Family Based Psychological Treatment For Obsessive

Clinical Child and Family Psychology Review (2019) 22:478–501
https://doi.org/10.1007/s10567-019-00296-y
Family‑Based Psychological Treatment for Obsessive Compulsive

Disorder in Children and Adolescents: A Meta‑analysis and Systematic
Review
Chloë A. McGrath1 · Maree J. Abbott1
Published online: 25 June 2019

© Springer Science+Business Media, LLC, part of Springer Nature 2019
Abstract
A significant number of children and adolescents with obsessive compulsive disorder (OCD) demonstrate poor response
to the current gold standard treatment, cognitive behaviour therapy (CBT) with exposure and response prevention (ERP).
Recent findings suggest that family variables affect treatment response highlighting the need for a meta-analytic review of the
precise impact of family variables on OCD-related symptoms and processes. The current review and meta-analysis examined
the effect of family-based interventions on OCD symptom and family factor outcomes for children and adolescents with
OCD. The moderating effects of the degree of parental involvement and number of family factors targeted in treatment were
investigated. An extensive literature search identified 37 eligible studies (1727 OCD participants). Large significant pooled
mean effect sizes for OCD symptoms and Family Accommodation (FA), respectively, were obtained at posttest (g = 1.56;
g = 1.00) and follow-up (g = 1.69; g = 1.98). Moderator analyses indicated that the number of family factors targeted in treat-
ment significantly moderated outcomes on measures of FA (z = 2.21, p = 0.03), but not on Children’s/Yale-Brown Obsessive
Compulsive Scale (C/Y-BOCS) outcomes. FA has been significantly correlated with OCD symptom severity and poorer
treatment outcomes, and there is data to suggest that FA may mediate OCD symptom outcomes (e.g., Piacentini et al. in
J Am Acad Child Adolesc Psychiatry 50:1149–1161, 2011). Findings show that the greater the number of family factors
targeted, the greater the reduction in FA at post, highlighting the importance of addressing a range of family factors in child
OCD treatment to optimise outcomes.
Keywords Obsessive compulsive disorder · Treatment · Child · Family · Meta-analysis · Systematic review
Introduction (e.g., hand washing) or mental acts (e.g., counting) that

an individual feels compelled to perform in response to
Obsessive compulsive disorder (OCD) affects 1–4% of obsessions or according to rigid rules (American Psychi-
children and adolescents (Heyman et al. 2003; Rapoport atric Association 2013). Obsessions and compulsions are
et al. 2000; Valleni-Basile et al. 1995; Zohar 1999) and is time-consuming and commonly cause significant impair-
characterised by obsessions and/or compulsions. Obses- ment in functioning across areas of life, including social,
sions include recurrent and unwanted intrusive thoughts, familial, academic, and occupational domains (American
images, or impulses that typically evoke significant anxiety Psychiatric Association 2013; Piacentini et al. 2003; Storch
or distress. Attempts are made to ignore or suppress these et al. 2010a). OCD in children and adolescents is thought
intrusions, or compulsions are performed to neutralise the to be similar to adult OCD in both prevalence and clinical
obsessions and related distress (American Psychiatric Asso- presentation. However, diagnostic criteria specify that young
ciation 2013). Compulsions involve repetitive behaviours persons are not required to have insight into their symptoms,
such as their excessive or unreasonable nature (American
Psychiatric Association 2013). In addition, young people
* Maree J. Abbott with OCD may present with compulsions without distinct
[email protected] or clearly defined obsessions (Geller and March 2012). In
1
Clinical Psychology Unit, School of Psychology (M02F), youth, the disorder typically has a chronic, yet fluctuating,
The University of Sydney, Sydney, NSW 2006, Australia course and can significantly disrupt development that occurs
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Clinical Child and Family Psychology Review (2019) 22:478–501 479
during childhood and adolescence (Piacentini et al. 2003; at pre-treatment showed poorer OCD symptom outcomes.
Storch et al. 2010a). Garcia et al. (2010) found that FA significantly predicted
Cognitive-behavioural therapy (CBT) that includes expo- treatment outcomes for young people with OCD: Youth with
sure and response prevention (ERP) has been established lower levels of FA demonstrated greater symptom improve-
as the psychological treatment of choice for children and ment across treatment conditions. FA accounted for changes
adolescents with OCD (Brauer et al. 2011; Freeman et al. in clinical symptoms in a study by Peris et al. (2017). Fur-
2018; Rosa-Alcázar et al. 2015). ERP involves prolonged thermore, in a trial by Piacentini et al. (2011), FA mediated
and repeated exposure to feared obsessional stimuli (e.g., OCD symptom outcomes and a reduction in FA was found
dirt; thoughts about death of a parent), while refraining from to temporally precede OCD symptom change.
engaging in compulsions (e.g., hand washing; checking on a Recent findings suggest that other family variables may
parent). As distress reduces with repeated exposure and by also affect treatment response. Peris et al. (2012a) found
refraining from performing rituals, the individual learns that that families demonstrating higher levels of cohesion and
compulsions are not necessary to manage distress or to pre- lower levels of family conflict and blame of the young per-
vent the occurrence of feared events. However, a significant son prior to treatment were more likely to have a child who
number of young people with OCD either fail to respond to responded to CBT. Families that exhibited higher function-
ERP-based CBT or demonstrate only partial response. In ing in all three aforementioned domains had a 93% response
the largest RCT to date examining treatment outcomes for to treatment compared to a 10% treatment response for fami-
children and adolescents with OCD, 60% of participants in lies with poorer functioning in these three domains. High
the ERP-based CBT condition failed to demonstrate clinical maternal expressed emotion (i.e., criticism and/or emotional
remission (POTS Paediatric OCD Treatment Study (POTS) overinvolvement) has been identified as a predictor of poor
Team 2004). Recent findings have identified that the family treatment response for young people with OCD (Peris et al.
environment can affect treatment response. 2012b). Other family factors associated with the develop-
Family accommodation (FA) has been the focus of much ment and maintenance of child/adolescent OCD, and there-
of the recent research examining family environment fac- fore relevant to treatment outcome, include over-responsi-
tors in child/adolescent OCD. FA is the process whereby bility placed on children (Farrell et al. 2013; Mathieu et al.
other family members participate in or assist with a child’s 2015; Pietrefesa et al. 2010), poor family problem-solving
OCD symptoms. FA can range from active participation in skills (Barrett et al. 2002), and high parental control of
symptoms (e.g., answering a child’s repetitive questions in child behaviour, such as overprotection (Haciomeroglu and
an attempt to reduce their distress) to family members assist- Karanci 2013; Timpano et al. 2010).
ing with the avoidance of anxiety-provoking situations and/ Practise guidelines and reviews of the child and adoles-
or modifying daily routines to assist with OCD (Lebowitz cent OCD literature commonly highlight the importance of
et al. 2012). The most common types of FA involve provid- involving family members in treatment to optimise treatment
ing reassurance and waiting for the completion of rituals response (e.g., Brauer et al. 2011; Freeman et al. 2018; Gel-
(Lebowitz et al. 2012). Rates of FA are remarkably high in ler and March 2012). However, the degree to which family
families with a child with OCD, with the majority of fami- members are included in treatment and the nature of their
lies involved in frequent accommodation of OCD symptoms. involvement vary significantly across studies and treatment
Flessner et al. (2011) found that 99% of parents reported programs. Interventions that involve family members typi-
participating in at least one type of accommodation behav- cally fall into two broad categories: (1) Interventions where
iour and 77.1% reported daily FA. FA can be negatively family member(s) attend treatment sessions to some extent,
reinforcing for parents by temporarily reducing both child however family factors are not specifically targeted; and (2)
distress and parental distress associated with managing a Interventions that involve family member(s) and actively
child with OCD symptoms (Kagan et al. 2017; Lebowitz target family factors. Category 1 acts as a useful control
et al. 2014). Although generally well intentioned, FA rein- with which to compare interventions that directly address
forces child avoidance behaviours (contradictory to the goals family factors.
of ERP) and maintains OCD symptoms and anxiety (Kagan In the only RCT to date to compare Category 1 and Cat-
et al. 2017; Wu et al. 2016). FA has been strongly associated egory 2 interventions for young people with OCD, Reyn-
with OCD symptom severity (e.g., Lebowitz et al. 2012; olds et al. (2013) investigated low and high levels of family
Strauss et al. 2015; Wu et al. 2016) and child functional involvement (FI) in a CBT intervention. Low FI was char-
impairment (e.g., Bipeta et al. 2013; Caporino et al. 2012). acterised by parents attending 3 of the 14 sessions and no
FA has also been linked to significantly reduced treatment family factors were directly addressed (Category 1), whereas
outcomes (e.g., Garcia et al. 2010; Gorenstein et al. 2015; high FI comprised parents attending all sessions and FA
Peris et al. 2017; Piacentini et al. 2011). In a trial by Gore- was targeted (Category 2). Low FI and High FI groups both
nstein et al. (2015), young people with higher FA scores demonstrated large positive effect sizes at posttest (d = 1.45;
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480 Clinical Child and Family Psychology Review (2019) 22:478–501
d = 1.27) and follow-up (d = 1.53; d = 1.50), with no signifi- and problem-solving) with results indicating nil significant
cant differences found between groups. However, the authors treatment-moderating effects. Importantly, the number of
acknowledged that the sample size was small and the study family factors addressed in treatment has yet to be explored
underpowered. Further investigation into Category 1 and as a potential treatment moderator.
2 studies is necessary to better understand optimal family
involvement. Aims and Objectives
Recent treatment programs have been extended to
directly target some of the family factors identified to date The current study aims to evaluate the effectiveness of fam-
in the child and adolescent OCD literature. Barrett et al. ily-based interventions for children and adolescents with
(2004) added 30 minutes of parent skills training (targeting OCD using both meta-analytic and systematic review tech-
problem-solving and FA) to one-hour child-focused CBT niques. A family-based intervention was broadly defined as
sessions. Similarly, Piacentini et al. (2011) supplemented an intervention that included a parent to some extent, regard-
child-focused sessions with 30-min family sessions address- less of whether or not family factors were specifically tar-
ing parental blame of the young person, FA, and unhelpful geted. This study, therefore, includes two broad categories of
patterns of family interaction. One-h family sessions were family-based interventions: (1) parental involvement without
added to child-focused sessions every second week in studies addressing family factors directly and (2) parental involve-
by Peris and Piacentini (2013) and Peris et al. (2017), target- ment with the direct targeting of family factors. The effect
ing FA, family conflict, and blame, and enhancing cohesion of Category 1 and Category 2 family-based treatments on
and problem-solving skills. Excellent treatment outcomes OCD symptoms as well as on FA, the primary family factor
have been reported where a number of family factors have assessed by included studies, is investigated. In addition, the
been addressed, as evidenced by large effect sizes (d = 2.65, effect of family-based treatments on a range of other family
Barrett et al. 2004; d = 2.37, Piacentini et al. 2011; d = 2.59, variables, including blame, cohesion, conflict, and general
Peris and Piacentini 2013; d = 2.07, Peris et al. 2017). A family functioning, is calculated in the systematic review.
better understanding is required of the key family factors This is the first study to consider the relative effectiveness
to target in OCD interventions for young people to enhance of CBT with, versus without, the direct targeting of family
treatment response. factors.
The current meta-analysis examines the moderating
Previous Meta‑analyses and Systematic Reviews effects of family-related treatment variables on OCD symp-
tom and FA outcomes for young people with OCD. This
The effectiveness of CBT in the treatment of child/adoles- is the first meta-analytic study to examine the number of
cent OCD has been well established (Freeman et al. 2018). family factors addressed in treatment as a potential treat-
Some initial meta-analytic support has been provided for the ment moderator. The effects on treatment outcomes of a
effectiveness of family-based CBT for young people with large number of family factors is examined, including FA,
OCD (Iniesta-Sepúlveda et al. 2017; Thompson-Hollands problem-solving skills, conflict, blame/criticism, and com-
et al. 2014). Very few studies have considered the effec- munication. In addition, this study explores the moderating
tiveness of these interventions regarding family factor out- effects of the type and degree of parental/family involve-
comes, such as FA. Importantly, meta-analytic studies have ment in treatment. Rather than code for parental/family
not yet identified many within-group treatment modera- involvement using broad categories or rating scales (e.g.,
tors systematically affecting response to treatment. Neither low, moderate, high), a more precise method was used: The
mode of treatment (e.g., individual vs group) nor therapeu- proportion of the total treatment time that parents were seen
tic components (e.g., psychoeducation, cognitive training, alone, as well as when participating in family sessions, was
contingency management) has been found to significantly calculated. Quantifying parental/family involvement allows
and consistently affect treatment outcomes at a meta-ana- for a more objective examination of the number of fam-
lytic level (e.g., Olatunji et al. 2013). Very few studies have ily factors targeted in treatment. The current study aims to
explored the effect of family-related within-group treatment illuminate family-related treatment factors associated with
moderators. Rosa-Alcázar et al. (2015) investigated the mod- improved outcomes.
erating effect of level of parental involvement on treatment The systematic review component of the current study
outcomes and found that parental involvement (low, moder- analyses eligible studies according to seven main categories:
ate, high) had a significant relationship (p = .002) with OCD Study design, participants, assessment, treatment, outcome
symptom outcomes, explaining 34% of variance. Iniesta- measures, and symptom and family factor outcomes. Stud-
Sepúlveda et al. (2017) examined various techniques used ies are also assessed for risk of bias according to domains
in parenting components of interventions (i.e., FA; expo- defined by the Cochrane Handbook for Systematic Reviews
sure assistance training; contingency management training; of Interventions (Higgins and Green 2011). Thus, the quality
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and reliability of the research and findings are evaluated for means and standard deviations) were excluded. In addition,
all included studies. The preferred reporting items for sys- studies with a very small sample size (n ≤ 5) were excluded.
tematic reviews and Meta-Analyses (PRISMA) guidelines Where studies included several diagnostic groups, the results
inform the summarising of information and reporting of for OCD participants were required to be reported separately
results, and meta-analytic guidelines for conducting statistics to be eligible for inclusion. Finally, studies with non-Eng-
are used (Liberati et al. 2009). The meta-analysis synthesises lish-speaking populations were excluded. All abstracts were
the results of eligible studies and examines the moderating reviewed by a second rater and a 97% agreement rate was
effects of family-related treatment factors, including number obtained. Differences in ratings were discussed and 100%
of family factors targeted in treatment, total parent hours, agreement was reached on abstracts to be retained for the
and total family hours, on treatment outcomes (both OCD full text review. Full text articles were reviewed and dis-
symptom and FA outcomes). cussed with the second rater prior to inclusion in the review
and 100% agreement was reached on papers meeting the
selection criteria. Out of the 872 articles screened, a total of
Method 37 studies were eligible for inclusion in the current review.
Publication dates ranged from 1994 to 2018.
Search Strategy
Data Analysis
An extensive literature search was conducted using the
databases: PsychInfo, Medline, Cochrane Central Register The 37 eligible research articles were reviewed to extract
of Controlled Trials, and PubMed to identify published treat- relevant data, including study design, participant character-
ment studies that included family-based treatment interven- istics, diagnostic and outcome measures, intervention type
tions for children and adolescents with OCD. The key search and characteristics (level of family involvement and whether
terms employed included: (obsessive compulsive disorder or or not family factors were targeted), and outcomes. Authors
OCD or 1obsessive/compulsive neurosis) AND (interven- were contacted to request any relevant information not
tion or therapy or trial or manual or treatment or cognitive included in the published articles and this data were incor-
behavio(u)r therapy, or CBT or exposure and response pre- porated where provided. All corresponding authors were
vention or ERP or psychotherapy or program) AND (child furnished with their study’s respective calculations compris-
or p(a)ediatric or adolescent or teen or schoolchild or boy ing Table 2 (and used in moderator analyses) and invited to
or girl or preschool or youth or young person/people) AND provide any additional information not included in the pub-
(family or parent or mother or father or home or primary lished papers. A total of 64% of studies’ authors responded,
carer/caregiver or attachment or paternal or maternal). the majority to confirm the data presented to them. To
Limits were set to include only peer-reviewed journal arti- evaluate the effectiveness of each study’s intervention(s), in
cles written in English. No limits were placed on publication particular the degree of symptom and family factor change
date. Reference lists of relevant articles were also examined over time, within-group effect sizes (Cohen’s d) for pre-post
to identify any additional studies relevant to the review. The and pre-follow-up treatment effects were calculated for all
final search was conducted on 16 May 2018. relevant outcome measures. Cohen’s d within-group effect
sizes for control conditions (e.g., waitlist) are available on
Selection and Exclusion request from authors.
Risk of bias was evaluated according to domains identi-
Titles, abstracts, and full texts were systematically reviewed fied in the Cochrane Collaboration’s Tool for Assessing Risk
to eliminate studies that did not meet inclusion criteria of Bias (Higgins et al. 2011): Selection bias (random alloca-
for the review. Refer to Fig. 1 for a PRISMA flowchart of tion; allocation concealment), performance bias (blinding
the selection process. Studies retained for further review of participants and personnel), detection bias (blinding of
were treatment trials involving children and adolescents outcome assessment—client report/externally rated), attri-
(0–18 years old) with a principal diagnosis of OCD. Stud- tion bias (incomplete outcome data—post/follow-up), and
ies were only included if the OCD intervention involved a reporting bias (selective reporting). Risk of bias ratings (low,
family member to some extent for all cases. Studies (e.g., high, or uncertain) were assigned to studies for each of the
case studies and case series) that did not include sufficient aforementioned categories, where relevant. Risk of bias was
quantitative statistics to calculate effect sizes (e.g., overall assessed by a second rater for 35% of the articles and a 96%
agreement rate was obtained.
1 Meta-analytic statistics were employed using the pro-
Current and past conceptualisations of OCD were used to broaden
the literature search and enhance identification of all potentially rel- gram Comprehensive Meta-Analysis (CMA; Borenstein
evant research articles. et al. 2005). The random effects model, rather than the fixed
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Fig. 1 PRISMA flowchart of
Psychinfo (n = 554)
study selection process Medline (n = 48)
Cochrane Register of Controlled Trials (n = 78)
Pubmed (n = 415)
Reference lists of relevant articles (n = 6)
Search results combined (n = 1101)
Duplicates deleted (n = 229)
Articles screened on titles (n = 872)
Excluded (n = 581)
68 Case study/series
275 Non-psychological treatment trial
201 Non-OCD
26 Adult population
11 Non-English-speaking population
Articles screened on abstracts (n = 291)
Excluded (n = 195)
28 Case study/series
17 Non-OCD/OCD-specific
22 Adult population
2 Focus not on OCD symptom outcome
2 Parent/s not involved
Review of full texts (n = 96)
Excluded (n = 59)
3 Non-OCD/OCD-specific
6 Adult population
8 Focus not on OCD symptom outcome
3 Parent/s not involved
22 Duplicate article derived from same sample
Included (n = 37)
effects model, was used for all analyses as the included (i.e., the true effects vary from study to study). The I2 statis-
studies varied somewhat in design and participant popula- tic indicates the degree to which variation between studies
tion (Borenstein et al. 2009). Within-group effect sizes and is due to heterogeneity and is reported in percentages, where
variances were calculated using the Hedge’s g statistic to 0% reflects no heterogeneity, 25% indicates low heterogene-
assess pre-post and pre-follow-up treatment effects for the ity, and 50% and 75% reflect moderate and high heterogene-
main OCD symptom and family factor measures. As rec- ity, respectively. Risk of publication bias was determined
ommended by Rosenthal (1993), a conservative estimate using Duval and Tweedie’s Trim and Fill Procedure (2000a,
(r = 0.7) of the correlations between pre- and post-treatment b). The pooled effect size is adjusted in order to yield an
measures was used as these were not typically reported in unbiased estimate of the effect size. In addition, the Classic
included articles. Within-group pooled mean effect sizes fail-safe N (Rosenthal 1979) was calculated to identify the
were also computed. Heterogeneity was assessed using number of missing papers required to reduce a significant
Cochran’s Q statistic and p value, and the I2 statistic. A sig- p value to less than alpha (< 0.05). Meta-regression analy-
nificant p value for the Q statistic indicates heterogeneity ses were employed to investigate moderators of treatment
13
effects. The variables investigated included Family Hours Yale-Brown Obsessive Compulsive Scale (CY-BOCS; Sca-
(the proportion of total treatment time that parents/family hill et al. 1997; 33 studies) or the Y-BOCS (Goodman et al.
members attended treatment sessions with the young per- 1989; 2 studies). A range of other symptom measures were
son), Parent Hours (the proportion of total treatment time also used, as reported in Table 1 and Table 3. A total of 32%
that parents were seen on their own during treatment), and of studies assessed family factors: All 12 studies assessed FA,
Number of Family Factors (the number of family factors predominately (75%; n = 9) using the Family Accommodation
directly targeted in treatment). Scale (FAS; Calvocoressi et al. 1995, 1999; FAS-PR; Flessner
et al. 2009). A second family variable was only assessed pre-
and post-treatment in 11% of studies (n = 4) using a range of
Results measures reported in Table 1 and Table 3. Behavioural tasks
were rarely used (5% of studies; n = 2).
Systematic Review
Treatment Program Characteristics
Demographics, Assessment and Outcome Measures
All studies used a CBT with ERP intervention. The majority
Refer to Table 1 for details. of studies (76%; n = 28) delivered treatment in an individual
face-to-face format (I), followed by group (G; 24%; n = 9) and
individual remote (R; audio/video calls; 16%; n = 6) formats.
Participant Characteristics A total of 32% of studies reported that treatment was based on
March and Mulle’s (1998) CBT manual. The remaining stud-
A total of 1727 participants comprised the 37 studies included ies used a range of other CBT treatment programs outlined
in the review. Sample sizes of included studies ranged from in Table 2.
6 to 204 participants, with a median sample size of 31 par- The total number of treatment hours provided across
ticipants. The mean age of OCD participants ranged from 5.8 studies ranged from 8 to 33 h over a range of 3–18 weeks
to 14.5 years (Mdn = 12.8 years). The median percentage of (Mdn = 17 h/13 weeks). Programs included time with par-
female participants was 45%, with a range of 17–67%. ents without the young person present in 49% of studies for a
median of 5.5 h (range = 0.5–13.5 h). The number of family
hours provided, where family members (usually parent/s) were
Study Design Characteristics included in sessions with the young person, ranged from 0 h
to 21 h across studies, with a median of 6 h.
The majority of studies were designed as uncontrolled tri- A total of 14% (n = 5) of studies did not directly address
als (UCT; 51%), followed by randomised controlled trials family factors during treatment, and therefore, comprise Cat-
(RCT; 41%) and multiple baseline controlled trials (MBCT; egory 1. The remaining 86% (n = 32) of studies met criteria for
8%). A total of 65% of the studies included a follow-up time Category 2 by targeting at least one family factor in treatment.
point for outcome measures, with a range of 1–18 months FA was the family factor most commonly targeted, in a total of
(Mdn = 6 months). 97% (n = 31) of Category 2 studies. The majority of Category
2 studies (47%; n = 15) reported addressing a total of one fam-
ily factor during treatment, either FA (93%; n = 14), or conflict
Assessment Measures (7%; n = 1). Fewer studies addressed a second (28%; n = 9) or
third (19%; n = 6) family factor. Only 2 studies (6%) reported
The majority of studies used semi-structured interviews to targeting more than three family factors in treatment: Peris and
establish clinical diagnoses for participants: 65% of stud- Piacentini (2013) and Peris et al. (2017) addressed a total of
ies used the Anxiety Disorders Interview Schedule – Child/ five family factors in their interventions.
Parent versions (ADIS-C/P; Silverman et al. 1996) and 11%
used the Kiddie Schedule for Affective Disorders and Schiz- Overall Treatment Effects for Symptom and Family Factor
ophrenia—Present/Lifetime versions (K-SADS-P/L; Kauf- Measures
man et al. 1997). Clinical interviews (CI) were employed in
the remaining 24% of studies. As detailed in Table 3, all studies demonstrated a large positive
within-group effect for pre- to post-treatment and pre-treatment
Outcome Measures to follow-up time points for the main OCD symptom measure
used, the C/Y-BOCS. Cohen’s d effect sizes for the C/Y-BOCS
The primary outcome measure used to assess OCD symp- ranged from d = 0.79 to d = 3.61 (Mdn d = 1.88) for Pre-Post,
toms in the majority (95%) of studies was the Children’s and d = 1.31 to d = 3.34 (Mdn d = 2.01) for Pre-Follow-up. The
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Table 1 Demographics, assessment and outcome measures

484
Outcome measures
13
No. Study N % F Age M (SD) Design Dx interview F/up C/Y-BOCS Other OCD Anxiety Depression Behaviour Parent FA Other fam. Beh. task
1 Barrett et al. (2003) 24 42 11.21 (0.54) RCT ADIS-P ✓ ✓ ✓

2 Barrett et al. (2004, 2005) 77 51 11.87 (2.74) RCT ADIS-P ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓
3 Benazon et al. (2002) 16 50 NR UCT K-SADS-L (C/P) ✓ ✓ ✓ ✓
4 Comer et al. (2017) 22 41 6.65 (1.3) RCT ADIS-C/P ✓ ✓ ✓ ✓
5 Farrell et al. (2010) 35 46 12.29 (2.59) UCT ADIS-P ✓ ✓ ✓ ✓
6 Farrell et al. (2012) 43 30 11.09 (2.52) UCT ADIS-P ✓ ✓ ✓
7 Farrell et al. (2016) 10 40 13.6 (1.84) MBCT ADIS-P ✓ ✓ ✓ ✓ ✓
8 Fernandez de la Cruz et al. 153 48 14.22 (2.38) UCT CI ✓
(2013)
9 Fernandez de la Cruz et al. 204 47 14.29 (2.29) UCT CI ✓
(2015)
10 Fischer et al. (1998) 15 40 14.5 (1.73) UCT CI ✓ ✓
11 Franklin et al. (1998) 14 29 14.1 (2.2) UCT CI ✓ ✓ ✓
12 Freeman et al. (2008) 42 57 7.11 (1.26) RCT K-SADS-PL (C/P) ✓
13 Freeman et al. (2014) 127 53 7.2 (1.2) RCT K-SADS-PL (C/P) ✓ ✓
14 Hudson et al. (2015) 34 NR NR UCT ADIS-C/P ✓ ✓ ✓
15 Lavell et al. (2016) 43 30 11.09 (2.52) UCT ADIS-P ✓ ✓ ✓
16 Lewin et al. (2014) 31 29 5.8 (1.6) RCT ADIS-P ✓ ✓ ✓ ✓ ✓
17 March et al. (1994) 15 67 14.3 (NR) UCT CI ✓ ✓ ✓
18 Martin and Thienemann 14 64 11.3 (NR) UCT CI ✓ ✓ ✓ ✓ ✓
(2005)
19 Merlo et al. (2010) 16 38 13.3 (3.0) RCT ADIS-C/P ✓
20 Nakatani et al. (2011) 109 49 NR UCT CI ✓
21 Peris and Piacentini (2013) 20 45 12.35 (2.58) RCT ADIS-C/P ✓ ✓ ✓ ✓ ✓
22 Peris et al. (2017) 62 43 13.12 (2.68) RCT ADIS-C/P ✓ ✓ ✓ ✓ ✓
23 Piacentini et al. (2002) 42 60 11.8 (3.5) UCT CI/ADIS-C/P ✓
24 Piacentini et al. (2011) 71 63 12.2 (2.5) RCT ADIS-C/P ✓ ✓ ✓ ✓
25 POTS (2004) 112 50 11.78 (2.74) RCT ADIS-C ✓
26 Reynolds et al. (2013) 50 52 14.38 (1.50) RCT ADIS-C/P ✓ ✓ ✓ ✓
27 Scahill et al. (1996) 7 29 13 (2.02) UCT CI ✓ ✓
28 Selles et al. (2018) 85 54 13.9 (2.49) UCT ADIS-P ✓ ✓ ✓ ✓ ✓ ✓
29 Storch et al. (2007) 40 55 13.3 (2.7) RCT ADIS-P ✓ ✓ ✓ ✓ ✓ ✓
30 Storch et al. (2010) 30 50 13.4 (3.2) UCT ADIS-P ✓ ✓ ✓ ✓ ✓ ✓ ✓
31 Storch et al. (2011) 31 39 11.10 (2.59) RCT ADIS-C/P ✓ ✓ ✓ ✓ ✓ ✓
32 Sukhodolsky et al. (2013) 6 17 13 (2.38) MBCT K-SADS-PL ✓ ✓
33 Turner et al. (2009) 10 20 NR UCT CI ✓ ✓ ✓
first follow-up time point was used in calculations where stud-
% F Percentage female participants, Age M (SD) Age mean (standard deviation), NR Not reported, RCTRandomised controlled trial, UCTUncontrolled trial, MCBT Multiple baseline controlled
lifetime version, CI Clinical interview, F/up Follow-up, C/Y-BOCS Children’s/yale-brown obsessive compulsive scale, Other OCD Other OCD symptom measures, FA Family accommodation,
trial, Dx interview Diagnostic interview, C Child; P Parent, ADIS Anxiety disorders interview schedule, K-SADS-PL Kiddie schedule for affective disorders and schizophrenia—present and
F/up C/Y-BOCS Other OCD Anxiety Depression Behaviour Parent FA Other fam. Beh. task
ies reported multiple follow-up time points.
All studies indicated positive treatment effects on measures
of FA: 10 studies demonstrated large effects and 1 study a
medium effect at posttest, and at follow-up 5 studies showed a
large effect and 1 study a small effect. Effect sizes for measures
✓
of FA ranged between d = 0.52 and d = 2.04 (Mdn d = 1.04) for

✓ Pre-Post and from d = 0.32 to d = 1.77 (Mdn d = 1.29) for Pre-
✓
Follow-up. An extended table with Cohen’s d within-group

effect sizes for anxiety, depression, behaviour, and parent
✓
symptom measures is available on request from authors.
Risk of Bias
Table 4 illustrates that overall a Low risk of bias status was

identified for studies in the categories: Blinding of outcome
assessment (client report), Incomplete outcome data—Post,
✓
✓
✓
and Follow-up (where relevant), and Selective reporting, with

the majority of studies receiving a Low risk rating. The catego-
ries comprising Selection bias, namely Random sequence gen-
✓
✓
eration and Allocation concealment, were not relevant to the

designs of a large percentage (51%) of included studies. Where
Outcome measures
relevant, the majority of studies (30%) received an Unclear

✓
✓
✓
✓
risk of bias rating as insufficient information was provided

in the aforementioned two categories to assist with making
clear decisions regarding how well studies complied with best
practise. The majority (86%) of the remaining seven studies
✓
✓
✓
✓
were evaluated to be at Low risk of bias in both categories. The

category of Blinding of participants/personal comprising Per-
✓
✓
✓
✓
formance bias was not applicable to the design of 86% of the

studies. Where applicable, most of the studies (80%) received
% F Age M (SD) Design Dx interview
an Unclear rating. The Blinding of outcome assessment (exter-

ADIS-C/P
ADIS-C/P
MBCT ADIS-C
ADIS-C
nally rated) category predominately received Low risk of bias

ratings (57%), however, a large percentage of studies (38%)
Other fam. Other family factor measures, Behav. Task Behavioural tasks
received Unclear ratings. Overall, the studies included in this

13.13 (2.1) UCT
UCT
review were evaluated as meeting criteria for low risk of bias,

14.35 (2.12) RCT
generally indicating research of sound quality. However, more

detailed information provided in published papers related to
12.59 (3.1)
randomisation (where relevant) and assessment procedures

would enhance appraisal of the quality of research and reli-
NR
ability of findings.
32
44
40
46
Meta‑analysis
22
16
72
N
C/Y‑BOCS Within‑Group Effects

Whiteside, McKay et al.
Whiteside and Jacobsen
Hedges’s g within-group effect sizes were generated for the

Waters et al. (2001)
Turner et al. (2014)
30 studies (N = 1227) assessing OCD symptoms at pre- and

Table 1 (continued)
post-treatment using the C/Y-BOCS (see Fig. 2a). All studies

indicated a significant positive effect: two studies showed a
(2014)
(2010)
No. Study
medium effect according to Cohen’s (1988) rule of thumb

and the remaining 32 studies demonstrated a large effect.
The pooled mean effect size was g = 1.56, 95% CI [1.42,
37
36
35
34
13

Table 2 Treatment characteristics
486
Family factors Intervention time
13
No. Study Treatment program Format FA Prob. S Confl. B/C Comm. Total Hrs/weeks Parent Hrs/total Hrs Fam. Hrs/total Hrs
1 Barrett et al. (2003) March and Mulle (1998); Waters I ✓ ✓ 21/14 7/21 3.5/21
et al. (2001) (parent)
2 Barrett et al. (2004, 2005) Barrett et al. (2004) I; G ✓ ✓ 21/14 7/21 2.3/21
3 Benazon et al. (2002) March and Mulle (1998); I ✓ 12/12-16 0/12 5.3 +/12
Schwartz (1996)
4 Comer et al. (2017) Freeman and Garcia (2009) I; R ✓ 12/14 0/12 12/12
5 Farrell et al. (2010) Barrett et al. (2004) I; G ✓ ✓ 12/12 (I); 18/12 (G) 3-6/12 (I); 3-6/18 (G) 0/12 (I); 0/18 (G)
6 Farrell et al. (2012) Farrell and Waters (unpublished) G ✓ ✓ ✓ 24.5/13 3/24.5 5.25/24.5
7 Farrell et al. (2016) Farrell et al. (2016) I + R ✓ ✓ 9.25/5 0/9.25 4.25-5.25/9.25
8 Fernandez de la Cruz et al. Turner et al. (unpublished) I ✓ 12-14/12-14 0/12-14 2-(12-14)/12-14
(2013)
9 Fernandez de la Cruz et al. Turner et al. (unpublished) I ✓ 12-14/12-14 0/12-14 2-(12-14/12-14
(2015)
10 Fischer et al. (1998) Krone et al. (1991) G ✓ ✓ 12/7 0/12 1.5/12
11 Franklin et al. (1998) Authors’ protocol I 16/16 or 27/4 0/16 or 0/27 1 + (e)/16 or 1.5 + (e)/27
12 Freeman et al. (2008) Freeman and Garcia (2009); I ✓ ✓ ✓ 13/14 3/13 10/13
Piacentini et al. (2007)
13 Freeman et al. (2014) Freeman and Garcia (2009) I ✓ ✓ ✓ 13/14 3/13 10/13
14 Hudson et al. (2015) Lyneham et al. (2003) G 18-24(e)/11-12 6.75-12 (e)/18-24 4.5-6 (e)/18-24
15 Lavell et al. (2016) Farrell and Waters (unpublished) G ✓ ✓ ✓ 24.5/13 3/24.5 5.25/24.5
16 Lewin et al. (2014) Freeman and Garcia (2009) I ✓ 12/6 0/12 12/12
(modified)
17 March et al. (1994) March and Mulle (1998) I ✓ 16/16 0/16 6.25(e)/16
18 Martin and Thienemann (2005) March and Mulle (1998) G ✓ ✓ 33/14 12/33 9/33
19 Merlo et al. (2010) Lewin et al. (2005) I 22-22.5/3 0/22-22.5 22-22.5/22-22.5
20 Nakatani et al. (2011) Turner et al. (unpublished) I; G; R ✓ 8-12/8-12 0/8-12 1-(8-12)/8-12
21 Peris and Piacentini (2013) Peris and Piacentini (2016) I ✓ ✓ ✓ ✓ ✓ 18/14 0.5/18 6/18
22 Peris et al. (2017) Peris and Piacentini (2016) I ✓ ✓ ✓ ✓ ✓ 18/14 0.5/18 6/18
23 Piacentini et al. (2002) Piacentini et al. (1994) I ✓ ✓ 12.5/12.5 (m) 3.1-4.13/12.5 0/12.5
24 Piacentini et al. (2011) Piacentini et al. (2007) I ✓ ✓ 18/14 8/18 0/18
25 POTS (2004) March and Mulle (1998) (modi- I ✓ 14/12 0/14 3/14
fied)
26 Reynolds et al. (2013) Derisley et al. (2008) I ✓ 11.7/14 0/11.7 11.7/11.7
27 Scahill et al. (1996) NR - Authors’ protocol I ✓ 19/9-14 5 +/19 3/19
28 Selles et al. (2018) McKenney and Simpson (2011) G ✓ ✓ ✓ 30-33/12 12-15/30-33 3-6/30-33
29 Storch et al. (2007) Lewin et al. (2005); POTS (2004) I ✓ ✓ 21/3 or 21/14 0/21 21/21
✓
30 Storch et al. (2010) POTS (2004) I 21/3 0/21 21/21

1.7], p = 0.000, indicating a large, significant effect. Tests
I Individual face-to-face treatment format, G Group, R Remote (audio/video calls), FA Family accommodation, Prob. S Problem solving, Confl. Conflict, B/C Blame/criticism, Comm. Commu-
of heterogeneity demonstrated the presence of high-mod-
Fam. Hrs/total Hrs
7.72-11.5/8.3-12.5
erate significant heterogeneity, Q (33) = 125.28, p = 0.000,
8.3-12.5/8.3-12.5
I2 = 73.66%. Hedges’s g within-group effect sizes were gen-
14-21/14-21
erated for the 20 studies (n = 575) reporting pre- and follow-
up scores for the C/Y-BOCS (see Fig. 2b). The pooled mean
3-5/18
2.3/14
2.3/14
6/21
effect size was g = 1.69, 95% CI [1.53, 1.85], p = 0.000,
indicating a large, significant effect. Tests of heterogeneity
Parent Hrs/total Hrs
showed significant moderate heterogeneity, Q (23) = 55.53,

p = 0.000, I2 = 58.58%. The difference between the pooled
mean effect size generated for pre-post and for pre-follow-up
0/8.3-12.5
0/8.3-12.5
time points was not significant (p = 0.22).
0/14-21
4.5/21
6/18
0/14
0/14
FA Within‑Group Effects
Intervention time
Format FA Prob. S Confl. B/C Comm. Total Hrs/weeks
Hedges’s g within-group effect sizes were computed for the

nine studies (n = 274) assessing FA at pre- and post-treat-
8.3-12.5/5
8.3-12.5/5
14-21/12
ment (the 11 values are detailed in Fig. 3a). All studies indi-

21/14
18/18
14/14
14/17
cated a significant positive effect: eight values demonstrated

a large effect, and two values a medium effect. A significant
large pooled mean effect size of 1.00, 95% CI [0.8, 1.21],
p = 0.000, was calculated. Significant moderate heteroge-
neity was indicated, Q (10) = 29.7, p = 0.001, I2 = 66.33%.
✓
Hedge’s g within-group effect sizes were calculated for the

six studies (n = 196) assessing FA at pre-treatment and fol-
low-up time points, outlined in Fig. 3b. A significant, large
✓
Family factors
pooled mean effect size of g = 1.98, 95% CI [0.83, 1.53],

p = 0.000, was computed. Significant, high heterogeneity
✓
was indicated, Q (7) = 36.38, p = 0.000, I2 = 80.76%. The dif-

ference between the pooled mean effect size for pre-post and
✓
✓
✓
✓
for pre-follow-up time points was not significant (p = 0.75).

I + R
I; R
R
I
I
I
Publication Bias
March and Mulle (1998); Barkley
Mulle 1998); Authors’ protocol
Authors’ manual (unpublished)

Authors’ manual (unpublished)
March et al. (1994; March and
et al. (1997; 1999) (parent)
Duval and Tweedie’s Trim and Fill Procedure (2000a, b)

Turner et al. (unpublished)
Turner et al. (unpublished)
was employed to provide an adjusted pooled mean effect

size for the C/Y-BOCS, taking into account any publica-
Treatment program
tion bias identified in the funnel plot (see Fig. 4). The mean
effect size was reduced from g = 1.56 to g = 1.42 (n = 8 val-
POTS (2004)
ues removed), to yield an estimate of the unbiased pooled

(parent)
effect size. An adjusted mean effect size for FA was also

computed: The pooled mean effect size was reduced from
g = 1.00 to g = 0.9 (n = 2 values removed).
Whiteside, McKay et al. (2014)
Whiteside and Jacobsen (2010)
Publication bias was also assessed using the Classic fail-

nication, (e) Estimated, (m) Mean
safe N calculation (Rosenthal 1979). The number of miss-

Sukhodolsky et al. (2013)
ing papers needed to reduce the p value to less than alpha

(< 0.05) was calculated as 6152 papers. As the total num-
Waters et al. (2001)
Storch et al. (2011)
ber of studies meeting inclusion criteria for this review was

37, it is highly unlikely that 6152 papers were missed. This

suggests that publication bias does not affect the significant
No. Study
relationship found between family-based interventions for

children and adolescents with OCD and OCD symptom out-
come measured by the C/Y-BOCS.
36
37
33
34
35
31
32
13

Table 3 Cohen’s d within-group pre-post and pre-follow-up effect sizes for OCD symptom and family factor measures
488
No. Dx d Dx F/up d C/Y-BOCS d C/Y-BOCS F/up d Other OCD d Other OCD F/up d FA d FA F/up d O. Fam. d O. Fam. F/up d
13
1 NR* NIMH-GOCS NR*
2 (I) 2.65* 12 m (I) 2.64b NIMH-GOCS (I) 12 m NIMH-GOCS (I) 3.11b SAS (I) NRb Mo FAD (I) -0.24 12 m (I) Mo FAD
2.66* 0.70* 0.46b
(G) 2.01* 18 m (I) 2.20b NIMH-GOCS (G) 18 m NIMH-GOCS (I) 2.71b SAS (G) Mo FAD (G) -0.23 18 m (I) Mo FAD
3.05* 0.65* 0.59b
12 m (G) 2.13b CGI-I (W6-P) (I) 12 m NIMH-GOCS (G) 3.79b Fa FAD (I) -0.27 12 m (I) Fa FAD
1.21* -0.13b
18 m (G) 2.28b CGI-I (W6-P) (G) 18 m NIMH-GOCS (G) 3.97b Fa FAD (G) 0.00 18 m (I) Fa FAD
2.47* 0.28b
12 m (G) Mo
FAD 0.37b
18 m (G) Mo
FAD 0.67b
12 m (G) Fa FAD
0.75b
18 m (G) Fa FAD
0.99b
3 1.65* NIMH-GOCS NR*
4 (R) 1.67* 6 m (R) (R) 1.35* 6 m (R) 1.52* CGI-S (R) 1.45* 6 m CGI-S (R) 1.25* FAS (R) 6 m FAS (R)
1.40* 1.14* 1.21*
(I) 1.61* 6 m (I) (I) 1.51* 6 m (I) 1.99* CGI-S (I) 1.0* 6 m CGI-S (I) 1.39* FAS (I) 6 m FAS (I)
1.24* 0.93* 1.55*
CGAS (R) 1.31* 6 m CGAS (R) 1.48*
CGAS (I) 0.61* 6 m CGAS (I) 0.86*
5 2.13* NIMH-COGS 2.01*
CGI-S 2.13*
COIS-P 0.51*
COIS-C 0.54*
6 1.61* 6 m 1.57* 0.92* 6 m 1.43* NIMH-COGS 1.65* 6 m NIMH-COGS 2.03*
COIS-P 0.90*
COIS-C 0.69*
7 2.11* 6 m 2.32* (C) 2.31* (C) 6 m 2.49* CGI-S 2.30* 6 m CGI-S 2.48*
(P) 1.97* (P) 6 m 1.77* NIMH GOCS 1.74* 6 m NIMH GOCS 1.72*
8 1.7*
9 1.77*
10 0.84* 6 m 1.31*
11 (Int) 2.48* 9 m (Int) 2.03*
(wkly) 3.57* 9 m (wkly) 3.10*
12 1.85b
13 2.05* COIS-P 0.96*

CGI-S 1.86*
14 SCAS-P-OC 1.37b 3-12 m SCAS-P-OC 1.38b
SCAS-C-OC 0.59b 3-12 m SCAS-C-OC 0.53b
15 NR 6 m NR* 1.21b 6 m 1.56* NIMH GOCS NRb 6 m NIMH GOCS NR*
12 m NR* 12 m 1.49* 12 m NIMH GOCS NR*
16 1.43b 1 m 1.86b 1.66b 1 m 2.34b NIMH GOCS 1.40b 1 m NIMH GOCS 2.23b FAI 1.19b 1 m FAI 1.77b
3 m 2.20b 3 m 2.31b CGI-S 1.20b 3 m NIMH GOCS 2.30b 3 m FAI 2.11b
CSDS 1.55b 1 m CGI-S 2.22b
3 m CGI-S 2.17b
1 m CSDS 1.98b
3 m CSDS 2.15b
17 1.57*a NR* NIMH GOCS NR* NIMH GOCS NR*
18 0.79* NIMH GOCS 0.98*

COIS-P 1.12*
COIS-C 0.23
19 3.24b CGI-S NRb
20 2.01*
21 2.59b 3 m 1.94b CGAS 2.26b 3 m CGAS 2.08b FAS 2.04b 3 m FAS PABS-Blame Mo 3 m PABS-Blame
1.72b 0.7b Mo 0.92b
PABS-Blame Fa 3 m PABS-Blame
1.15b Fa 1.19b
FES-Cohes. Mo 3 m FES-Cohes.
0.10b Mo 0.03b
FES-Cohes. Fa 3 m FES-Cohes.
0.62b Fa 0.38b
FES-Confl. Mo 3 m FES-Confl.
0.08b Mo 0.51b
FES-Confl. Fa 3 m FES-Confl.
0.70b Fa 0.70b
22 2.07* 2.35* COIS-P 0.98* FAS 1.65* PABS-Blame 0.73*
FES-Cohesion
0.39*
FES-Conflict 0.65*
23 NIMH-GOCS 1.75*
24 2.37b 1 m NRb COIS-P 1.01b 1 m; 6 m COIS-P NRb FAS 0.78b FAS NRb
6 m NRb COIS-C 0.81b 1 m; 6 m COIS-C NRb
13
489

490
13
25 1.61
26 1.27* 6 m 1.51*
27 2.04* 1 m 1.80*
3 m 2.16*
28 (C) 1.47* (C) 1.46* COIS-P 0.67* COIS-P 1.01* FAS 1.02* FAS 1.31* OFF-C 1.05* OFF-C 1.29*
(P) 1.32* (P) 1.61* COIS-C 0.87* COIS-C 0.98* OFF-P Fa 0.88* OFF-P Fa 0.79*
OFF-P Mo 0.5* OFF-P Mo 1.04*
29 (Int) 2.62* 3 m (Int) 2.20* CGI-S (int) 3.29* 3 m CGI-S (Int) 3.11* FAS (Int) 3 m FAS (int)
1.41* 1.24b
(wkly) 1.73* 3 m (wkly) 2.33* CGI-S (wkly) 1.68* 3 m CGI-S (wkly) 2.44* FAS 3 m FAS
(wkly) (wkly) 0.32b
0.52*
COIS-P (Int) 1.3* 3 m (int) COIS-P 1.89*
COIS-P (wkly) 3 m (wkly) COIS-P 0.57*
0.45*
30 2.37* 3 m 2.24* CGI-S 2.91* 3 m CGI-S 2.85* FAS 0.79*
COIS-P 0.75*
COIS-C 0.72*
31 1.81* 3 m 1.98* COIS-P 1.08* 3 m CGI-S 2.01* FAS 0.83
COIS-C 1.05*
CGI-S 1.56*
32 NRb
33 1.8* 6 m 1.70* ChOCI-P 0.71* 6 m ChOCI-P 1.15*
12 m 1.77* ChOCI-C 0.86* 12 m ChOCI-P 1.30*
6 m ChOCI-C 0.98*
12 m ChOCI-C 0.96*
34 2.41 (I)b 3 m (I) 2.2b ChOCI-C (I) 1.05b 3-12 m ChOCI-C (I) 1.07-1.21b
1.91 (R)b 6 m (I) 2.56b ChOCI-C (R) 1.21b 3-12 m ChOCI-C (R) 1.16-1.19b
12 m (I) 2.70b ChOCI-P (I) 1.14b 3-12 m ChOCI-P (I) 1.07-1.20b
3 m (R) 1.84b ChOCI-P (R) 1.11b 3-12 m ChOCI-P (R) 1.21-1.27b
6 m (R) 1.97b CGAS (I) 2.11b 3-12 m CGAS (I) 1.84-2.25b
12 m (R) 2.09b CGAS (R) 1.58b 3-12 m CGAS (R) 1.56-2.15b
CGI-I (I) 3.61b 3-12 m CGI-I (I) 2.39-2.86b
CGI-I (R) 2.63b 3-12 m CGI-I (R) 3.05-3.17b
35 3.61* 3 m 3.34* CGAS 1.35 3 m CGAS 1.88 FAS NR* FAD-General NRb
NIMH GOCS NR* 3 m NIMH GOCS NR*
36 (C + P) 2.07* 5 m (C) 2.77*
Exploration of Within‑Group Effects Moderators
severity, CGAS Children’s global assessment scale, COIS-C/P Child obsessive compulsive impact scale, ChOCI Children’s obsessional compulsive inventory, SCAS-OC Spence children’s anxi-
Dx Diagnostic assessment, d Cohen’s d effect size, F/up Follow-up, I Individual face-to-face treatment format, G Group treatment format, R Remote treatment format (telephone/web), m
ety scale—obsessive compulsive subscale, SAS Sibling accommodation scale, FAS Family accommodation scale, FAI Family accommodation interview, FAD Family assessment device, PABS
Weekly measures, C/Y-BOCS Children’s/yale-brown obsessive compulsive scale, NIMH GOCS NIMH global obsessive compulsive scale, CGI-I/S Clinical global impression—improvement/
Months, C Child, P Parent, NR Not reported, FA Family accommodation, Mo. Mother, Fa. Father, Cohes. Cohesion, Confl. Conflict, (W6-P) Week 6—Post-treatment, Int. Intensive, Wkly
Significant differences (< .05) between pre- and post-treatment score and gains maintained or continued at follow-up. A minus before an ES indicates worsening score (no improvement). An
O. Fam. F/up d
The continuous variables of family hours, parent hours, and
number of family factors were employed in meta-regression
analyses for OCD symptom and FA outcomes using the ran-
dom effects model. The number of family factors targeted in
treatment was found to significantly moderate outcome on
measures of FA (z = 2.21, p = 0.03). The greater the number
of family factors targeted in treatment, the larger the effect
O. Fam. d
size for FA and therefore the greater the reduction in FA

from pre- to post-treatment. Considering the variables of
Parent Hours and Family Hours for the nine studies that
assessed FA at pre- and post-treatment, 67% yielded an
FA F/up d
identical score for both Parent Hours (Mdn = 0) and Family

3 m FAI
1.27*
Hours (Mdn = 1). Due to the low variability in scores evi-

dent for parent hours and family hours for the small number
of studies assessing FA, no further analyses for FA were
FAI 1.04*
undertaken using these two variables. Neither family hours

FA d
(z = 0.07, p = 0.94), parent hours (z = −0.17, p = 0.86), nor

number of family factors (z = –0.72, p = 0.47) yielded sig-
nificant point estimates of the slope for the symptom out-
come measure, the C/Y-BOCS, including when combined.
The categorical variable of Category 1/Category 2 studies
was investigated as a potential moderator of OCD symptom
3 m COIS-C 0.70*
Other OCD F/up d
3 m COIS-P 0.90*
and FA outcomes. Category of study was not found to be a

Parental attitudes and behaviors scale, FES Family environment scale, OFF OCD family functioning scale
significant moderator of OCD (z = −1.3, p = 0.19) nor FA

(z = −0.19, p = 0.85) outcomes.
Discussion
The current meta-analysis and systematic review examined

C/Y-BOCS d C/Y-BOCS F/up d Other OCD d
COIS-C 0.09
COIS-P 0.55
the effect of family-based interventions on OCD symptom

outcomes as well as on a range of family factor outcomes
(including FA, blame, cohesion, conflict, and general fam-
ily functioning) for children and adolescents with OCD.
The broad inclusion criteria encompassed controlled and
5 m (P) 2.88*
uncontrolled studies with a wide range of parental involve-

3 m 1.98*
ment in treatment, including interventions that directly

sought to address family factors (Category 2) as well as
those that did not target family factors (Category 1). The
ES of .2 is small, .5 is medium, and .8 is large
current meta-analysis aimed to illuminate family-related

treatment factors associated with improved outcomes and
uniquely considered the relative impact on treatment out-
1.37*
comes of CBT with, versus without, the direct targeting of

ES from Barrett et al. (2008)
family factors for young people with OCD. This is the first
Dx F/up d
3 m 1.34*
Significance not reported
meta-analytic study to consider the moderating effects of

the number of family factors targeted in treatment on OCD
symptoms and FA outcomes, including precise calcula-

tions of the proportion of total treatment time that parents
0.86*
were seen alone, and when involved in family sessions.

No. Dx d
Overall, family-based interventions were found to be

effective for children and adolescents with OCD. All studies
37
*
a
13

Table 4 Risk of bias
Type of bias
No. Study Selection Performance Detection Attrition Reporting
Random Allocation Blinding of Blinding of Blinding of Incomplete Incomplete Selective
sequence concealment participants/ outcome ax outcome ax outcome data outcome data reporting
generation personnel (client report) (externally (post) follow-up
rated)
1 Barrett et al. ? ? n/a + + + n/a +

(2003)
2 Barrett et al. ? ? n/a + + + ? +
(2004, 2005)
3 Benazon et al. n/a n/a n/a + ? + n/a −
(2002)
4 Comer et al. + + n/a + + + + +
(2017)
5 Farrell et al. n/a n/a n/a + ? + + +
(2010)
6 Farrell et al. n/a n/a n/a + ? + ? +
(2012)
7 Farrell et al. + + n/a + + + + +
(2016)
8 Fernandez de n/a n/a n/a + ? + n/a +
la Cruz et al.
(2013)
9 Fernandez de n/a n/a n/a + ? + n/a +
la Cruz et al.
(2015)
10 Fischer et al. n/a n/a n/a + + + + +
(1998)
11 Franklin et al. − − n/a + + + + +
(1998)
12 Freeman et al. ? ? n/a + + + n/a +
(2008)
13 Freeman et al. + + n/a + + + n/a +
(2014)
14 Hudson et al. n/a n/a n/a + + + + +
(2015)
15 Lavell et al. n/a n/a n/a + ? + + +
(2016)
16 Lewin et al. ? ? − + + + + +
(2014)
17 March et al. n/a n/a n/a + ? ? + +
(1994)
18 Martin and n/a n/a n/a + ? + n/a +
Thienemann
(2005)
19 Merlo et al. ? ? ? + + + n/a +
(2010)
20 Nakatani et al. n/a n/a n/a + ? + n/a +
(2011)
21 Peris and ? ? ? + + + + +
Piacentini
(2013)
22 Peris et al. ? ? n/a + + + + +
(2017)
23 Piacentini n/a n/a n/a + − + n/a +
et al. (2002)
13
Type of bias
No. Study Selection Performance Detection Attrition Reporting
Random Allocation Blinding of Blinding of Blinding of Incomplete Incomplete Selective
sequence concealment participants/ outcome ax outcome ax outcome data outcome data reporting
generation personnel (client report) (externally (post) follow-up
rated)
24 Piacentini ? ? n/a + + + + +
et al. (2011)
25 POTS (2004) + + ? + + + n/a +
26 Reynolds ? ? ? + + + + +
et al. (2013)
27 Scahill et al. n/a n/a n/a + ? + + +
(1996)
28 Selles et al. n/a n/a n/a + − − − +
(2018)
29 Storch et al. ? ? n/a + + + ? +
(2007)
30 Storch et al. n/a n/a n/a + + + + +
(2010)
31 Storch et al. + + n/a + + + + +
(2011)
32 Sukhodolsky ? ? n/a + ? + n/a +
et al. (2013)
33 Turner et al. n/a n/a n/a + ? + + +
(2009)
34 Turner et al. + + n/a + + + + +
(2014)
35 Waters et al. n/a n/a n/a + ? + + +
(2001)
36 Whiteside and n/a n/a n/a + ? + + +
Jacobsen
(2010)
37 Whiteside, n/a n/a n/a + + − − +
McKay et al.
(2014)
+ Low risk of bias, - High risk of bias, ? Unclear risk of bias, n/a Not applicable, ax Assessment
evaluated demonstrated a significant positive treatment effect moderated treatment outcomes on measures of FA. Thus,
for both OCD symptoms and FA, at posttest and follow-up, the greater the number of family factors targeted in treat-
regardless of whether family factors were directly targeted ment, the greater the reduction in FA, an unhelpful fam-
(i.e., Category 1 and Category 2 interventions). The pooled ily response, from pre- to post-treatment. FA scores have
mean effect size for the C/Y-BOCS was large and significant been significantly correlated with OCD symptom severity
for both pre-post and pre-follow-up comparisons. Large, sig- in previous meta-analyses (e.g., Strauss et al. 2015; Wu
nificant treatment effects were also demonstrated for FA at et al. 2016). Treatment trials have demonstrated the asso-
both time points. The large treatment effects obtained for ciation between FA and poorer treatment outcomes (e.g.,
OCD symptoms and FA are consistent with findings of pre- Garcia et al. 2010; Merlo et al. 2009; Storch et al. 2008).
vious meta-analyses (e.g., Iniesta-Sepúlveda et al. 2017), Peris et al. (2017) found that changes in FA accounted
lending further support for the effectiveness of family-based for changes in clinical symptoms, and therefore clinical
interventions in reducing OCD symptoms, as well as FA, in improvement, for young people with OCD. The authors
young people with OCD. identified FA as a potential mechanism for change in the
One of the primary findings of this study was that the treatment of youth with OCD, contributing to previous
number of family factors targeted in treatment significantly findings by Piacentini et al. (2011). Piacentini et al. (2011)
13

A
Study name Subgroups within study Statistics for each study Hedges's g and 95% CI
Hedges's Standard Lower Upper
g error Variance limit limit Z-Value p-Value
Barrett et al. (2004; 2005) Group 1.878 0.237 0.056 1.414 2.342 7.931 0.000
Barrett et al. (2004; 2005) Individual 2.299 0.299 0.089 1.712 2.885 7.687 0.000
Benazon et al. (2002) Nil 1.564 0.282 0.080 1.011 2.118 5.542 0.000
Comer et al. (2017) Individual 1.070 0.279 0.078 0.524 1.617 3.840 0.000
Comer et al. (2017) Remote 1.077 0.280 0.078 0.529 1.625 3.854 0.000
Farrell et al. (2010) Nil 2.045 0.229 0.052 1.597 2.493 8.948 0.000
Farrell et al. (2012) Nil 1.026 0.144 0.021 0.744 1.309 7.116 0.000
Farrell et al. (2016) Nil 1.804 0.384 0.148 1.051 2.558 4.693 0.000
Fernandez de la Cruz et al. (2013) Nil 1.617 0.095 0.009 1.431 1.803 17.037 0.000
Fernandez de la Cruz et al. (2015) Nil 1.659 0.083 0.007 1.495 1.823 19.876 0.000
Fischer et al. (1998) Nil 0.787 0.219 0.048 0.357 1.217 3.586 0.000
Freeman et al. (2008) Nil 1.037 0.200 0.040 0.645 1.429 5.184 0.000
Freeman et al. (2014) Nil 1.730 0.153 0.024 1.429 2.031 11.274 0.000
Lavell et al. (2016) Nil 1.161 0.151 0.023 0.864 1.457 7.677 0.000
Lewin et al. (2014) Nil 1.460 0.264 0.070 0.943 1.978 5.534 0.000
Martin and Thienemann (2005) Nil 0.674 0.218 0.048 0.246 1.102 3.085 0.002
Merlo et al. (2010) Nil 2.503 0.542 0.294 1.440 3.567 4.615 0.000
Nakatani et al. (2011) Nil 1.946 0.126 0.016 1.700 2.193 15.458 0.000
Peris and Piacentini (2013) Nil 1.790 0.383 0.146 1.041 2.540 4.681 0.000
Peris, Rozenman et al. (2017) Nil 1.717 0.213 0.045 1.299 2.135 8.051 0.000
POTS (2004) Nil 1.275 0.194 0.038 0.894 1.655 6.569 0.000
Reynolds et al. (2013) Nil 1.201 0.200 0.040 0.810 1.593 6.020 0.000
Scahill et al. (1996) Nil 1.985 0.483 0.234 1.038 2.933 4.106 0.000
Selles et al. (2018) Nil 1.379 0.117 0.014 1.150 1.608 11.807 0.000
Storch et al. (2007) Intensive 2.445 0.343 0.117 1.774 3.117 7.138 0.000
Storch et al. (2007) Weekly 1.488 0.247 0.061 1.005 1.972 6.033 0.000
Storch et al. (2010) Nil 2.086 0.250 0.063 1.596 2.576 8.346 0.000
Storch et al. (2011) Nil 1.246 0.251 0.063 0.755 1.738 4.968 0.000
Turner et al. (2009) Nil 1.527 0.347 0.120 0.848 2.207 4.406 0.000
Turner et al. (2014) Individual 2.167 0.235 0.055 1.707 2.627 9.233 0.000
Turner et al. (2014) Remote 1.481 0.185 0.034 1.118 1.843 8.004 0.000
Waters et al. (2001) Nil 2.977 0.667 0.445 1.670 4.284 4.465 0.000
Whiteside and Jacobsen (2010) Nil 1.897 0.318 0.101 1.273 2.521 5.962 0.000
Whiteside, McKay et al. (2014) Nil 1.663 0.251 0.063 1.171 2.155 6.623 0.000
1.562 0.070 0.005 1.424 1.700 22.249 0.000
-4.00 -2.00 0.00 2.00 4.00
No improvement Degree of improvement
B
Hedges'sStandard Lower Upper
Barrett et al. (2004; 2005) Group 1.946 0.242 0.059 1.471 2.421 8.027 0.000
Barrett et al. (2004; 2005) Individual 2.278 0.297 0.088 1.696 2.861 7.669 0.000
Farrell et al. (2012) Nil 1.396 0.164 0.027 1.074 1.719 8.488 0.000
Farrell et al. (2016) Nil 1.840 0.389 0.152 1.076 2.603 4.723 0.000
Fischer et al. (1998) Nil 1.248 0.259 0.067 0.741 1.755 4.825 0.000
Lavell et al. (2016) Nil 1.524 0.172 0.030 1.186 1.861 8.848 0.000
Lewin et al. (2014) Nil 2.216 0.344 0.119 1.541 2.891 6.433 0.000
Reynolds et al. (2013) Nil 1.367 0.212 0.045 0.952 1.783 6.449 0.000
Scahill et al. (1996) Nil 1.561 0.411 0.169 0.755 2.367 3.794 0.000
Selles et al. (2018) Nil 1.315 0.114 0.013 1.091 1.539 11.517 0.000
Storch et al. (2010) Nil 1.927 0.237 0.056 1.462 2.391 8.135 0.000
Storch et al. (2011) Nil 1.415 0.267 0.071 0.891 1.938 5.298 0.000
Turner et al. (2009) Nil 1.376 0.327 0.107 0.735 2.017 4.207 0.000
Turner et al. (2014) Individual 1.934 0.217 0.047 1.508 2.359 8.908 0.000
Turner et al. (2014) Remote 1.420 0.181 0.033 1.066 1.775 7.847 0.000
Waters et al. (2001) Nil 2.444 0.566 0.321 1.334 3.555 4.315 0.000
Whiteside and Jacobsen (2010) Nil 2.369 0.373 0.139 1.638 3.100 6.354 0.000
1.692 0.081 0.007 1.532 1.851 20.814 0.000
-4.00 -2.00 0.00 2.00 4.00
Fig. 2 a Forest plot of Hedges’s g indices for OCD symptoms (C/Y-BOCS) pre-post treatment. b Forest plot of Hedges’s g indices for OCD
symptoms (C/Y-BOCS) pre-follow-up
13
A

Lewin et al. (2014) Nil 1.131 0.234 0.055 0.673 1.589 4.840 0.000
Selles et al. (2018) Nil 0.981 0.102 0.010 0.782 1.181 9.656 0.000
Storch et al. (2010) Nil 0.651 0.152 0.023 0.353 0.950 4.274 0.000
Storch et al. (2011) Nil 0.706 0.208 0.043 0.299 1.113 3.400 0.001
1.002 0.104 0.011 0.798 1.206 9.638 0.000
-4.00 -2.00 0.00 2.00 4.00
B

Lewin et al. (2014) Nil 1.652 0.283 0.080 1.097 2.207 5.835 0.000
Selles et al. (2018) Nil 1.162 0.108 0.012 0.950 1.374 10.743 0.000
Storch et al. (2007) Weekly 0.257 0.169 0.029 -0.075 0.589 1.519 0.129
Whiteside et al. (2014) Nil 1.669 0.252 0.063 1.176 2.162 6.632 0.000
1.180 0.177 0.031 0.833 1.527 6.670 0.000
-4.00 -2.00 0.00 2.00 4.00
Fig. 3 a Forest plot of Hedges’s g indices for family accommodation measures pre-post treatment. b Forest plot of Hedges’s g indices for family
accommodation measures pre-follow-up
demonstrated that FA-mediated OCD symptom outcomes The number of family factors targeted in treatment
and found that changes in FA preceded OCD symptom did not significantly moderate OCD symptom outcomes
change. The findings of the current study highlight the as measured by the C/Y-BOCS. It may be that measures
importance of reducing family-related maintaining factors, of FA better assess behaviour associated with unhelpful
such as FA, by specifically targeting these family factors family factors than a measure assessing OCD symptom
in OCD interventions for young people to optimise treat- severity. Mounting evidence suggests that changes in FA
ment response. The current findings indicate that FA is may moderate or even mediate OCD symptom change
not the only critical family variable to target in treatment (Peris et al. 2017; Piacentini et al. 2011). Although this
to enhance outcomes. In fact, the more family factors tar- relationship was not significant in the current study, this
geted, the greater are these outcomes. This study’s findings may be due to the small number of studies assessing FA
add further support to preliminary results presented in the at pre- and post-treatment. Despite the limited measure-
treatment literature that specific family factors, such as ment of FA outcomes, a small correlation of r = 0.35 was
family cohesion, conflict, and parental blame of the young still identified in the current study between change in FA
person, can affect response to treatment for young people scores and change in OCD symptom scores (C/Y-BOCS)
with OCD (Peris et al. 2012, Peris et al. 2017). scores pre- to post-treatment. Nil significant moderating
13

Fig. 4 Funnel plot of standard

error by Hedges’s g indices for
observed and imputed compari-
sons of OCD symptoms (C/Y-
BOCS) pre-post treatment
effects were found for Category 1 versus Category 2 stud- family factors may have been targeted directly as part of a
ies on OCD symptom and FA outcomes. As the continu- study’s standard treatment protocol without authors includ-
ous variable, Number of Family Factors, is a more precise ing this information in their written description of treatment.
operationalisation of the family factors targeted in treat- In an effort to overcome the latter limitation, authors of all
ment compared to the aforementioned categorical variable studies were contacted to confirm the specific family factors
that uses only two broad categories (family factors vs no addressed in each treatment trial. The majority of authors
family factors), the former variable likely better identified responded and verified the family factors collated by the
the moderating effects of family factors on FA outcomes. current study.
The current study found that the amount of time parents Only 32% of included studies assessed at least one family
spent in family sessions and/or alone with the therapist did factor both pre- and post-treatment. All 12 studies measured
not significantly moderate OCD symptom outcomes. The FA and only four studies assessed a family factor other than
impact of Parent Hours and Family Hours on FA outcome FA. Due to the small number of studies assessing FA and
was not analysed due to low variability in scores for the few the limited variability in scores for Parent Hours and Family
eligible studies that measured FA. Nonetheless, the current Hours for these studies, moderator analyses for FA could
findings possibly suggest that the amount of family/parent not be performed for the two aforementioned variables. The
time may be of less importance than the number of family impact of potential moderators on other family factors, such
factors addressed during this time. A previous meta-analysis as blame, criticism, cohesion, could not be explored due
by Rosa-Alcázar and colleagues (Rosa-Alcázar et al. 2015) to the extremely small number of studies measuring these
found that parents’ active participation in treatment, such additional family factors.
as when parents were trained to assist their children as ERP While all Category 2 studies addressed family factors,
coaches, had a significant positive association with the effect predominately FA, there is likely to have been variation
size for OCD symptoms. This may be the case for family across studies in how family factors were addressed. Dif-
factors, such that time spent by parents actively participat- ferences in therapist level of training, therapist style, and
ing in treatment to address family maintaining factors may content of the treatment programs addressing family fac-
have more of an impact on OCD symptoms than merely tors could have affected treatment outcomes. In particular,
the amount of time spent by parents attending treatment some programs may have addressed family factors in the
sessions. context of psychoeducation, whereas other programs may
have included a more practical skills-training approach.
Limitations and Future Directions In addition, more experienced therapists may be adept at
experientially addressing a range of family factors, and
Limitations of the current study include that family factors understanding the function of these factors for individual
may have been indirectly targeted in Category 1 studies families in the maintenance of OCD symptoms. The quality
when parents were present in treatment sessions, even when of the approach employed to address family factors and the
not part of the treatment protocol, particularly if these fac- nature of the potential differences between studies would
tors were interfering with treatment progress. Alternatively, only be quantifiable through observation of sessions, such
13
as the coding of treatment session recordings. As such, this not addressed (Category 1 vs. Category 2). Studies compar-
remains a focus area for future research, however, relies on ing interventions that target different types of family fac-
the availability of recordings (or transcripts thereof) and/or tors would significantly assist to identify key family fac-
publicly available data. tors affecting treatment response. The relationship between
Moving forward, relatively little is still known about the family factors addressed in treatment, FA change, and OCD
components of family-based interventions that enhance symptom change pre- to post-treatment needs further inves-
treatment response for young people with OCD, including tigation, including the mediatory relationship between FA
optimal family-related treatment content as well as the dose and OCD symptom change proposed by previous research
and nature of family involvement. Future meta-analyses (e.g., Piacentini et al. 2011).
would advance the literature and build on current findings This systematic review and meta-analysis highlights the
by focusing further on family-related treatment moderators importance of addressing a range of family factors in the
for young people with OCD, particularly as additional data treatment of child/adolescent OCD in order to enhance out-
becomes available. Findings from the current study’s exami- comes for young people and their families. Further research
nation of treatment moderators emphasise the importance is warranted to improve theoretical models and explain the
of addressing a number of family factors (e.g., FA, conflict, impact of parental involvement in treatment and the direct
blame/criticism, problem-solving, and communication) in targeting of family factors on family factor outcomes impli-
future interventions for young people with OCD. Further cated in the maintenance of OCD.
research is needed to better understand the most effective
way of addressing these family factors. Questions for further
exploration include whether family factors need to be exten- Compliance with Ethical Standards
sively addressed and the relevant skills practised by families
or whether merely educating families about the unhelpful Conflict of interest The authors declare that they have no conflict of
interest.
nature of these factors and the role they play in maintain-
ing OCD is sufficient. In addition, whether particular fam- Ethical Approval This article does not contain any studies with human
ily factors play more of a maintaining role in the disorder participants or animals performed by any of the authors.
and, therefore, need greater attention in treatment to bolster
symptom improvement remains unclear.
Improved reporting of the specific family factors
addressed in treatment will assist in identifying those asso- References
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Family Based Psychological Treatment For Obsessive

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Clinical Child and Family Psychology Review (2019) 22:478–501

Family‑Based Psychological Treatment for Obsessive Compulsive

Published online: 25 June 2019

Introduction (e.g., hand washing) or mental acts (e.g., counting) that

Search results combined (n = 1101)

Duplicates deleted (n = 229)

Articles screened on titles (n = 872)

Articles screened on abstracts (n = 291)

Review of full texts (n = 96)

Table 1 Demographics, assessment and outcome measures

1 Barrett et al. (2003) 24 42 11.21 (0.54) RCT​ ADIS-P ✓ ✓ ✓

first follow-up time point was used in calculations where stud-

of FA ranged between d = 0.52 and d = 2.04 (Mdn d = 1.04) for

Follow-up. An extended table with Cohen’s d within-group

symptom measures is available on request from authors.

Table 4 illustrates that overall a Low risk of bias status was

and Follow-up (where relevant), and Selective reporting, with

eration and Allocation concealment, were not relevant to the

relevant, the majority of studies (30%) received an Unclear

risk of bias rating as insufficient information was provided

were evaluated to be at Low risk of bias in both categories. The

formance bias was not applicable to the design of 86% of the

an Unclear rating. The Blinding of outcome assessment (exter-

nally rated) category predominately received Low risk of bias

received Unclear ratings. Overall, the studies included in this

review were evaluated as meeting criteria for low risk of bias,

generally indicating research of sound quality. However, more

randomisation (where relevant) and assessment procedures

C/Y‑BOCS Within‑Group Effects

Hedges’s g within-group effect sizes were generated for the

30 studies (N = 1227) assessing OCD symptoms at pre- and

post-treatment using the C/Y-BOCS (see Fig. 2a). All studies

medium effect according to Cohen’s (1988) rule of thumb

Family factors Intervention time

30 Storch et al. (2010) POTS (2004) I 21/3 0/21 21/21

1.7], p = 0.000, indicating a large, significant effect. Tests

showed significant moderate heterogeneity, Q (23) = 55.53,

Hedges’s g within-group effect sizes were computed for the

ment (the 11 values are detailed in Fig. 3a). All studies indi-

cated a significant positive effect: eight values demonstrated

Hedge’s g within-group effect sizes were calculated for the

pooled mean effect size of g = 1.98, 95% CI [0.83, 1.53],

was indicated, Q (7) = 36.38, p = 0.000, I2 = 80.76%. The dif-

for pre-follow-up time points was not significant (p = 0.75).

Mulle 1998); Authors’ protocol

Authors’ manual (unpublished)

Duval and Tweedie’s Trim and Fill Procedure (2000a, b)

was employed to provide an adjusted pooled mean effect

ues removed), to yield an estimate of the unbiased pooled

effect size. An adjusted mean effect size for FA was also

Publication bias was also assessed using the Classic fail-

safe N calculation (Rosenthal 1979). The number of miss-

ing papers needed to reduce the p value to less than alpha

ber of studies meeting inclusion criteria for this review was

37, it is highly unlikely that 6152 papers were missed. This

relationship found between family-based interventions for

13 2.05* COIS-P 0.96*

18 0.79* NIMH GOCS 0.98*

Exploration of Within‑Group Effects Moderators

size for FA and therefore the greater the reduction in FA

identical score for both Parent Hours (Mdn = 0) and Family

Hours (Mdn = 1). Due to the low variability in scores evi-

undertaken using these two variables. Neither family hours

Table 1 Demographics, assessment and outcome measures

1 Barrett et al. (2003) 24 42 11.21 (0.54) RCT ADIS-P ✓ ✓ ✓

Fig. 4 Funnel plot of standard