families and children and child/parent interaction.

Family accommodation of symptoms conflicts with the primary goals of cognitive-behavioral therapy for pediatric obsessive-compulsive disorder (OCD) and can be an obstacle to positive outcomes. This study examined a structural equation model of parent and child variables related to family accommodation using a sample of 65 parent-child dyads recruited from a university-based clinic. Additionally, parents' motivations for engaging in accommodation were explored. Results generally supported the hypothesized model. Family accommodation mediated the relationship between OCD symptom severity and parent-rated functional impairment, child internalizing problems mediated the relationship between parent anxiety and family accommodation, and parent empathy and consideration of future consequences interacted to predict accommodation. Child externalizing problems significantly influenced family accommodation but neither of these two variables was affected by parent depression. Excessive reassurance seeking and cleaning/washing compulsions were relatively likely to be accommodated. Implications for clinical practice and directions for future research are discussed.

Pediatric OCD is frequently complicated by co-occurrences with ADHD, mood and anxiety disorders. Although each of these disorders is associated with impaired self-regulation, there has been little examination of impaired self-regulation (i.e., dysregulation) in youth with OCD. Dysregulation is characterized by affective, behavioral and cognitive problems, and can be assessed using the Child Behavior Checklist-Dysregulation Profile (CBCL-DP). Dysregulation may help account for the varied yet related findings identified for symptom severity, impairment and treatment outcome in pediatric OCD. This study examined the role of dysregulation on symptom severity, impairment and treatment outcome in a large sample of youth with OCD. A total of 144 youth with primary OCD participated in this study. Clinicians administered the Children's Yale-Brown Obsessive Compulsive Scale (CY-BOCS), Clinical Global Impression of Severity (CGI-S) and a 13-item scale of family accommodation. Children completed the Multidimensional Anxiety Scale for Children (MASC), and the Child Depression Inventory (CDI). Parents completed the CBCL, with both children and parents completing parallel versions of the Child OCD Impact Scale (COIS-C/P). Within this sample, 97 of these youth received exposure-based CBT and completed the same assessment battery along with the Clinical Global Impression of Improvement (CGI-I) after treatment. Twenty-nine youth (20%) with OCD met categorical criteria for dysregulation. Dysregulated youth had greater obsessive-compulsive symptom severity, depressive mood, and exhibited greater rates of family accommodation and impairment than children without dysregulation. Hierarchical regressions revealed that the level of dysregulation predicted child-and-parent rated impairment, above and beyond obsessive-compulsive severity. Additionally, dysregulation predicted clinician-rated family accommodation above and beyond obsessive-compulsive severity. When examining treatment outcome to exposure-based CBT, a logistic regression indicated that baseline dysregulation did not predict treatment responder status. Although not predicting treatment response, it was found that youth who discontinued treatment (18%) had significantly higher dysregulation than youth who completed treatment (p < .02). For youth who completed exposure-based CBT, a significant decrease in obsessive-compulsive symptom severity and dysregulation was observed (p < .01). Collectively, these findings suggest that youth with OCD and dysregulation experience more severe symptoms and have greater impairment than youth with more regulated functioning. As dysregulation was associated with treatment discontinuation, dysregulated youth with OCD may require more individualized interventions to treat dysregulated behavior prior to receiving exposure-based CBT. For youth who complete treatment, exposure-based CBT reduces obsessive-compulsive symptom severity and its benefits generalize to reductions in dysregulated behaviors as well.

O transtorno obsessivo-compulsivo (TOC) é uma doença crônica que causa prejuízos para o paciente, bem como para a maioria dos familiares. Frequentemente interfere no funcionamento familiar, pois muitas vezes os membros da família modificam suas rotinas devido aos sintomas do paciente. Esses comportamentos observados nos familiares são chamados de acomodação familiar (AF). Os comportamentos de AF podem reforçar os sintomas do paciente e, consequentemente, contribuir para a manutenção da doença. A AF tem sido correlacionada com maior gravidade dos sintomas obsessivo-compulsivos e está associada a resposta menos satisfatória a tratamento, por exemplo, terapia cognitivo-comportamental. No entanto, estudos que avaliam o impacto de intervenções para o TOC na AF em curto e longo prazos ainda são escassos. Esta tese é composta de três artigos com os seguintes objetivos: 1) analisar as propriedades psicométricas da versão adaptada para o Brasil da Escala de Acomodação Familiar para o TOC – versão pontuada pelo entrevistador (FAS-IR); 2) verificar o impacto da terapia cognitivo-comportamental em grupo (TCCG), com duas sessões destinadas a família, na AF e identificar as variáveis sociodemográficas e clínicas preditoras de redução da AF após as 12 sessões de tratamento (curto prazo); e 3) avaliar o impacto da TCCG na AF 3 anos após o término do tratamento e verificar a correlação entre a gravidade dos sintomas do TOC e AF em longo prazo. Trata-se de um estudo com pacientes com diagnóstico de TOC e seus respectivos familiares. Para a avaliação dos sintomas obsessivo-compulsivos, foram aplicados os seguintes instrumentos: Inventário de Obsessões e Compulsões – Revisado (OCI-R), Escala Obsessivo-Compulsivo de Yale-Brown (Y-BOCS) e Escala de Impressão Clínica Global (CGI). Também foram aplicados os Inventários de Beck para Depressão (BDI) e Ansiedade (BAI), além da Entrevista Clínica Estruturada para Transtornos de Eixo I do DSM-IV, Versão Clínica (SCID-I), para a verificação de possíveis comorbidades. Para a avaliação da AF, a FAS-IR foi aplicada nos familiares. Após o estudo de validação da FAS-IR, foi realizado um ensaio clínico randomizado com alocação aleatória dos pacientes para o grupo intervenção (12 sessões de TCCG, sendo duas com a participação dos familiares) ou para o grupo controle (lista de espera). Por fim, foi realizado um estudo de seguimento naturalístico 3 anos após o término da TCCG. O estudo foi aprovado pelo Comitê de Ética em Pesquisa do Hospital de Clínicas de Porto Alegre. Observou-se que a versão da FAS-IR em português brasileiro apresenta propriedades psicométricas satisfatórias, reforçando que este instrumento se mostra confiável para avaliar a participação e modificação da rotina dos familiares em decorrência dos sintomas dos pacientes. No que se refere ao tratamento realizado, o ensaio clínico randomizado compreendeu uma amostra de 98 pares de pacientes com TOC e seus respectivos familiares, sendo que 52 (53.1%) foram randomicamente alocados para o grupo intervenção e 46 (46.9%) para a lista de espera. Houve melhora significativa de todos os sintomas de TOC e também da AF após TCCG no grupo intervenção quando comparado ao grupo controle (p < 0,001). As seguintes variáveis foram preditoras de redução da AF após a análise multivariada: características dos pacientes – ausência de comorbidade com transtorno unipolar (β = 0,338; p = 0,014), pontuação mais baixa de obsessão (β = 0,244; p = 0,045) e maior nível de escolaridade (β = -0,351; p = 0,006); e características dos familiares – pontuação mais elevada de sintomas de colecionismo (β = -0,461; p = 0,001). O modelo explicou 47,2% da variação na AF após a TCCG. No estudo de seguimento, foi observado que os resultados de redução na AF obtidos ao final da TCCG se mantiveram ao longo do tempo (3 anos). Os resultados do presente estudo somam-se às evidências atuais, não somente confirmando que a TCCG é efetiva na redução dos sintomas do TOC, mas também por mostrar que a TCCG com uma breve participação dos familiares com foco na AF contribui para reduzir os níveis de envolvimento da família nos sintomas do paciente, e que esses resultados se mantêm ao longo do tempo. Algumas características dos pacientes e dos familiares foram preditoras da redução da AF, um resultado que pode contribuir para a qualificação dos protocolos de TCCG atualmente empregados. Este é o primeiro estudo a avaliar o impacto da TCCG (com a participação da família em duas sessões) na AF em curto e longo prazos. A partir dos resultados, pode-se concluir que é importante avaliar a AF permanentemente, assim como incluir a família no tratamento para o TOC. / Obsessive-compulsive disorder (OCD) is a chronic illness that negatively affects the lives of patients and usually of family members as well. It frequently interferes with family functioning, as very often family members modify their routines because of the patient’s symptoms. These behaviors observed among family members are referred to as family accommodation (FA). FA behaviors can reinforce the patient’s symptoms and thus contribute to maintain the disorder. FA has been correlated with an increased severity of obsessive-compulsive symptoms and is associated with poorer response to treatment approaches, e.g., cognitive-behavioral therapy. However, there is a scarcity of studies designed to assess the impact of interventions for OCD on FA in both short and long terms. The present thesis includes three research articles, which had the following objectives: 1) to analyze the psychometric properties of the Brazilian version of the Family Accommodation Scale for OCD – Interviewer-Rated (FAS-IR); 2) to assess the impact of cognitive-behavioral group therapy (CBGT) with the involvement of family members in two sessions on FA and to identify sociodemographic and clinical variables predictive of FA reduction after the 12 treatment sessions (short term); and 3) to assess the impact of CBGT on FA 3 years after completion of the program and to investigate the correlation between severity of OCD symptoms and FA in the long term. The study included patients with a diagnosis of OCD and their family members. Obsessive-compulsive symptoms were assessed using the following instruments: Obsessive-Compulsive Inventory – Revised (OCI-R), Yale-Brown Obsessive Compulsive Scale (Y-BOCS), and Clinical Global Impressions Scale (CGI). Beck Depression (BDI) and Anxiety (BAI) Inventories, as well as the Structured Clinical Interview for DSM-IV Axis I Disorders, Clinician Version (SCID-I), were also administered to investigate the presence of possible comorbidities. FA was assessed using the FAS-IR, administered to family members. Upon completion of the FAS-IR validation study, a randomized clinical trial was conducted, randomly assigning patients to either the intervention group (12 sessions of CBGT, of which two involved family members) or to a control group (waiting list). Finally, a naturalistic follow-up study was conducted 3 years after completion of the CBGT program. The study was approved by the Research Ethics Committee of Hospital de Clínicas de Porto Alegre. We found that the Brazilian Portuguese version of the FAS-IR had sound psychometric properties, reinforcing that this is a reliable instrument for assessing the participation and modifications of the routines of family members as a result of the patient’s symptoms. With regard to treatment outcomes, the randomized clinical trial included a sample of 98 pairs of patients with OCD and their family members, of which 52 (53.1%) were randomly allocated to the intervention group and 46 (46.9%) to the waiting list. There was a significant improvement of all OCD symptoms and also of FA levels after CBGT in the intervention group when compared to the control group (p < 0.001). The following variables were predictors of FA reduction after the multivariate analysis: patient characteristics – absence of comorbid unipolar disorder (β = 0.338; p = 0.014), a lower obsession score (β = 0.244; p = 0.045), and higher education level (β = -0.351; p = 0.006); and family member characteristics – a higher hoarding score (β = -0.461; p = 0.001). The model explained 47.2% of the variance in FA scores after CBGT. Finally, in the follow-up study, the FA reduction results obtained at the end of CBGT were found to remain in the long term (3 years). These results add to the current body of evidence not only by confirming that CBGT is effective in reducing OCD symptoms, but also by showing that CBGT with a brief family intervention focused on FA contributes to reduce the level of involvement of family members in the patient’s symptoms, and that these results are maintained over time. Some patient and family member characteristics were found to predict FA reduction, a finding that can contribute to qualify the CBGT protocols currently employed. This is the first study to assess the impact of CBGT (with the participation of family members in two sessions) on FA in both short and long terms. These findings underscore the importance of permanently assessing FA, as well as of involving family members in the treatment of patients with OCD.

O Transtorno Obsessivo-Compulsivo (TOC) é um transtorno crônico que causa prejuízos significativos tanto para o paciente como para os seus familiares. De um modo geral, interfere no funcionamento familiar, pois muitas vezes leva os membros de uma família a modificar suas rotinas em função dos sintomas do paciente. As mudanças de comportamentos dos familiares em decorrência desses sintomas são chamadas de Acomodação Familiar (AF). O presente estudo teve como objetivos: primeiramente traduzir e adaptar para o português a Family Accommodation Scale for Obsessive-Compulsive Disorder: Interviewer-Rated (FAS-IR) e, em segundo lugar, examinar se fatores sociodemográficos e clínicos estão ou não associados à AF. Após realizada a tradução e adaptação da escala, foi realizada a segunda etapa do trabalho com uma amostra ambulatorial constituída de 114 pacientes com TOC e seus respectivos familiares. Para avaliação dos sintomas obsessivo-compulsivos (OC) nos pacientes, foram aplicadas as seguintes escalas: DY-BOCS, Y-BOCS e CGI. Para analisar sintomas de depressão e ansiedade, foram aplicados o BDI e o BAI, e para a verificação de possíveis comorbidades, o SCID. Nos familiares, para avaliar a AF foi aplicada a FAS-IR, e para verificação de sintomas OC, a Y-BOCS e a OCI-R. Dois modelos de regressão linear múltipla foram utilizados: o primeiro modelo foi utilizado para avaliar a relação entre as variáveis do paciente e a AF; já o segundo foi utilizado para avaliar as variáveis do familiar e a AF. Averiguou-se que a AF era altamente prevalente entre os familiares na população em estudo. O fator do paciente associado positivamente com a AF foi gravidade do TOC, enquanto AF estava associada inversamente a pior dimensão do paciente ser obsessões com conteúdo agressivo. As características dos familiares associadas positivamente com AF foram sintomas OC nos familiares e o familiar ser o cônjuge do paciente. A AF é muito comum nas famílias de portadores do TOC, mas ainda são pouco conhecidas as razões que levam os familiares a mudarem seu comportamento. É importante estar atento a esse fato, pois tais comportamentos de acomodação podem servir de reforço aos sintomas do paciente e consequentemente contribuir para sua manutenção. / Obsessive-Compulsive Disorder (OCD) is a chronic disorder that causes significant impairments both to patient and his/her family members. Generally, it interferes with familiar functioning, since it frequently drives family members to modify their routines because of the patient‟s symptoms. Changes on family members‟ behaviors as a consequence of these symptoms are termed as Family Accommodation (FA). The present study aimed at: firstly translate into and adapt to Portuguese the Family Accommodation Scale for Obsessive-Compulsive Disorder: Interviewer-Rated (FAS-IR) and, secondly, to examine whether or not socio-demographic and clinical factors are associated to FA. After the scale was translated and adapted into Portuguese, the second step of the research was performed with an outpatient sample comprised 114 patients with OCD and their respective family members. To evaluate the obsessive-compulsive (OC) symptoms on patients, the following scales were applied: DY-BOCS, Y-BOCS, and CGI. To analyze depressive and anxiety symptoms, the BDI and BAI scales were used, and to verify possible comorbidities, the SCID. On family members, to evaluate the FA, FAS-IR was applied, and to verify the OC symptoms, the Y-BOCS and OCI-R scales. Two multiple linear regression models were used: the first one was used to evaluate the relationship between patient‟s variables and the FA; and the second one, to evaluate the relationship between family member‟s variables and the FA. It was noted that FA was highly prevalent among the family members in the studied population. The patient‟s factor positively associated with FA was OCD severity, whereas FA was inversely associated with the patient‟s worst dimension being obsessions with aggressive content. Family members‟ characteristics positively associated with FA were OC symptoms in family members and the family member being the patient‟s spouse. The FA is highly common among OCD carriers‟ families, but the reasons that drive family members to modify their own behaviors are not yet well known. It is important to be aware of this fact, since these accommodation behaviors may serve as a reinforcer of the patient‟ symptoms, and, consequently, contribute in keeping them.

O transtorno obsessivo-compulsivo (TOC) é uma doença crônica que causa prejuízos para o paciente, bem como para a maioria dos familiares. Frequentemente interfere no funcionamento familiar, pois muitas vezes os membros da família modificam suas rotinas devido aos sintomas do paciente. Esses comportamentos observados nos familiares são chamados de acomodação familiar (AF). Os comportamentos de AF podem reforçar os sintomas do paciente e, consequentemente, contribuir para a manutenção da doença. A AF tem sido correlacionada com maior gravidade dos sintomas obsessivo-compulsivos e está associada a resposta menos satisfatória a tratamento, por exemplo, terapia cognitivo-comportamental. No entanto, estudos que avaliam o impacto de intervenções para o TOC na AF em curto e longo prazos ainda são escassos. Esta tese é composta de três artigos com os seguintes objetivos: 1) analisar as propriedades psicométricas da versão adaptada para o Brasil da Escala de Acomodação Familiar para o TOC – versão pontuada pelo entrevistador (FAS-IR); 2) verificar o impacto da terapia cognitivo-comportamental em grupo (TCCG), com duas sessões destinadas a família, na AF e identificar as variáveis sociodemográficas e clínicas preditoras de redução da AF após as 12 sessões de tratamento (curto prazo); e 3) avaliar o impacto da TCCG na AF 3 anos após o término do tratamento e verificar a correlação entre a gravidade dos sintomas do TOC e AF em longo prazo. Trata-se de um estudo com pacientes com diagnóstico de TOC e seus respectivos familiares. Para a avaliação dos sintomas obsessivo-compulsivos, foram aplicados os seguintes instrumentos: Inventário de Obsessões e Compulsões – Revisado (OCI-R), Escala Obsessivo-Compulsivo de Yale-Brown (Y-BOCS) e Escala de Impressão Clínica Global (CGI). Também foram aplicados os Inventários de Beck para Depressão (BDI) e Ansiedade (BAI), além da Entrevista Clínica Estruturada para Transtornos de Eixo I do DSM-IV, Versão Clínica (SCID-I), para a verificação de possíveis comorbidades. Para a avaliação da AF, a FAS-IR foi aplicada nos familiares. Após o estudo de validação da FAS-IR, foi realizado um ensaio clínico randomizado com alocação aleatória dos pacientes para o grupo intervenção (12 sessões de TCCG, sendo duas com a participação dos familiares) ou para o grupo controle (lista de espera). Por fim, foi realizado um estudo de seguimento naturalístico 3 anos após o término da TCCG. O estudo foi aprovado pelo Comitê de Ética em Pesquisa do Hospital de Clínicas de Porto Alegre. Observou-se que a versão da FAS-IR em português brasileiro apresenta propriedades psicométricas satisfatórias, reforçando que este instrumento se mostra confiável para avaliar a participação e modificação da rotina dos familiares em decorrência dos sintomas dos pacientes. No que se refere ao tratamento realizado, o ensaio clínico randomizado compreendeu uma amostra de 98 pares de pacientes com TOC e seus respectivos familiares, sendo que 52 (53.1%) foram randomicamente alocados para o grupo intervenção e 46 (46.9%) para a lista de espera. Houve melhora significativa de todos os sintomas de TOC e também da AF após TCCG no grupo intervenção quando comparado ao grupo controle (p < 0,001). As seguintes variáveis foram preditoras de redução da AF após a análise multivariada: características dos pacientes – ausência de comorbidade com transtorno unipolar (β = 0,338; p = 0,014), pontuação mais baixa de obsessão (β = 0,244; p = 0,045) e maior nível de escolaridade (β = -0,351; p = 0,006); e características dos familiares – pontuação mais elevada de sintomas de colecionismo (β = -0,461; p = 0,001). O modelo explicou 47,2% da variação na AF após a TCCG. No estudo de seguimento, foi observado que os resultados de redução na AF obtidos ao final da TCCG se mantiveram ao longo do tempo (3 anos). Os resultados do presente estudo somam-se às evidências atuais, não somente confirmando que a TCCG é efetiva na redução dos sintomas do TOC, mas também por mostrar que a TCCG com uma breve participação dos familiares com foco na AF contribui para reduzir os níveis de envolvimento da família nos sintomas do paciente, e que esses resultados se mantêm ao longo do tempo. Algumas características dos pacientes e dos familiares foram preditoras da redução da AF, um resultado que pode contribuir para a qualificação dos protocolos de TCCG atualmente empregados. Este é o primeiro estudo a avaliar o impacto da TCCG (com a participação da família em duas sessões) na AF em curto e longo prazos. A partir dos resultados, pode-se concluir que é importante avaliar a AF permanentemente, assim como incluir a família no tratamento para o TOC. / Obsessive-compulsive disorder (OCD) is a chronic illness that negatively affects the lives of patients and usually of family members as well. It frequently interferes with family functioning, as very often family members modify their routines because of the patient’s symptoms. These behaviors observed among family members are referred to as family accommodation (FA). FA behaviors can reinforce the patient’s symptoms and thus contribute to maintain the disorder. FA has been correlated with an increased severity of obsessive-compulsive symptoms and is associated with poorer response to treatment approaches, e.g., cognitive-behavioral therapy. However, there is a scarcity of studies designed to assess the impact of interventions for OCD on FA in both short and long terms. The present thesis includes three research articles, which had the following objectives: 1) to analyze the psychometric properties of the Brazilian version of the Family Accommodation Scale for OCD – Interviewer-Rated (FAS-IR); 2) to assess the impact of cognitive-behavioral group therapy (CBGT) with the involvement of family members in two sessions on FA and to identify sociodemographic and clinical variables predictive of FA reduction after the 12 treatment sessions (short term); and 3) to assess the impact of CBGT on FA 3 years after completion of the program and to investigate the correlation between severity of OCD symptoms and FA in the long term. The study included patients with a diagnosis of OCD and their family members. Obsessive-compulsive symptoms were assessed using the following instruments: Obsessive-Compulsive Inventory – Revised (OCI-R), Yale-Brown Obsessive Compulsive Scale (Y-BOCS), and Clinical Global Impressions Scale (CGI). Beck Depression (BDI) and Anxiety (BAI) Inventories, as well as the Structured Clinical Interview for DSM-IV Axis I Disorders, Clinician Version (SCID-I), were also administered to investigate the presence of possible comorbidities. FA was assessed using the FAS-IR, administered to family members. Upon completion of the FAS-IR validation study, a randomized clinical trial was conducted, randomly assigning patients to either the intervention group (12 sessions of CBGT, of which two involved family members) or to a control group (waiting list). Finally, a naturalistic follow-up study was conducted 3 years after completion of the CBGT program. The study was approved by the Research Ethics Committee of Hospital de Clínicas de Porto Alegre. We found that the Brazilian Portuguese version of the FAS-IR had sound psychometric properties, reinforcing that this is a reliable instrument for assessing the participation and modifications of the routines of family members as a result of the patient’s symptoms. With regard to treatment outcomes, the randomized clinical trial included a sample of 98 pairs of patients with OCD and their family members, of which 52 (53.1%) were randomly allocated to the intervention group and 46 (46.9%) to the waiting list. There was a significant improvement of all OCD symptoms and also of FA levels after CBGT in the intervention group when compared to the control group (p < 0.001). The following variables were predictors of FA reduction after the multivariate analysis: patient characteristics – absence of comorbid unipolar disorder (β = 0.338; p = 0.014), a lower obsession score (β = 0.244; p = 0.045), and higher education level (β = -0.351; p = 0.006); and family member characteristics – a higher hoarding score (β = -0.461; p = 0.001). The model explained 47.2% of the variance in FA scores after CBGT. Finally, in the follow-up study, the FA reduction results obtained at the end of CBGT were found to remain in the long term (3 years). These results add to the current body of evidence not only by confirming that CBGT is effective in reducing OCD symptoms, but also by showing that CBGT with a brief family intervention focused on FA contributes to reduce the level of involvement of family members in the patient’s symptoms, and that these results are maintained over time. Some patient and family member characteristics were found to predict FA reduction, a finding that can contribute to qualify the CBGT protocols currently employed. This is the first study to assess the impact of CBGT (with the participation of family members in two sessions) on FA in both short and long terms. These findings underscore the importance of permanently assessing FA, as well as of involving family members in the treatment of patients with OCD.

O Transtorno Obsessivo-Compulsivo (TOC) é um transtorno crônico que causa prejuízos significativos tanto para o paciente como para os seus familiares. De um modo geral, interfere no funcionamento familiar, pois muitas vezes leva os membros de uma família a modificar suas rotinas em função dos sintomas do paciente. As mudanças de comportamentos dos familiares em decorrência desses sintomas são chamadas de Acomodação Familiar (AF). O presente estudo teve como objetivos: primeiramente traduzir e adaptar para o português a Family Accommodation Scale for Obsessive-Compulsive Disorder: Interviewer-Rated (FAS-IR) e, em segundo lugar, examinar se fatores sociodemográficos e clínicos estão ou não associados à AF. Após realizada a tradução e adaptação da escala, foi realizada a segunda etapa do trabalho com uma amostra ambulatorial constituída de 114 pacientes com TOC e seus respectivos familiares. Para avaliação dos sintomas obsessivo-compulsivos (OC) nos pacientes, foram aplicadas as seguintes escalas: DY-BOCS, Y-BOCS e CGI. Para analisar sintomas de depressão e ansiedade, foram aplicados o BDI e o BAI, e para a verificação de possíveis comorbidades, o SCID. Nos familiares, para avaliar a AF foi aplicada a FAS-IR, e para verificação de sintomas OC, a Y-BOCS e a OCI-R. Dois modelos de regressão linear múltipla foram utilizados: o primeiro modelo foi utilizado para avaliar a relação entre as variáveis do paciente e a AF; já o segundo foi utilizado para avaliar as variáveis do familiar e a AF. Averiguou-se que a AF era altamente prevalente entre os familiares na população em estudo. O fator do paciente associado positivamente com a AF foi gravidade do TOC, enquanto AF estava associada inversamente a pior dimensão do paciente ser obsessões com conteúdo agressivo. As características dos familiares associadas positivamente com AF foram sintomas OC nos familiares e o familiar ser o cônjuge do paciente. A AF é muito comum nas famílias de portadores do TOC, mas ainda são pouco conhecidas as razões que levam os familiares a mudarem seu comportamento. É importante estar atento a esse fato, pois tais comportamentos de acomodação podem servir de reforço aos sintomas do paciente e consequentemente contribuir para sua manutenção. / Obsessive-Compulsive Disorder (OCD) is a chronic disorder that causes significant impairments both to patient and his/her family members. Generally, it interferes with familiar functioning, since it frequently drives family members to modify their routines because of the patient‟s symptoms. Changes on family members‟ behaviors as a consequence of these symptoms are termed as Family Accommodation (FA). The present study aimed at: firstly translate into and adapt to Portuguese the Family Accommodation Scale for Obsessive-Compulsive Disorder: Interviewer-Rated (FAS-IR) and, secondly, to examine whether or not socio-demographic and clinical factors are associated to FA. After the scale was translated and adapted into Portuguese, the second step of the research was performed with an outpatient sample comprised 114 patients with OCD and their respective family members. To evaluate the obsessive-compulsive (OC) symptoms on patients, the following scales were applied: DY-BOCS, Y-BOCS, and CGI. To analyze depressive and anxiety symptoms, the BDI and BAI scales were used, and to verify possible comorbidities, the SCID. On family members, to evaluate the FA, FAS-IR was applied, and to verify the OC symptoms, the Y-BOCS and OCI-R scales. Two multiple linear regression models were used: the first one was used to evaluate the relationship between patient‟s variables and the FA; and the second one, to evaluate the relationship between family member‟s variables and the FA. It was noted that FA was highly prevalent among the family members in the studied population. The patient‟s factor positively associated with FA was OCD severity, whereas FA was inversely associated with the patient‟s worst dimension being obsessions with aggressive content. Family members‟ characteristics positively associated with FA were OC symptoms in family members and the family member being the patient‟s spouse. The FA is highly common among OCD carriers‟ families, but the reasons that drive family members to modify their own behaviors are not yet well known. It is important to be aware of this fact, since these accommodation behaviors may serve as a reinforcer of the patient‟ symptoms, and, consequently, contribute in keeping them.