تحقیقات مقدماتی از تاثیر اختلال وسواس و اختلال پانیک بر والدین و کودکان

Although there is evidence for the intergenerational transmission of anxiety disorders, there is little research in relation to specific parental disorders. This study evaluated three groups of mothers with at least one child aged 7–14, defined in terms of maternal obsessive-compulsive disorder (OCD; n = 23), panic disorder (n = 18), and healthy controls (n = 20). Parental perceptions and symptomatology, general and disorder-specific child symptoms and mother–child interactions were investigated using self-report, informant report and independent assessment. Mothers with OCD and panic disorder expressed high levels of concern about the impact of their anxiety disorder on their parenting. Group differences in terms of child anxiety were subtle rather than clinically significant. In interactions, anxious mothers were less warm and promoting of psychological autonomy than healthy controls, and they exhibited elevated expressed emotion. Overall, the results suggested a mix of effects including trans-diagnostic and disorder-specific issues. Implications for future research are discussed.

Anxiety disorders are debilitating both for the affected individual and those around them including children (Lochner et al., 2003, Magliano et al., 1996 and Olatunji et al., 2007) and there is now considerable research evidence that they aggregate in families (Beidel and Turner, 1997, Last et al., 1991, Merikangas et al., 1999, Mufson et al., 1992, Turner et al., 1987 and Weissman, 1993). Parenting, in particular an over-controlling style, has been implicated as an important environmental variable for the development of childhood anxiety, while lack of parental sensitivity and warmth has been linked with depression (Bogels and Brechman-Toussaint, 2006, Chorpita and Barlow, 1998, Rapee, 1997 and Wood et al., 2003). Parental inconsistency and harshness in discipline may also impact on child anxiety (Cartwright-Hatton, McNally, & White, 2005). Parenting style of anxious parents is therefore of relevance in understanding the intergenerational transmission of disturbance. The importance of understanding the impact of having a parent suffering from an anxiety disorder goes far beyond considerations of etiology; clinicians are often faced with the problem of how best to identify, understand, and deal with risk issues arising from parental anxiety. Anxious parents themselves frequently report concerns about the effect of their own problems on their parenting and their children, although the extent and degree of such perceptions have not been systematically evaluated. At its most severe, an anxiety disorder may render a parent incapable of caring for his or her child. Such instances are usually obvious; however, we do not know whether more subtle (but nevertheless negative or even harmful) effects might occur as a result of untreated anxiety in a parent. Concurrent child diagnosis per se is not a sensitive measure of potential adverse effects, which are likely to be more subtle, possibly manifesting as diagnosable mental health problems only later in the child's life ( Ginsburg, Grover, & Ialongo, 2004). Within the context of a broad diathesis-stress model, there are three main ways of characterizing the impact of parental anxiety and anxiety disorders. These are (1) the inheritance of traits or general vulnerabilities to anxiety, (2) broadly defined stress caused by living with the parent, and (3) the transmission of specific symptoms. These factors represent different types of influence, which are not mutually exclusive (and indeed, if more than one were present, would be expected to interact) and would be likely to vary in their specificity for particular anxiety disorders. (1) “Trait” approaches are based on the view that general characteristics related to anxiety (such as neuroticism and behavioral inhibition) are either biologically inherited by the children of parents who have high levels of anxiety or are acquired through early experience. While a moderate level of genetic vulnerability for anxiety and anxiety disorders has been identified (Eley et al., 2003 and Hettema et al., 2005), environmental factors, primarily parenting, are likely to play an important role. In terms of the candidate phenotypes, there is some support for a genetic contribution to neuroticism (Hettema, Neale, Myers, Prescott, & Kendler, 2006) and behavioral inhibition (Robinson, Kagan, Reznick, & Corley, 1992), and there is evidence for an association between these general traits and the development of subsequent disorders in some but not all individuals (Biederman et al., 1995 and Turner et al., 1996). Given the non-specific heritability of most anxiety disorders, it has been suggested that underlying temperamental factors represent a common diathesis (Merikangas et al., 1999). Environmental factors may influence the particular focus, or ameliorate or exacerbate the risks of anxiety at different developmental stages (Last et al., 1996, Manassis et al., 2004 and Warren et al., 2003). (2) “General Stress” approaches emphasize the view that living with an anxious parent or parents is in itself pathogenic, and that this experience influences the child in ways which make them vulnerable to developing anxiety problems. Emergence and maintenance of a disorder may occur as a result of two types of factor related to the parental anxiety problem: either chronic low-level stresses including parenting style, or more discrete ‘traumatic’ incidents. This approach to conceptualizing transmission of anxiety suggests that there may be ‘cycles of disadvantage,’ with the affected parent perhaps having been subject to the same types of stressors themselves. Also subsumed in the notion of general stress is the idea that children may as a result be prone to other types of psychopathology such as depression or be otherwise compromised in functioning. Several studies have examined aspects of the parenting style of anxious parents. A high level of parental ‘expressed emotion’ defined by emotional over-involvement or criticism has been related to anxiety disorders in the children of anxious or depressed parents (Hirshfeld, Biederman, Brody, & Faraone, 1997). Observational research examining parent–child interactions has indicated that parents with anxiety disorders may be less warm and promoting of children's psychological autonomy (DiBartolo and Helt, 2007, Ginsburg et al., 2004 and Whaley et al., 1999), although this may be more related to child than parental anxiety (Moore, Whaley, & Sigman, 2004). In non-clinical samples parental anxiety–depression and over-control have been linked to child internalizing problems (Bayer, Sanson, & Hemphill, 2006), as has the extent to which parental anxiety is expressed to children (Gruner et al., 1999 and Muris and Merckelbach, 1998). Thus, children may start to conceive the world as a dangerous place and themselves as less competent to deal with the danger or feelings of anxiety (Gallagher & Cartwright-Hatton, 2008). The third approach, (3) “Symptom transmission and specific stress,” is based on the idea that the child learns particular fear responses through observation of parental fearful responses or sharing of fearful information. Children may then reproduce their parent's symptoms as a consequence of the identification of a link between the parent's own fears and anxious responses (e.g., (i) an obsessional washer teaches the child to wash after touching potentially contaminated objects, and/or the parent teaches the child that anxiety is best coped with by avoidance or escape) or (ii) by the parent sensitizing the child to inappropriate ideas of serious danger (e.g., by involving the child in rituals while explaining the danger which is being prevented; by warning the child that particular symptoms are characteristic of a threatening event such as a heart attack or going insane). There is some evidence of children learning anxious responding through parent's modeling of their fears (de Rosnay et al., 2006, Gerull and Rapee, 2002 and Muris et al., 1996). One laboratory study indicated that although anxious parents did not restrict their children in the laboratory situation, they reported more distress than healthy controls at what they perceive to be child risk taking (Turner, Beidel, Roberson-Nay, & Tervo, 2003). There have been relatively few studies to date which have sought to look at the parenting factors which may be involved in specific disorders as opposed to anxiety disorders as a broader grouping. Schneider, Unnewehr, Florin, and Margraf (2002) found that children of parents with panic disorder made more anxious interpretations of physical symptoms in a vignette after priming than children of phobics and healthy controls. Although more anxious than healthy controls, the children were not suffering from panic attacks, leading the authors to suggest rather that they displayed disorder-specific vulnerabilities. To date there has been no published research on parenting issues specific to parents with obsessive-compulsive disorder (OCD), a problem characterized by distressing intrusive thoughts and/or compulsive behaviors aimed at alleviating distress or avoiding a feared outcome. Typically, OCD interferes with day-to-day activities such as washing/hygiene, and leaving the house (due to checking). Researchers have recently noted that the levels of impairment observed in OCD are comparable to those seen in psychotic disorders (Torres et al., 2006). Families of sufferers often feel compelled to ‘accommodate’ symptoms, for example by changing their personal and family routines, performing rituals for the sufferer, or providing extensive reassurance. The extent of such changes in family behaviors has been associated with broader indices of family dysfunction, rejecting attitudes to the sufferer, and high levels of burden in family members (Calvocoressi et al., 1995 and Magliano et al., 1996). Black, Gaffney, Schlosser, and Gabel (1998) examined the impact of parental/adult OCD on nineteen families with at least one child of 7–18 using the Family Assessment Device (FAD). OCD-affected families scored significantly higher (i.e., worse) than matched controls on communication and general functioning. A follow-up to this study found the children to be more likely than controls to be suffering from a range of internalizing disorders including broadly defined OCD (Black, Gaffney, Schlosser, & Gabel, 2003). This finding is consistent with other studies indicating familiality in OCD (e.g., Grabe et al., 2006). Presence of possible cognitive and behavioral vulnerabilities pertinent to OCD (as identified by Unnewehr et al. (2002) in the case of children of parents with panic disorder) was not investigated in this study. The present study aimed to investigate how aspects of parenting might be affected by the presence of OCD in mothers because of the likelihood that children may observe the clear behavioral manifestation of symptoms for many sufferers, and the adverse impact on relationships often noted. A comparison with mothers with panic disorder was included as the levels of manifest anxiety are similar to those in OCD, and it has previously been shown that children of parents suffering from this problem are statistically more likely than healthy controls to develop anxiety problems themselves (Biederman et al., 2001 and Hettema et al., 2001). In line with most previous research, the current study examined the issues in relation to mothers; it was beyond the scope of the study to include fathers (or their relationships with mothers), who are likely to have an important and unique contribution to risk and resilience in their offspring (Bögels & Phares, 2008). In the current study, assessments of both mothers and children were carried out in order to identify (a) the mothers’ perception of how their anxiety impacted on their children and attitudes to child anxiety; (b) whether there was evidence of actual impact on the children in terms of both general child adjustment problems or disorder-specific symptomatology (c) whether the mother's diagnosis had a detectable impact on their interaction with the child, the quality of their relationship or their attitudes to the child's own anxiety. To evaluate these questions, women with children between the ages of 7 and 14 were recruited; mothers were identified as having a diagnosis of OCD, panic disorder (anxious controls), or no psychiatric diagnosis (healthy controls). It was hypothesized that the children of mothers with OCD would exhibit more general anxiety and psychopathology than healthy control children, as well as more obsessive symptomatology than both other groups. In addition, it was expected that both groups of anxious mothers would be less warm and less promoting of autonomy in interactions and would exhibit more ‘expressed emotion’ than control mothers.