TYPE Original Research

PUBLISHED 11 August 2022

DOI 10.3389/fpsyt.2022.970747

The Chinese version of the

OPEN ACCESS family accommodation scale for
EDITED BY
Katarzyna Prochwicz,
Jagiellonian University, Poland
obsessive-compulsive disorder
REVIEWED BY
Mohammadreza Shalbafan,
self-rated: reliability, validity,
Iran University of Medical Sciences,
Iran
Pengchong Wang,
factor structure, and mediating
Beijing Anding Hospital, Capital
Medical University, China effect
*CORRESPONDENCE
Wenchang Zhang
wenchang2008@126.com Zhenhua Liao1 , Lijun Ding2,3 , Ciping You2 , Ying Chen2 and
SPECIALTY SECTION Wenchang Zhang1*
This article was submitted to
1
Anxiety and Stress Disorders, School of Public Health, Fujian Medical University, Fuzhou, China, 2 Xiamen Xianyue Hospital,
a section of the journal Xiamen, China, 3 School of Health, Fujian Medical University, Fuzhou, China
Frontiers in Psychiatry

RECEIVED 16 June 2022

ACCEPTED 25 July 2022
PUBLISHED 11 August 2022 Background: Family accommodation (FA) in obsessive compulsive disorder
CITATION (OCD) is a common phenomenon. Based on the cost of training interviewers
Liao Z, Ding L, You C, Chen Y and
Zhang W (2022) The Chinese version
and the time required to administer the scale, the Family Accommodation
of the family accommodation scale Scale for Obsessive-Compulsive Disorder Interviewer-Rated (FAS-IR) has
for obsessive-compulsive disorder
been restricted to specific settings. A self-rated version of the family
self-rated: reliability, validity, factor
structure, and mediating effect. accommodation scale may solve these problems. The aim of this study
Front. Psychiatry 13:970747. was to examine the reliability, validity and factor structure of the Family
doi: 10.3389/fpsyt.2022.970747
Accommodation Scale Self-rated version (FAS-SR), and the relationship
COPYRIGHT
© 2022 Liao, Ding, You, Chen and
among FA, symptom severity and functional impairment.
Zhang. This is an open-access article
distributed under the terms of the
Methods: In total, 171 patients with OCD and 145 paired relatives participated
Creative Commons Attribution License in this study. The Sheehan Disability Scale (SDS), Obsessive-Compulsive
(CC BY). The use, distribution or
Inventory Revised (OCI-R), Zung Self-Rating Depression Scale (Zung-SDS),
reproduction in other forums is
permitted, provided the original 12-item Family Assessment Devices (FAD-12), Clinical Global Impression of
author(s) and the copyright owner(s) Severity Scale (CGI-S), Global Assessment of Functioning (GAF), and Yale-
are credited and that the original
publication in this journal is cited, in Brown Obsessive-Compulsive Scale (Y-BOCS) were used as tools for patients.
accordance with accepted academic The FAS-SR, FAS-IR, FAD-12, and the patients’ symptom severity of Y-BOCS
practice. No use, distribution or
reproduction is permitted which does compulsion were used as tools for relatives. The psychometric properties
not comply with these terms. of the FAS-SR were evaluated using Cronbach’s alpha coefficient, test-
retest reliability and validity. Mediation analysis was used to determine the
relationship among FA, symptom severity and functional impairment.
Results: A total of 97.9% of relatives of OCD patients reported at least one kind
of FA behavior, and 56.6% of participants engaged in FA every day in the past
week. The FAS-SR includes a three-factor structure: (1) providing reassurance
and participation; (2) facilitation; and (3) modification. The scale’s Cronbach’s
alpha and test-retest coefficients were 0.875 and 0.970, respectively. The total
FAS-SR score was significantly positively associated with the Y-BOCS, FAD-12,
CGI-S, FAS-IR, and SDS scores, and negatively associated with the total GAF

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Liao et al. 10.3389/fpsyt.2022.970747

score. FA partially mediated the relationship between symptom severity and

functional impairment.
Conclusion: The FAS-SR was proven to have satisfactory psychometric
properties, and can play an important role in the evaluation and early
intervention of OCD. This result indicates the importance of assessing
symptom severity in conjunction with FA when evaluating OCD patients’
functional impairment.

KEYWORDS

family accommodation, self-rated, reliability, validity, mediating effect

Introduction The original intention of family members of OCD patients was

an attempt to relieve their loved ones’ anxiety and distress,
Obsessive-compulsive disorder (OCD) is relatively and perhaps accelerate the compulsive behavior process, while
prevalent among mental disorders and has a lifetime prevalence their responses might be “successful” in the short term, the
of 2.4% in China, according to a recent national epidemiological behaviors are maintained and repeated later (10, 18). As a result,
study (1). In addition, OCD was estimated to strongly contribute FA behaviors actually prevent patients from confronting their
to the global burden of disease (2). OCD is a chronic, prolonged, obsessions, compulsions and anxiety. Furthermore, the patient’s
serious and disabling disorder that frequently interferes with symptoms ultimately expand seriously, and an escalating loop
individuals’ ability to function in society and decreases their between OCD symptoms and FA behaviors is established.
quality of life (3–6). The negative or adverse consequences Selective serotonin reuptake inhibitors (SSRIs) and
of OCD are not limited to patients alone (7, 8). Their family exposure-based cognitive-behavioral therapy (CBT) make up
members, including parents, spouses, siblings and significant the standard first-line pharmacotherapy and psychotherapy
others, are also affected and distressed by symptoms in both options for OCD treatment (6, 19, 20). However, approximately
adult and pediatric OCD patients, which cause unpleasant half of individuals with OCD do not benefit from standard
experiences and create a great burden for their caregivers. treatments and become refractory (21, 22). Factors associated
Patients’ symptoms and behaviors play an important role in with poor response to treatment of OCD have been widely
the course of the disorder and treatment outcomes (9, 10). reported, and there is some consensus among healthcare
According to recent research, it is clear that in addition to the providers regarding these factors. For example, FA has been
symptoms of OCD that affect patients, their family members’ associated with poor treatment response in both adult and
responses have a deleterious effect on treatment outcomes pediatric OCD patients, hindering the goals of CBT treatment
(9–14). and serving as an obstacle to the improvement of symptoms and
In the last two decades, the relationship between OCD family functioning in both pharmacological and psychotherapy
disorders and family dynamics has attracted increasing attention regimens (10, 11, 13). Thus, the reduction of FA is increasingly
from researchers, and awareness of family accommodation referred to as an important part of the treatment plan and
(FA) has aroused growing interest in the illustration of OCD clinical target for OCD patients and even serves as a possible
etiology and treatment outcomes (15–17). The terminology mediating factor of treatment outcomes (9, 12, 23, 24). As a
of FA refers to family members participating and assisting result, the integration and management of FA as a plan to treat
in the patients’ rituals and accommodating their compulsions OCD patients could further advance the knowledge of OCD
to prevent and alleviate their anxiety, which are behaviors and improve clinical outcomes. In addition, research on FA
frequently observed and reported in the families of both adult will contribute to clinicians’ understanding of the recognition,
and pediatric OCD patients (8). On the basis of previous assessment and treatment outcomes of OCD.
reports, almost all family members of OCD patients frequently Based on the abovementioned definition and various
experience this phenomenon on a daily basis or in extreme manifestations, several instruments have been developed to
situations (7, 8). Accommodating behaviors can be maladaptive measure and individually assess FA by the pattern method
responses to OCD, even if FA is often treated as a global of evaluation based on relatives’ reports on the Family
construct. The primary forms of FA included providing verbal Accommodation Scale Interviewer-Rated (FAS-IR) and Family
reassurance, refraining from saying or doing things to trigger Accommodation Scale for OCD Self-Rated version (FAS-
behaviors, participating in and facilitating compulsions, and SR) (18, 25–27). The FAS-IR was originally developed by
following and respecting the rigid rules established by patients. Calvocoressi et al. and was improved, revised and readjusted

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Liao et al. 10.3389/fpsyt.2022.970747

from the 13-item FAS reported in 1999 (18). The FAS-IR Moreover, we hypothesized that the total score of the FAS-SR
was regarded as the gold standard inventory to measure would be strongly correlated with the FAS-IR, which displayed
FA behaviors, and has been adapted and translated into excellent convergent validity. We also hypothesized that the
Brazilian Portuguese and Chinese versions (26, 28). The FAS-SR scores would be moderately associated with symptom
scale is extensively used in clinical and research settings severity, poor family function and functional impairment
and has demonstrated strong psychometric features (18, in OCD patients. Second, exploratory factor analysis was
26, 28). Unfortunately, some common disadvantages limit performed to explore the factor structure of the FAS-SR. We
the use of clinician-administration instruments. First, it is hypothesized that FA has multiple constructs rather than a
costly and time-consuming to apply the instruments due to single construct. Third, the study aimed to explore a mediation
interviewer training and instrument administration. Second, model in which FA mediated the association between symptom
it may miss some important information if the interviewees severity and functional impairment. We hypothesized that FA
are unwilling to admit and report their responses to the would mediate the relationship between OCD symptom severity
OCD family member in the interviewer-rater investigation, and functional impairment.
especially when they realize that the patients’ behaviors and/or
requests were unreasonable. Third, the interviewers may easily
recognize the distributed group in face-to-face interviews Materials and methods
even if a blinded method is used in the random control
study. As a result, the self-report questionnaire for assessing Participants
FA will improve the corresponding items and evaluate the
occurrence or incidence of FA in a targeted manner by The translation and adaptation procedures of the family
retaining the overall structure of the FAS-IR and refining accommodation scale have been reported in our previous study
the items. Compared with the clinician-rated instrument, the (29). Additionally, the recruitment strategy for patients and
FAS-SR addresses these shortcomings and facilitates a more corresponding relatives and the inclusion and exclusion criteria
widespread collection of FA data. Additionally, the FAS-SR have been reported in detail (28). One relative was paired
refers to family members who can independently measure with each OCD patient in this study. Because information
and evaluate the incidence of FA according to the standard on 26 family members was lost, a total of 171 patients and
items and some examples, and the evaluation result is usually 145 paired relatives were recruited from a specialized OCD
easy to understand. outpatient clinic in Xiamen Xianyue Hospital from 2018 to
Although FA in the OCD population has a relatively 2020 for the present study. All patients and relatives provided
high incidence globally, individualized assessment of FA and informed consent before the beginning of the investigation, and
associated factors related to treatment response is required the protocol of the study was reviewed by the Xiamen Xianyue
in China (8). Similar to Western countries and other Hospital ethics commitment (2018-KY-010).
Asian countries, FA frequently occurs in family members of
OCD patients in China according to our previous report
and clinical experience (28, 29). However, few studies have Measures
emphasized OCD-related family pathology in the Chinese
population. Although our previous study reported the Chinese To ensure the stability of the result, the FAS-SR was first
version of the FAS-IR (28), the lack of these FAS-SR self-reported for the family member, and then, the trained
studies led to a lag in the development of family therapy interviewer evaluated the FAS-IR based on the blinded results
and intervention for OCD patients, especially in regions of the FAS-SR. The instruments were detailed as follows. The
with a paucity of trained clinical professionals. Therefore, assessments of patients and relatives were conducted in different
the development and adaptation of the Chinese version of rooms so that the relatives and OCD patients could respond
the FAS-SR will allow clinicians to observe and quantify without interference. The aim of the decision was to create
the frequency and types of FAs in Chinese OCD patients a comfortable environment in which the relatives of OCD
and easily observe their associations with illness and as patients could thoroughly express and report their experiences
treatment-related variables based on relatives’ understanding of frustration or other negative emotions toward OCD patients.
and realization. If a patient went to the clinic alone, the corresponding relative
This primary aim of this study is based on the agreed to an interview at the next clinic in 7- to 10- days. The
abovementioned research in three ways. First, this study retest assessment of the FAS-SR was measured between 7 and
assessed the incidence of FA and examined the reliability and 10 days in a partial sample.
validity of the Chinese version of the FAS-SR. We hypothesized A specifically created questionnaire was used to collect
that the frequent incidence of FA behavior is based on the demographic and clinical variables for OCD patients, such as
evaluation of the FAS-SR in individuals with OCD in China. age, gender, educational level, marital status, occupational

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Liao et al. 10.3389/fpsyt.2022.970747

status, region, religion, age at the onset of symptoms, symptoms. The total scores ranged from 0 to 72, and
course period of illness and treatment, and family history every item was measured on a 5-point scale from 0 to 4
of OCD. Demographic variables for family members (not at all, a little, moderately, a lot, and extremely). The
included age, gender, educational level, marital status, and scale displayed strong psychometric properties in OCD
relationship with patients. patients and non-clinical individuals (36). The OCI-R has
also been widely used in OCD symptom assessment and
improvement in both clinical practice and research settings
Self-report measure (34, 37).

Family accommodation scale for obsessive Zung self-rating depression scale (Zung SDS)
compulsive disorder self-rated (FAS-SR) The scale is a 20-item self-report by patients about their
The original version of the FAS-SR was developed by Pinto depression (38). Every item of the scale is scored 1–4 (1 = a
et al. to measure the frequency of FA in the past week based little of the time, 2 = some of the time, 3 = a good part of the
on the first section of the OCD symptoms checklist, which was time, 4 = most of the time). The Zung SDS is widely used in the
self-reported by the patients’ relatives (25). The structure of the clinic to evaluate some moods and conditions related to some
FAS-SR was identical to that of the FAS-IR, which included two patients with psychiatric disorders (38). The scale has displayed
sections, a symptom checklist and 19 items on accommodating satisfactory psychometric features (39).
behaviors. To help relatives more thoroughly understand and
accurately comprehend their FA behaviors, some wording and Family assessment device general functioning
the structuring of these FA items were modified in the FAS-SR (FAD-12)
(25). Some items from the FAS-IR that were originally evaluated The FAD-12 was extracted from the original FAD and
by one item were individually divided into two items in the evaluates family functioning with 12 items for both patients and
FAS-SR. For example, the item providing reassurance in FAS- their relatives (40–42). The scale includes 6 forward-scored and
IR was divided into two items about providing reassurance 6 reverse-scored items, which measure responses on a scale from
of obsession and compulsion. The FAS-SR item description 1 to 4 for a total score of 12–48. Higher scores on the scale
and content were made clearer and more comprehensive, and indicated worse levels of family functioning. The FAD-12 has
more information and examples were provided in comparison been identified as a brief scale to measure family functioning
to the FAS-IR. Consistent with the FAS-IR scoring method, with excellent reliability and validity (41).
the 19 items are scored on a 5-point Likert scale, and the
responses are none, 1/week, 2–3/week, 4–6/week, and every
day. The total score of the scale ranges from 0 to 76, and Clinical interview measure
higher scores demonstrate more severe FA behaviors. The FAS-
SR has been widely used in clinical and research settings, and Family accommodation scale interviewer-rated
has been adapted and translated into different languages (27, (FAS-IR)
30, 31). The average time of assessment of the FAS-SR was The FAS-IR is a 12-item clinician-rated semistructured
24.42 ± 7.09 minutes. instrument that is regarded as the gold standard in measuring
accommodating behaviors (18). The FAS-IR was first developed
Sheehan disability scale (SDS) by Calvocoressi et al. and was revised and improved from the
The SDS was administered to assess the patients’ functional 13-item FAS in 1999 (18). The instrument includes two sections,
impairment for all psychiatric disorders and is widely used the OCD symptom checklist and 12 items on accommodating
in clinical and research settings (32). The SDS includes three behaviors. The first section includes eight kinds of obsession,
domains: work/academic, social life/leisure, and family/home seven kinds of compulsion, and five kinds of other OCD-
responsibilities. The total scores of the scales range from 0 related problems. The interviewer obtains information from
to 30, and are measured on a visual analog scale as 0 (no the family member regarding the patient’s symptoms in the
impairment), 1–3 (moderated), 4–6 (moderated), 7–9 (marked), previous week and assesses the extent to which the family
or 10 (extreme). The SDS has demonstrated good reliability and member participates in accommodating the patient’s symptoms.
validity (32, 33). The second section elaborates on an OCD relative’s reports of
the type of FA behaviors and the level of interference they
Obsessive compulsive inventory revised engage in (18, 26). Each item includes common examples of
(OCI-R) accommodating behaviors, but the interviewers may wish to
The OCI-R is an 18-item scale used to evaluate OCD develop additional examples based on information collected
symptom dimensions in the past month for OCD patients from the relative’s report of the patient’s symptoms. The total
(34–36). The scale includes six dimensions: obsessing, scores of the scale range from 0 to 48, and responses are
washing, checking, hoarding, neutralizing, and ordering scored on a 5-point Likert scale (0 = none, 1 = 1/week,

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2 = 2–3/week, 3 = 4–6/week, 4 = everyday; 0 = not at was calculated to evaluate the agreement between the FAS-
all, 1 = mild, 2 = moderate, 3 = severe, 4 = extreme). SR and FAS-IR total scores. Exploratory factor analysis was
The FAS-IR has excellent psychometric properties and has employed to understand the factor structure of the FAS-SR.
been commonly used to evaluate the reduction in FA as Primary components were extracted using varimax rotation,
a treatment target in studies of OCD patients’ family-based and eigenvalues were calculated to assess the amount of
psychotherapy (13, 18, 26). The Chinese version of the FAS-IR variance accounted for by a factor. The number of factors was
was reported in 2021 and has satisfactory reliability and validity determined based on both eigenvalues greater than 1 and screen
(28). plots. Two-way mixed consistency was used in the test-retest
between the first and retested assessments of the FAS-SR.
Clinical global impression of severity scale Spearman correlation coefficients were calculated to evaluate
(CGI-S) the convergent validity of the total FAS-SR scores associated
The CGI-S was extracted from the CGI and has a single item with the FAS-IR, Y-BOCS, SDS, GAF, and FAD-12 scores
to assess the overall clinical severity of the patients’ symptoms based on the non-parametric distribution. The magnitude of
and functional impairment (43). The total score ranges from 0 associations between the total FAS-SR and FAS-IR scores on
(healthy) to 6 (extremely or severe mental illness). The CGI- each of the criterion measures was compared by Steiger’s Z
S was widely exploited in clinical and research settings, and test (50).
the instrument had satisfactory properties in previous studies Mediation analyses were performed to examine whether
(43, 44). FA as measured on the FAS-SR mediated the relationship
between symptom severity and functional impairment
Global assessment of functioning (GAF) using the PROCESS macro for SPSS (51), which utilizes
The GAF is a single item that measures the overall the bootstrapped standard errors method for the direct
psychosocial and occupational functioning of individuals with and indirect effects of the mediator variable. The basic
a mental illness (45). The total score ranges from 1 to 100 and is information of this procedure is the same as the class Baron
divided into 10 equal intervals. A lower scale score shows worse and Kenny method, but this approach was required to
global psychosocial function. The GAF is frequently used in both increase statistical power through bootstrapping procedures
research and clinical settings and has adequate reliability and and take measures to specific tests for the mediated
validity (45). effect. The number of bootstrapped resamples was set at
5,000, and the indirect mediation effect was regarded as
Yale-Brown obsessive compulsive scale significant when the exclusion of zero was between the 95%
(Y-BOCS) confidence intervals.
The Y-BOCS is a 10-item instrument that evaluates OCD All analyses were performed using the Statistical Package for
symptom severity in the past month and is regarded as the the Social Science (SPSS) version 21.0. P < 0.05 was used to
gold standard instrument to measure changes and improvement determine statistical significance.
in severity during OCD treatment (46–48). The scale includes
two subscales, with five items about obsessions and five items
about compulsions. The scale is widely used in both clinical
and non-clinical settings. The total scores range from 0 to 40, Results
and every item is scored 0–4 (none, mild, moderate, severe,
and extreme). The Y-BOCS has demonstrated satisfactory Frequency data for the family
reliability and validity (46, 49). In the present study, the accommodation scale self-rated
severity of OCD was assessed by the Y-BOCS based on the
patient’s experience and the compulsive subscale based on the A total of 171 patients and 145 paired relatives participated
relative’s report. in the survey because 26 relatives did not complete the interview.
Table 1 describes the demographic and clinical information of
the participants. The age range of patients was 18–78 years old,
Statistical analyses with a mean age of 30.90 ± 10.61 years, and 54.4% were females.
The relatives included 73 (50.3%) parents, 68 (46.9%) spouses
The level of agreement between family members’ and 4 (2.8%) others. The age range of relatives was 23–74 years
observations and understanding of the OCD patients’ symptom old, with a mean age of 44.40 ± 10.54 years, and 53.8% were
dimensions on the FAS-IR and the FAS-SR was examined females. There were no significant differences in patient age,
by the kappa coefficients. The item-level frequencies and gender, or the total Y-BOCS scores of patients based on either
Cronbach’s alpha coefficient were used to assess the reliability patient or relative reports between relatives who completed the
of the FAS-SR. The intraclass correlation coefficient (ICC) FAS-SR and those who did not (all P > 0.05).

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TABLE 1 Demographic and clinical characteristics of participants.

Variables Patients (n = 171) Family members (n = 145)

Age (years) (Mean ± SD) 30.91 ± 10.61 44.40 ± 10.54

Gender- n,%
Female 93 (54.4) 78 (53.8)
Educational level- n,%
Primary school and below 8 (4.7) 15 (10.3)
Junior middle school 19 (11.1) 27 (18.6)
High school 53 (31.0) 39 (26.9)
College and above 91 (53.2) 64 (44.2)
Marital status- n,%
Married 90 (52.6) 135 (93.1)
Occupational status- n,%
Employed 68 (39.8) 93 (64.1)
Retired 3 (1.8) 15 (10.3)
Housewife 18 (10.5) 13 (9.0)
Unemployed 34 (19.9) 10 (6.9)
Student 41 (24.0) 1 (0.7)
Other 7 (4.1) 13 (9.0)
Region- n,%
Urban 124 (72.5) 101 (69.7)
Suburban 8 (4.7) 7 (4.8)
Rural 39 (22.8) 37 (25.5)
Age at the onset of symptom (years) (Mean ± SD) 23.88 ± 10.73 –
Illness duration (years) (Mean ± SD) 7.04 ± 7.16 –
Treatment duration (years) (Mean ± SD) 2.47 ± 4.47 –
Relationship with patient- n,%
Parents – 73 (50.3)
Spouse – 68 (46.9)
Other* – 4 (2.8)

*Include adult child, sibling, and significant other.

Table 2 compares the agreement of relatives’ proportion food (29.0%), making it possible for patients to perform
of OCD symptom dimensions between the FAS-SR and FAS- compulsions (23.4%), and providing items needed to perform
IR. There was significant agreement on relatives’ proportion compulsions (22.6%).
of types of OCD symptoms between the two scales, except for The total FAS-SR score ranged from 0 to 68, and the mean
miscellaneous compulsions. of the total scores was 20.01 ± 14.39.
Table 3 displays the frequency data for items on the FAS-
SR. In sum, the proportion of participants who endorsed at
least one, and daily (or an extreme) type of accommodating The factor structure of the family
behavior in the past week was 97.9 and 56.6%, respectively. accommodation scale self-rated
Both the provision of reassurance associated with obsessions
(71.7%) and the reduction of leisure time (67.6%) were There were five factors with eigenvalues greater than
the most common phenomena. In addition, approximately 1 (6.065, 1.716, 1.434, 1.209, and 1.067). According to
half of the relatives believed that they provided reassurance the results of the screen plot and the eigenvalue figures,
about compulsions (59.3%), avoided talking about OCD the three factors of the scale were more reasonable and
triggers (62.8%), stopped themselves from doing things were finally identified. Moreover, both Bartlett’s test
that could trigger OCD behaviors (54.5%), did not stop was 940.427 (df = 171, P < 0.001), and Kaiser-Meyer-
unusual OCD-related behaviors (53.8%), and changed their Olkin (KMO) was 0.844, indicating that the sample was
work/school schedules (53.1%). The least frequently endorsed appropriate for describing factor analysis. The cumulative
accommodating behaviors included helping patients prepare contribution rate was 48.50%. The scale included three

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TABLE 2 The agreement in relatives’ endorsement of patient OCD symptom categories on FAS-IR vs. FAS-SR (n = 145).

Symptom dimension FAS-IR FAS-SR Kappa P

n 100% n 100%

Obsessions
Harming obsessions 62 42.8 58 40.0 0.574 <0.001
Contamination obsessions 89 61.4 83 57.2 0.686 <0.001
Sexual obsessions 2 1.4 2 1.4 – –
Saving/losing obsessions 21 14.5 27 18.6 0.452 <0.001
Religious obsessions 14 9.7 15 10.3 0.349 <0.001
Obsession with need for symmetry or exactness 28 19.3 46 31.7 0.360 <0.001
Somatic obsessions 36 24.8 40 27.6 0.501 <0.001
Miscellaneous obsessions 51 35.2 71 50.0 0.445 <0.001
Compulsions
Cleaning/washing compulsions 101 69.7 98 67.6 0.664 <0.001
Checking compulsions 82 56.6 78 53.8 0.554 <0.001
Repeating rituals 46 31.7 49 33.8 0.546 <0.001
Counting compulsions 12 8.3 15 10.3 0.225 0.006
Ordering/arranging compulsions 19 13.1 14 9.7 0.693 <0.001
Saving/collecting compulsions 7 4.8 8 5.5 0.508 <0.001
Miscellaneous compulsions 56 38.6 78 53.8 0.241 0.002

factors: (1) providing reassurance, participation, (2) (rs = 0.286, P < 0.001), OCI-washing (rs = 0.357, P < 0.001),
facilitation, and (3) modification. The details are described OCI-ordering (0.181, P = 0.030), and a lower GAF score (rs = -
in Table 4. 0.399, P < 0.001). There was no statistical association between
the FAS-SR scores and Zung SDS scores (rs = 0.048, P = 0.563).
The results of Steiger’s Z test demonstrated that there was
Reliability and validity no significant difference between the FAS-IR and FAS-SR on
each of the criterion instruments. The results are displayed in
The FAS-SR demonstrated Cronbach’s alpha of 0.879, and Table 5.
the corresponding Cronbach’s alpha of three factors were 0.826
(factor 1), 0.741 (factor 2) and 0.746 (factor 3), respectively.
Additionally, the total FAS-IR score ranged from 0 to 44, with a
mean of 13.49 ± 8.24. The ICC between the FAS-SR and FAS-IR
scores was 0.795 (95% CI, 0.715–0.852). Mediation of the relationship between
A total of 16 relatives were evaluated to measure the symptom severity and functional
test-retest reliability. The ICC was 0.97 (95% CI: 0.92–0.99) impairment by family accommodation
between the first assessment (P50:28, P25-P75:7–38) and
retest assessment (P50:25, P25-P75:6.25–30). There were no This model examined whether FA was a mediator
statistically significant differences in age, gender, or Y-BOCS variable to measure the relationship between symptom
total scores of OCD patients rated by relatives’ reports between severity on the clinically administered Y-BOCS and
the relatives who completed and did not complete the retest of functional impairment, controlling for patient age, gender,
the FAS-SR (all P > 0.05). educational level, marital status, occupational status and
A higher level of FA was significantly associated with more region. The results demonstrated that FA significantly and
severe symptom severity in OCD patients measured by the independently mediated the association between symptom
Y-BOCS based on relative reports (rs = 0.327, P < 0.05) severity and functional impairment (a∗ b path, β = 0.0548,
but was slightly significantly associated with patient reports 95% CI: 0.0033–0.1270). Higher symptom severity was
(rs = 0.188, P = 0.023). In addition, a higher total FAS-SR associated with higher FA score, and FA score was positively
score was associated with a worse level of family function associated with functional impairment. The direct effect
(rs = 0.157, P = 0.060 for patient interview, rs = 0.342, P < 0.001 of symptom severity on OCD functional impairment
for relative-rated), a higher level of functional impairment remained significant after the inclusion of mediators (c’ path,

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Liao et al.
TABLE 3 The percentage of FAS-SR items.

FAS-SR items Mean ± SD Item-total r Alpha if removed Range Frequency of endorsement Percentagea

0 1 2 3 4

1. Reassured patient that there were no grounds for OCD concern 1.77 ± 1.47 0.481 0.868 0–4 41 (28.3) 27 (18.6) 27 (18.6) 24 (16.6) 26 (17.9) 104 (71.7)
2. Reassured patient that compulsions took care of OCD concern 1.43 ± 1.49 0.466 0.868 0–4 59 (40.7) 24 (16.6) 26 (17.9) 13 (9.0) 23 (15.9) 86 (59.3)
3. Waited for patient 1.26 ± 1.52 0.362 0.869 0–4 75 (51.7) 15 (10.3) 18 (12.4) 17 (11.7) 20 (13.8) 70 (48.3)
4. Directly participated in compulsions 0.99 ± 1.49 0.480 0.867 0–4 91 (62.8) 12 (8.3) 15 (10.3) 6 (4.1) 21 (14.5) 54 (37.2)
5. Made it possible for patient to complete compulsions 0.48 ± 0.99 0.555 0.866 0–4 111 (76.6) 12 (8.3) 14 (9.7) 3 (2.1) 5 (3.4) 34 (23.4)
6. Provided items needed to perform compulsions 0.47 ± 1.01 0.460 0.869 0–4 112 (77.2) 13 (9.0) 10 (6.9) 5 (3.4) 5 (3.4) 33 (22.6)
7. Made it possible for patient to avoid OCD triggers 0.94 ± 1.39 0.390 0.869 0–4 88 (60.7) 18 (12.4) 15 (10.3) 8 (5.5) 16 (11.0) 57 (39.3)
8. Helped patient make simple decisions 0.68 ± 1.06 0.435 0.868 0–4 91 (62.8) 25 (17.2) 17 (11.7) 8 (5.5) 4 (2.8) 54 (37.2)
08

9. Helped patient with personal tasks 0.56 ± 1.14 0.430 0.869 0–4 110 (75.9) 11 (7.6) 10 (6.9) 6 (4.1) 8 (5.5) 35 (24.1)
10. Helped patient prepare food 0.77 ± 1.36 0.405 0.868 0–4 103 (71.0) 11 (7.6) 3 (3.3) 10 (6.9) 14 (9.7) 42 (29.0)
11. Took on patient’s family or household responsibilities 1.10 ± 1.50 0.374 0.869 0–4 85 (58.6) 10 (6.9) 8 (8.8) 10 (6.9) 20 (13.8) 60 (41.4)
12. Avoided talking about OCD triggers 1.68 ± 1.62 0.405 0.872 0–4 54 (37.2) 23 (15.9) 8 (8.8) 16 (11.0) 34 (23.4) 91 (62.8)
13. Stopped self from doing things that could trigger OCD 1.50 ± 1.63 0.429 0.868 0–4 66 (45.5) 18 (12.4) 8 (8.8) 15 (10.3) 31 (21.4) 79 (54.5)
14. Made excuses or lied for patient to cover up OCD 0.50 ± 0.92 0.273 0.874 0–4 100 (69.0) 28 (19.3) 5 (5.5) 3 (2.1) 4 (2.8) 45 (31.0)
15. Didn’t stop unusual OCD-related behaviors 1.37 ± 1.53 0.304 0.871 0–4 67 (46.2) 17 (11.7) 15 (16.5) 10 (6.9) 25 (17.2) 78 (53.8)
16. Put up with unusual conditions in home due to OCD 1.06 ± 1.49 0.324 0.871 0–4 88 (60.7) 8 (5.5) 11 (12.1) 8 (5.5) 20 (13.8) 57 (39.3)
17. Cut back on leisure time 1.51 ± 1.42 0.549 0.870 0–4 47 (32.4) 35 (24.1) 14 (15.4) 14 (9.7) 22 (15.2) 98 (67.6)
18. Changed my work/school schedule 1.12 ± 1.36 0.560 0.868 0–4 68 (46.9) 32 (22.1) 10 (11.0) 7 (4.8) 17 (11.7) 77 (53.1)
19. Put off my own family responsibilities 0.83 ± 1.22 0.442 0.869 0–4 84 (57.9) 30 (20.7) 10 (11.0) 8 (5.5) 10 (6.9) 98 (42.1)

FAS-SR, Family Accommodation Scale for Obsessive-compulsive Disorder, Self-reported. 0 = none/never, 1 = 1 day, 2 = 2–3 days, 3 = 4–6 days, 4 = every day. a Percent of respondents reporting frequency of accommodation as “often-at least once per day”
or greater (≥1).

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TABLE 4 Exploratory factor analysis of the Chinese version of the FAS-SR.

FAS-SR items Factor 1 Factor 2 Factor 3

5. Made it possible for patient to complete compulsions 0.753 0.176 0.175

6. Provided items needed to perform compulsions 0.693 0.205 0.017
7. Made it possible for patient to avoid OCD triggers 0.675 0.150 0.019
4. Directly participated in compulsions 0.644 0.058 0.272
2. Reassured patient that compulsions took care of OCD concern 0.618 0.064 0.223
3. Waited for patient 0.604 0.204 0.047
1. Reassured patient that there were no grounds for OCD concern 0.602 0.072 0.242
15. Didn’t stop unusual OCD-related behaviors 0.498 0.203 0.124
8. Helped patient make simple decisions 0.473 0.393 0.155
9. Helped patient with personal tasks 0.286 0.712 -0.015
10. Helped patient prepare food 0.193 0.701 0.165
11. Took on patient’s family or household responsibilities 0.139 0.637 0.259
14. Made excuses or lied for patient to cover up OCD -0.023 0.628 0.154
16. Put up with unusual conditions in home due to OCD 0.320 0.484 0.049
13. Stopped self from doing things that could trigger OCD 0.227 0.464 0.356
17. Cut back on leisure time 0.118 0.061 0.859
18. Changed my work/school schedule 0.179 0.172 0.789
19. Put off my own family responsibilities 0.281 0.149 0.611
12. Avoided talking about OCD triggers 0.090 0.284 0.570
Cronbach’s 0.826 0.741 0.746

FAS-SR, Family Accommodation Scale for Obsessive-compulsive Disorder, Self-rated.

The factor loadings ≥ 0.40 are marked in the bold.

TABLE 5 Convergent validity of FAS-SR with criterion measures as compared to FAS-IR.

FAS-SR total P FAS-IR total P Steiger’s Za

Patients rated (n = 171)

Y-BOCS total 0.188 0.023 0.289 <0.001 −1.756
Patient obsession severity 0.140 0.092 0.214 <0.001 −1.267
Patient compulsion severity 0.207 0.013 0.298 <0.001 −1.589
Patient global functioning (GAF) −0.399 <0.001 −0.433 <0.001 0.637
Functioning impairment (SDS) 0.286 <0.001 0.300 <0.001 −0.248
Work/school 0.133 0.112 0.160 0.054 −0.460
Social life 0.290 <0.001 0.285 0.001 0.088
Family life/home responsibility 0.315 <0.001 0.344 <0.001 −0.521
Family global functioning (FAD) 0.157 0.060 0.158 0.057 −0.017
OCI total score 0.155 0.062 0.157 0.060 −0.034
OCI hoarding 0.107 0.217 0.013 0.878 1.583
OCI ordering 0.181 0.030 0.177 0.033 0.069
OCI checking 0.060 0.470 −0.036 0.666 0.404
OCI neutralizing −0.025 0.767 0.013 0.876 −0.639
OCI obsessing −0.036 0.669 −0.036 0.664 0.000
OCI washing 0.357 <0.001 0.414 0.000 −1.051
Zung SDS 0.048 0.563 0.134 0.108 −1.464
Relative rated (n = 145)
Patient compulsion severity (Y-BOCS) 0.332 <0.001 0.436 <0.001 −1.944
FAS-IR total 0.749 <0.001 – – –
Family global functioning (FAD) 0.342 <0.001 0.373 <0.001 −0.564

a Two-tailedZ-critical is 1.96 for P < 0.05 and 2.58 for P < 0.01. FAS-SR, Family Accommodation Scale for Obsessive-compulsive Disorder, Self-rated. FAS-IR, Family Accommodation
Scale for Obsessive-compulsive Disorder, Interviewer-Rated.

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FIGURE 1
Mediation effects of family accommodation on symptom severity and functional impairment. *P < 0.05, **P < 0.01. Y-BOCS, Yale-Brown
Obsessive-Compulsive Scale; FAS-SR, Family Accommodation Scale for OCD Self-rated version; SDS, Sheehan Disability Scale.

β = 0.5464, SE = 0.1101, P < 0.001). Figure 1 illustrates the most common type of accommodation (7, 8, 25, 27, 30, 52,
meditation model. 53). Compared to other obvious behaviors, this method of
accommodation was perceived as more passive and with less
direct involvement and participation, so this behavior was more
Discussion common in relatives of OCD patients. On the other hand,
making it possible for patients to perform compulsions and
To the best of our knowledge, this is the first study to report providing items needed to do compulsions were less frequently
FAS-SR in adult OCD patients in China. Similar to previous reported. There are more overt tasks that family members
reports, this study demonstrated that the Chinese version of need to direct to take part in some compulsions. Overt tasks
the FAS-SR has satisfactory reliability and validity. The Chinese benefit from increased focus on direct family involvement
version of the FAS-SR can be widely used in Chinese OCD compared to providing assurance, needing more time and
participants to assess and quantify family members’ responses increasing the burden.
to the symptoms of their loved ones. Considering the high incidence of FA and common
Consistent with previous research, family members reported behaviors in relatives of OCD patients, it may be that
high rates of FA, again confirming that FA is believed to be professional policies should be developed to target these myriad
a common and ubiquitous phenomenon in Chinese family behaviors and integrate the relatives into the treatment plan
members of OCD patients (7–9, 18, 27, 30, 52). The results on evidence-based relative management strategies to help
demonstrated that almost all subjects endorsed at least one the patients with OCD better tackle OCD-related distress
kind of FA behavior, and more than half of the participants and anxiety with self-efficacy. Additionally, providing and
endorsed every day or had facilitated an extreme FA behavior popularizing some knowledge on proper psychoeducation about
within the past week. These results are also consistent with the the deleterious consequences of FA, integrating family members
original version in a previously reported study (25). Although into the patients’ treatment and training them on appropriate
the behaviors may be seemingly relatively innocuous, they responses to OC symptoms would increase family support and
unfortunately caused undesired consequences of symptom eliminate maladaptive behaviors.
maintenance and reinforced OCD symptomology in the long As expected, the result of the test-retest analysis was
run. The family members aimed to help the patients feel excellent. To the best of our knowledge, this is the first
safe by relieving their in-the-moment anxiety and distress study to explore the test-retest reliability of the FAS-SR. These
and not to disrupt daily life routines or time spent executing results reinforced the stability of the self-reported instrument
compulsions. However, FA was usually detrimental to the for assessing FA. In addition, internal consistency was similar
patients’ long-term mental health and function by preventing to the original and other language versions of the FAS-SR,
OCD patients from habituating to anxiety and learning that the which reported coefficients of 0.90, 0.88, and 0.936, respectively,
consequences they feared typically did not occur. As a result, the demonstrating strong internal consistency of the instrument
finding of a high incidence of FA affirmed that it is necessary (25, 27, 30). The results confirmed that the Chinese version of
to focus on the important role of FA in OCD occurrence, the FAS-SR had satisfactory reliability.
development, and outcome. Because the sample size of the study taking the original
The most frequent FA behavior was offering reassurance version of the FAS-SR was too small, the factor structure
about continued obsessions and cutting back on leisure time. of the FAS-SR was not explored (25). This hinders the
Consistent with previous studies, the provision of reassurance contradistinction compared to the original version of the FAS-
related to obsessions also confirmed that this item was the SR. Our result was not consistent with the Hindi versions

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Liao et al. 10.3389/fpsyt.2022.970747

of the FAS-SR (30). The reasons for the difference between significantly associated with the total FA scores, and the FAS-
the Chinese and Indian language versions of the FAS-SR are SR had good convergent validity. The symptom of OCI washing
as follows. Owing to some cultural differences between the was the most common symptom reported. This result may have
two countries and the differences in the inclusion criteria for application in the clinic, especially when doctors encounter
participants in the two studies, these discrepancies may explain patients who have this primary symptom. However, some other
the different factor structures of the Chinese and Hindi versions symptoms were not associated with FA, which is particularly
of the FAS-SR. Additionally, the multiple structure of the FAS- true if the patient struggles with sharing behaviors perceived
SR showed that the assessment of FA required the consideration as grotesque or amoral, making him or her less prone to seek
and analysis of these problematic behaviors from different accommodation from family members. Owing to the limitation
dimensions and aspects. In conclusion, the Chinese version of of the research design, it was not obvious that the family
the FAS-SR displayed multiple structures, not a global structure. members had such psychopathologies before or after the onset
The hypothesis that the total FAS-SR score was moderately of OCD symptoms. There was no statistical association between
correlated with several variables related to patient symptom the FAS-SR and Zung SDS scores, and the results showed that
severity and OCD-related family pathology was supported. the FAS-SR displayed excellent discrimination validity.
In addition, the association between the FAS-SR score and Inconsistent with the hypothesis, FA partially mediated
observed variables did not differ from the association between the relationship between symptom severity and functional
the FAS-IR scores and the same observed variables (27, 52). The impairment. Similar to previous reports, the mediation model
results were consistent with those reported by Pinto et al. in the demonstrated that more severe OCD symptomology was
original version of the FAS-SR (25). Moreover, our results are in linked with increased FA behaviors, which ultimately caused
accordance with previous reports that demonstrated severe FA greater functional impairment in OCD patients (9). Contrary
behaviors related to poorer family functioning, higher symptom to the hypothesis, the direct effect of symptom severity
severity, and more severe functional impairment (52, 53). on functional disability-associated OCD remained significant
These results suggested that dysfunctional family interactions, in the mediation model. Piacentini et al. also reported a
family conflict and distress due to the home environment change in FA before the change in OCD symptom severity
described FA behaviors. and functional impairment, suggesting the importance of
Consistent with the hypothesis, the total score of the FAS-SR reducing accommodating behaviors to decrease symptom
was significantly associated with OCD symptom severity in both severity and functional impairment (54). Therefore, regarding
patient-rated and relative reports, and the relationship was very their respective contributions to functional impairment in OCD
weak. This result was consistent with the majority of previous patients, the results showed the importance of identifying FA
reports, especially from a recent meta-analysis (25, 30), and it behaviors and targeting symptom severity. In conclusion, it
was likely that OCD patients who displayed higher symptom is important to target these FA behaviors in OCD evaluation
severity demand increased FA behavior. However, the result was and treatment. As such, family-based treatments designed to
inconsistent with a study of the Japanese population reported in target these specific symptoms and integrate family members
2016 (27). Compared to the association between the total FAS- in the therapeutic process are expected to be particularly
IR scores and patient-rated OCD symptom severity, the figure efficacious.
was relatively lower than the abovementioned results, even Based on the study design and other factors, future research
though the difference was not statistically significant. There was should explore the shortcomings related to this study. First,
a possibility that the relatives of OCD patients underestimated because the FAS-SR and FAS-IR had differences in the number
their accommodating behaviors by self-reporting despite the of items and the response options, the FAS-SR was developed
existence of severe OCD symptoms. Moreover, family members based on the structure of the FAS-IR. As a result, there was no
may believe their accommodating behavior is simply supportive way to compare each individual item between the FAS-SR and
of OCD patients. Additionally, the reported high levels of FAS-IR. Second, our study design was not designed to evaluate
shame, embarrassment and stigma attached to OCD often result the sensitivity of FA to changes in treatment. It is necessary
in the patients intentionally ignoring and decreasing OCD to conduct follow-up studies to understand the relationship
symptom severity. In addition, it should be emphasized that the between the accommodating behavior and treatment outcome
relationship between OCD symptom severity and FA is likely of OCD in future studies. Third, these findings should be
bidirectional, necessitating future longitudinal investigations to considered within the limitations of developing a meditation
understand its clinical course. model in a cross-sectional design. Fourth, the FAS-SR reported
Similar to previous studies, in regard to the clinical that one’s own behavior was susceptible to certain biases and
correlates of FA in OCD, poor family functioning, washing different levels of understanding, and it was limited to people
symptoms, higher CGI-S scores, and lower GAF scores were with low levels of education. Because the sample of other
significantly correlated with the total FA score (25, 27, 30, 50). relatives was small, the type of kinship should be diversified
These results supported the hypothesis that some factors were and balanced to assess how this variable affects the extent of

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Liao et al. 10.3389/fpsyt.2022.970747

accommodating behaviors in future studies. In addition, the Ethics statement

sample of the present study was insufficient to explore the factor
structure of the FAS-SR with confirmatory factor analysis; future The studies involving human participants were reviewed
studies should include larger sample sizes to further understand and approved by the Xiamen Xianyue Hospital Ethics
the factor structure of the FAS-SR. Commitment. The patients/participants provided their written
informed consent to participate in this study.

Conclusion
In sum, the FAS-SR could overcome the limitations
Author contributions
of interviewer administration and systematically evaluate
ZL, WZ, and LD designed the protocol in this study. ZL,
problematic behaviors based on the relatives’ view and
CY, YC, and LD collected the data and performed the clinical
understanding. The FAS-SR provided the opportunity to target
assessment. ZL, CY, and YC analyzed the data. ZL wrote the
FA behaviors through relative self-report, which may be
manuscript. All authors contributed to and have approved the
beneficial for reducing clinicians’ time, saving labor costs and
final manuscript.
speeding up the diagnostic process compared to the use of
clinician-administered instruments. Additionally, the present
study filled a current gap in the literature by establishing a
self-reported instrument for relatives of OCD patients that
enables a standardized method of assessing FA behaviors in
Funding
OCD patients and has some implications for clinical assessment,
This work was financially supported by the Xiamen
intervention and academic areas in China. First, the FAS-SR
Municipal Bureau of Science and Technology (Nos.
may be a cost- and time-effective instrument to evaluate the
3502Z20189054 and 3502Z20194082).
involvement of family members in OCD patients’ symptoms,
which could help clinicians identify the level of accommodation
and obtain more detailed information on family behaviors.
Second, given the high incidence of FA behaviors reported in
this study and linking FA with family functioning, symptom
Acknowledgments
severity, and functioning impairment, it seems that the
We thank Lisa Calvocoressi and Fayong Li for providing
evaluation of FA behaviors should be incorporated into all
original instruments and helping to translate and cross-
pretreatment assessments of OCD to help guide clinicians in
culturally adapt of the Chinese version of FAS-SR. We
the formulation of family-based treatment plans. Third, having
would also like to sincerely thank the participants for their
more detailed information about the most common type of
consideration cooperation.
accommodating behaviors guides clinicians in their assessment
of family dynamics, providing more specific psychoeducation
and enabling the development of exposures and other desirable
strategies to reduce FA behaviors. Fourth, FA partially mediated
the relationship between symptom severity and functional
Conflict of interest
severity. Given the association with decreased function and
The authors declare that the research was conducted in the
poorer treatment response, targeted intervention and treatment
absence of any commercial or financial relationships that could
for those associations and construal are expected to improve
be construed as a potential conflict of interest.
the treatment outcome of OCD patients. In sum, these results
demonstrated that the Chinese version of the FAS-SR has sound
psychometric properties, which suggests that the instrument is
a useful tool to measure FA and could aid in early treatment
intervention and personalized treatment efforts in the future.
Publisher’s note
All claims expressed in this article are solely those of the
authors and do not necessarily represent those of their affiliated
Data availability statement organizations, or those of the publisher, the editors and the
reviewers. Any product that may be evaluated in this article, or
The raw data supporting the conclusions of this article will claim that may be made by its manufacturer, is not guaranteed
be made available by the authors, without undue reservation. or endorsed by the publisher.

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