New research reveals that families of youth with misophonia are highly involved in the child’s symptoms, possibly even more so than young people with anxiety disorders

Individuals with misophonia are no strangers to using devices and modifying routines to reduce their contact with troublesome sounds. From trusty foam earplugs to elaborate noise cancelling technology to visiting the cinema at the unsocial hour of 11am on a Monday, for many of us with misophonia, modifications are part of life. But new research suggests that for youth with misophonia, these kinds of strategies might extend to the rest of the family too.

The study, led by Eric Storch at Baylor College of Medicine and published in the journal Behaviour Medicine, found that family accommodation strategies were frequently used by families of youth with misophonia, with rates of accommodation higher than in families of youth with anxiety disorders.

What are family accommodations?

The authors described family accommodation as “the extent and manner in which family members take part in an individual’s symptoms”. More commonly described in relation to anxiety disorders and OCD, where the term refers to behaviours that help the child to avoid or alleviate anxiety or that assist them to complete rituals. Examples include repeated reassurance that an anxious child is not sick and purchasing cleaning products for a child’s cleaning rituals.

Though well-intentioned, these actions are are theorised to maintain anxiety by contributing to avoidance, reducing opportunities to test feared beliefs and develop age-appropriate, independent coping strategies.

Family accommodation is associated with more severe symptoms in young people with OCD and anxiety disorders. However, it’s not clear if increased symptoms lead to increased family accommodation, or the other way around, or both.

The authors of the new study expected that they would find an association between misophonia and family accommodation, similar to what has been found for anxiety and OCD.

How was the study conducted?

The researchers surveyed 102 children (aged 8–17) with misophonia and 95 children with an anxiety disorder, and their parents. They completed the Family Accommodation Scale for Anxiety (FAS-A), which they modified for the misophonia group, e.g. replacing the word “anxiety” with “misophonia”. They also completed two scales related to misophonia, and the Child Behaviour Checklist, with a particular interest in the part of this questionnaire that captures “internalising” symptoms (e.g. withdrawal and anxiety) and “externalising” symptoms (e.g. aggression).

Family accommodation and misophonia

The researchers found that the parents of youth with misophonia used more total family accommodation strategies than parents of youth with anxiety disorders. They also found some differences in the nature of the behaviours used, with reassurance being used more frequently for those with anxiety disorders, and for those with misophonia, families were more likely to assist their child to avoid things and to modify family routines. They also found that there were more accommodations for younger children than older children.

Within the misophonia group, they found that more family accommodation was associated with higher externalising symptoms (e.g. aggression), but there was no significant association with internalising symptoms (e.g. withdrawal).

When looking at whether severity of misophonia could be predicted based on levels of family accommodation, internalising and externalising symptoms, the researchers looked at both parent- and child-rated misophonia severity. Family accommodation significantly predicted misophonia severity in both tests. Interestingly, internalising symptoms (e.g. withdrawal and anxiety) was an additional predictor of child-rated misophonia severity, but not parent-rated misophonia severity, suggesting differences in the ways parents and children rate misophonia symptoms.

The authors proposed that there could be a bidirectional relationship between misophonia severity and family accommodations. They suggest that as severity increases, families respond with more accommodations, and that these accommodations may maintain or exacerbate the impact of misophonia. For example, they suggest that family accommodations may reduce the child’s ability or confidence in coping with distress, limit their life experiences and reinforce unhelpful ways of coping with stressful situations. This was not something that was tested in the study.

What does this mean for families affected by misophonia?

Don’t throw out the earplugs or switch off the white noise machine just yet. More research is needed to better understand the impact of family accommodation on misophonia.

The authors suggest that family accommodation might be a potential target for treatment. Reductions in family accommodations are related to greater improvements during treatment for both OCD and anxiety disorders. For those conditions, avoidance behaviour and rituals can maintain or exacerbate the problem. Family treatment usually goes alongside individual therapy, where the young person completes exposure-based CBT, and the family reduces the extent to which they assist the child to avoid anxiety. They might also be taught techniques that validate the child’s experience of anxiety, enhance the child’s belief in their capacity to cope, reduce family conflict and improve family problem solving skills.

However, it is too soon to apply this to misophonia. We don’t yet know whether misophonia follows a similar pattern to OCD and anxiety disorders, whereby avoidance, devices and modified routines can maintain or exacerbate symptoms. Research may well discover that some of those strategies might reduce distress and impairment in misophonia. We need a lot more information about the impact of both individual and family behaviour before any recommendations can be made.

What were the limitations of this study?

The authors acknowledged several limitations to this exploratory study, notably that this was a cross-sectional study and therefore does not provide any information about whether one aspect causes another. They noted some limitations of their recruitment method and the lack of diversity in their sample. Additionally, family accommodation was measured using a slightly modified questionnaire that is usually used for children with anxiety. This questionnaire requires further testing to find out whether it can meaningfully be applied to misophonia.

Take home message

Misophonia is a problem that can affect the whole family. The study found that the more severe a child’s symptoms are, the more strategies parents are likely to use in an attempt to reduce distress. However, a lot more research is needed before we can convert this into practical steps for families affected by misophonia.

For clinicians working with families affected by misophonia, it’s important not to make assumptions about the role of family accommodation. Families may benefit from more strategies to add to their repertoire and support to decide what works best for each child’s unique family circumstances.

Read the full paper here: https://www.sciencedirect.com/science/article/abs/pii/S000578942300117X

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